Study Material on PGDHHM Correspondence Course POST GRADUATE DIPLOMA IN HOSPITAL AND HEALTCARE MANAGEMENT (PGDHHM

Study Material on PGDHHM Correspondence Course

HOSPITAL SUPPORTIVE SERVICES

Compiled by Dr. Suhas Gangurde MD. (OB& GY), DHA, Mphil. (Hospital Management)

POST GRADUATE DIPLOMA IN HOSPITAL AND HEALTCARE MANAGEMENT (PGDHHM)

Symbiosis Centre of Health Care (SCHC) AUTHOR

Dr. Suhas Gangurde MD. (OB& GY), DHA, Mphil. (Hospital Management)

All rights reserved. No part of this work may be reproduced in any form, by mimeograph or any other means, without permission in writing from the Symbiosis Centre of Health Care. Printed and Published on behalf of the Symbiosis Centre of Health Care by Dr. Rajiv Yeravdekar, Hon. Director, SCHC. Printed at Chaturthi Enterprises, Pune - 411 051. 2

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Introduction to Insurance & Income Tax Index No. A) 1 2 3 4 5 6 7 8 9 10 11 12 13. B) 1. a) b) c) d) 2. 3. 4. 5. 6. 7. 8. 9. 10. 11 12

Chapter

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CLINICAL SERVICES : : : : : : : : : : : : :

Introduction Outpatient Department Inpatient Department ICU Accident & Emergency Department Day Care Surgery Department Maternity Services Physical &Rehabilitation Department Nursing Department Pathology and Laboratory Department Radiology Department Blood Bank Dental Services

: : : : : : : : : : : : : : :

Administrative Departments Reception/Front Office & Billing Department Purchase & Store Department Accounts Department Human Resources Department Linen & Laundry Department Housekeeping Department Central Sterile Supply Department Biomedical Engineering Department Medical Record Department Bio Medical Waste Management Department Fire Safety Services Department Pharmacy Public Relation Food Services Autopsy Services

05 10 18 20 22 23 25 27 29 40 51 55 57

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79 84 87 90 106 131 150 156 164 171 179

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About the Author: DR. Suhas Gangurde is an M.D. in Obstetrics and Gynaecology. He did his M. phil. in Hospital Management from BITS PILANI, and DHA from TISS,Mumbai. He has more than 30 years of Clinical & Administrative experience. He is currently working as Medical Director of D.S.Kothari Hospital, Mumbai.

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CHAPTER - 1

INTRODUCTION There has been a significant increase in the private sector provision and financing of health care services in India in recent past. Not only has the number increased, but more and more sophisticated and specialised healthcare is being brought to the 'door steps' of the general population. This certainly is the picture in urban India, though the situation is fast improving in the second rung cities across the country too. The utilisation surveys suggest that on an average 3/4th of outpatients and 1/3rd of in patients seek care from the private sector. One of the components of private health care set up is the hospitals set up by the corporates. These facilities depend on the main business of the parent company for financial allocation. The financial sustainability of these facilities is closely linked to the financial prudence of the healthcare entity. Few industries, operating upon such a scale, would be able to continue in business. Millions of rupees are being expended on research and development of drugs and new methods of treatment. Hospital programs must keep pace with advances in medical science if that science has to be applied effectively. Herein lies a great challenge; the vista is exciting and stimulating to hospital personnel in proportion to their vision, desire for knowledge, exchange of information and dedication to a life of service. The approach to better patient care must be a positive and objective approach. The institution that we know today as the hospital is a phenomenon of the twentieth century. The early institutions from which it developed bear little resemblance to this important part of current community life that we call the hospital.


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Brief history of hospital as an organisation It is interesting to note that hospitals came to care for the sick only somewhat incidentally. In its earliest form, the hospital was aimed at care of the indigent - and indeed it is only in the relatively recent past that the almshouse aura has disappeared. Lodging for the pilgrim and the wayfarer was often a primary function of the early hospital. The reputations of some of these early hospitals were not enviable. Because of the toll exacted by severe epidemics and the fact that the hospital was considered a last resort, their death rates were terrifically high. The techniques that have made the modern hospital such a valuable tool in prevention and early diagnosis had not yet been developed. The little surgery that was attempted added its share to the high death rates and to the pessimistic view in which hospitals were held. Aside from the scientific advances of this period, there was a socio-cultural impetus to hospital expansion. The industrialization of the last quarter of the 19th century provided funds for the philanthropic and the cultural milieu was such as to encourage gifts to hospitals. Physicians came to regard the hospital as a valuable adjunct to the professional service they had to offer people, rich and poor alike. But often the hospital grew and functioned without any regard to real community need. It is only within the last generation that the hospital began to reach full stature as a community institution. Emphases on early diagnosis and out patient activities have made the hospital a real force in the community's program for the prevention of disease. Changing role of modern hospitals The functions of a good hospital of today include the entire spectrum devoted to the medical care of patients - prevention, diagnosis, therapy, rehabilitation, education, and research. With respect to these functions, the patient always comes first; the purpose of the hospital including these can be expressed in Pasteur's epitaph: "To cure sometimes, to alleviate often, and to comfort always". In discharging these functions, through the medical staff, other personnel and administration, the hospital utilizes the miracles of modern science, the social consciousness of service; and increasing utilization, understanding and appreciation of all the people. It is for the people that the hospital exists. A modern hospital in a community brings advantages over and above the 6

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medical and surgical care of individual patients. Perhaps even more important is the hospital's influence. More than likely it will raise the quality of care and the general standards of local medical practice through the provision of needed facilities and services. The hospital is probably the center of all community health activities, participating in the application of preventive medicine. Thus the procedures developed in the laboratory are actually put to use through the hospital. This is a field of new and growing importance in community life and has already proven its value in lowering the incidence of disease through early detection and treatment. In plotting the responsibilities of hospitals, it must be kept in mind that their functions are broadening continuously. It is by no means sufficient for the hospital to concern itself with the treatment of acute conditions, nor, indeed is it sufficient for the hospital to be in the vanguard of preventive medicine. The hospital is responsible for maintaining effective co-operation with public health and welfare officials. This is particularly important where there is a single hospital in a community. The community hospital must work cooperatively with the local health department to bring the best in knowledge to the people. Health education programs should be planned for the community at large. Often merging the activities and programs of the hospital and the health department and establishing better understanding with medical practitioners can accomplish this. This is the true realization of an integrated community health service. A future responsibility of the hospital is to spur medical science. Even the smallest hospitals have to contribute. If the doctor and nurse receive their training in the large teaching hospitals, they still must have practical working experience. This is their graduate education. Education of medical personnel is never complete; each day's experiences are added to the fund of knowledge to make the man or woman the versatile person he must be. The same thing is true of all technologists. They must keep abreast of advances in their fields and the best place for them to secure this is the smaller hospitals in the area. Hospitals can no longer function independently. The whole trend of modern medicine is towards integration, for the betterment of all. Also the community has responsibilities to the hospital that should not be overlooked. These are both moral and financial. No business can operate without sufficient funds and the hospital is no exception. Medical care is costly at best and in this era of high incomes and high prices there is little prospect that hospital will be able to lower costs. Inevitably the community HOSPITAL SUPPORTIVE SERVICES

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will be called upon to share the burden of cost for those unable to pay their own way. Beyond this, the community owes its hospital unwavering support thought, word and deed. But only through deep understanding of the needs of a community can the hospital be well understood and deserve and receive the support. Such an understanding is the result of everyone's effort continuing efforts, not a sporadic public relations program. The community must have real knowledge of the hospital and understanding of its problems and aims to appreciate the position the hospital occupies. Given that, the community can hardly withhold its loyalty and support. Clinical & Supportive Services Traditionally it is believed that the success of a hospital depends on its doctors and the efficiency of its clinical services. With the advancement of medical technology and the increasing expectation of patients, supportive services also assume greater importance for the success of the hospital. Today, the clinician has to depend upon a host of supportive services to function efficiently in the hospital. Supportive services like CSSD, maintenance & stores are vital for the successful delivery of hospital services. Success of the clinical services is normally seen openly as compared to the supportive services in the form of cured and satisfied patient. The efficiency of supportive services depends are embedded in the success of clinical services. Apart from achieving good quality of patient care through good supportive services, good management of supportive services will lead to cost containment of hospital services, which is a major concern of many hospitals. The cost of hospital input per admission has increased to such an extent in metropolitan cities like Mumbai, Delhi, Kolkata etc., that many people are not able to afford services. Therefore, good management of support services in hospitals assumes greater importance. The supportive services are more systems oriented and eat far too less resources compare to the clinical services. The success lies in proper planning and rigorous implementation of the systems INPATIENTS: Inpatient admissions, a critical statistic in measuring hospital utilization and services, have been maintaining a fairly steady growth of about three percent per year over the past decade. The increase is largely accounted for in the hospitals, which have over 90 percent of all admissions. 8

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OUTPATIENTS: The increased use of outpatient services has moved beyond all bounds of anticipation. This impact upon hospitals and upon patterns of medical practice has revolutionized our concepts. There are many indications that outpatient services, including emergency care, are no longer looked upon as ''free care'' for the unfortunate indigent. Individual patients and their families, agencies and other third parties are demanding, receiving and paying for the high quality of care deemed necessary and desirable by the public, physicians and hospitals. The functions of the outpatient department are to provide diagnostic, curative, preventive and rehabilitative services on an ambulatory basis to the people of the community. The emphasis is on the promotion of health through these measures, through continuity of patient care, health professionals and through research. Orderly planning should be achieved by the hospital through: 1. Acceptance by the hospital's administrator of primary responsibility for both short and long-range planning, with support and assistance from a long-range planning and development committee and competent financial, organizational, functional, and architectural advice. 2. Identification of the hospital's service area and determination of the area's population, socio-economic, and housing trends, travel patterns and barriers, and location of physicians' offices and other health care resources. 3. Analysis of the hospital's medical staff as to its members' age, location of office, specialty, type of appointment, extent of privileges, and number of patients admitted by each in the last three years as the basis for projecting admission trends of major clinical service. 4. Examination of use of major clinical service departments, and such supportive service departments as food service, operating rooms, emergency, X-ray, laboratory, physical therapy, etc. over the past five years as the basis for a use projection into the future for each of these departments. 5. Establishment of short and long-range planning objectives with a table of priorities and target dates on which such objectives may be achieved. 6. Preparation of a functional program that describes the short range objectives to be achieved and the facilities, equipment and staffing necessary to achieve them. HOSPITAL SUPPORTIVE SERVICES

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CHAPTER - 2

OUTPATIENT DEPARTMENT With the advent of accurate and fast diagnostic and therapeutic tools in the armamentarium of the clinician, the need for hospitalizing the patient is obviated. Apart from the inconvenience and loss of earning to the patient, the hidden cost of traveling, food and similar such out of pocket expenses make OPD treatment more attractive to most of the patients. A good outpatient department, with its services correlated with and as an adjunct to preventive health practices in the community, can be a potent force towards this end. Hospital beds are not available in sufficient numbers, nor are they indicated for all who need diagnostic and therapeutic services. Beds are costly to build and maintain, and it is often an economic waste to utilize inpatient care when outpatient services would suffice. There are many indications that outpatient services, including emergency care, are no longer looked upon as "free care" for the unfortunate indigent. Individual patients and their families, organizations, insurance programs and other third parties are demanding, receiving and paying for the high quality of care deemed necessary and desirable by the public, by physicians and by hospitals. In terms of diagnostic, preventive, and restorative health programs, outpatient services do not constitute competition to the private physician if properly organized and directed. Rather, they should complement his efforts, making available to him facilities which he need not personally furnish, as well as consultation and educational opportunities of much value. Also, they help the hospital fulfill its role as the true focal point of community health, professional education and service to humanity. Hospital outpatient services are being increasingly utilized, to a dramatic extent by the populations of practically all communities. This poses many problems related to community planning, clinical aspects, administration, personnel and staffing, finance, and provision of adequate space and equipment. Planning and evaluation of outpatient services cannot be done in isolation 10

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from total needs of the community and hospital, its resources and problems that beset them. Nor can the latter be examined and evaluated without full consideration of outpatient services. This planning and evaluation naturally will vary with the individual hospital and the community because of many factors, the most important of which are the interest and vision of community leaders, the medical staff, and hospital administration in meeting community needs. That pattern of medical practice is changing and that more and more hospitals and their medical staffs are using outpatient services in meeting community needs and demands is exemplified by the tremendous increases in such services in the past few years. OUTPATIENT: The person given general or emergency diagnostic, therapeutic, or preventive health services provided through a hospital's facility or health program and who, at the time, is not registered as an inpatient in the hospital. The term includes persons given care through an organized home care program which is hospital based, coordinated and directed as an extension of its outpatient services. There are three categories of outpatients. GENERAL OUTPATIENT: A person given diagnostic or therapeutic services on an outpatient basis, for other than an emergency condition and who has not been directly referred for such services by his attending physician or dentist; the responsibility for continuing care and disposition of the patient is assumed by the hospital. REFERRED OUTPATIENT: A person referred directly to the outpatient department by his attending medical or dental practitioner for specific diagnostic or treatment procedures, for other than an emergency condition, and who will return to the practitioner for further care and disposition. EMERGENCY OUTPATIENT: A person given emergency or accident care for conditions determined clinically, or considered by the patient (or his representative), ad requiring immediate physician, dentist, or allied services. OUT PATIENT VISIT: The arrival of a person at the outpatient department of the hospital to receive diagnostic or therapeutic services and for who appropriate data is recorded. There are two types of visits. HOSPITAL SUPPORTIVE SERVICES

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NEW OUT PATIENT VISIT: An outpatient visit by a person who appears for the first time, or beyond a specified period of time which is concurrent with reporting periods for inpatient admissions REPEAT OUTPATIENT VISIT: An outpatient visit by a person who appears for the first time, or within a specified period of time subsequent to a new outpatient visit AMBULATORY: This means able to walk and applies to both inpatients and outpatients. Some inpatients are ambulatory; not all outpatients are ambulatory. The term should not be used as a synonym for the latter. UNIT OF SERVICE: A measurable part of the volume of work or service produced or rendered in diagnostic or therapeutic facilities of the hospital, expressed in terms of time and / or quantity. OUTPATIENT DEPARTMENT: That section of the hospital with allotted physician facilities, regularly scheduled hours, and personnel in sufficient numbers assigned for established hours, to provide care for patients who are not registered as inpatients while receiving physician, dentist, or allied services. OUTPATIENT CLINICS (UNITS): Those units (excluding adjunct Services Units) of the outpatient department responsible for general and specially management of designated diagnostic and treatment procedures. As many as fifty different types of clinics are in operation in some hospitals, including emergency general medicine, surgery, and their related specialties, dental, eye, maternity, pediatric, rehabilitation and others. Each should be closely related to its counterpart for inpatient services. EMERGENCY CLINIC: This is an integral unit of total outpatient department and is that clinic where services are rendered to outpatients in the diagnosis or treatment of conditions determined clinically, or considered by the patient (or his representative) as requiring immediate physician, dentist, or allied services.

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ADJUNCT SERVICES UNITS: Those special diagnostic and therapeutic facilities and services established in the hospital for assisting in the determination and confirmation of the physician's or dentist's diagnosis, and or the provision of treatment ordered by and under the supervision of the physician or dentist. Included in this group would be such services as anesthesiology, blood, bone and eye banks, laboratory, pharmacy, poison center, radiology, and physical therapy. ORGANIZATION: The good outpatient department is far more than buildings and equipment. There are facilities which make it possible, or easier, to discharge its responsibility i.e. the care of sick people by the health professions. Such care can be furnished, to the satisfaction of the patient, the public the medical staff and others concerned, only if administrative organization and execution is alert, dynamic, and understanding. Here, like elsewhere, good administration is more than simply a means to an end. It involves planning, organization, execution, and evaluation, in their broadest concepts. It is concerned with people, money and things, and, in relation to the first, is concerned with human and social engineering. Making this concept effective in every department and units makes for a better hospital. Insofar as the public is concerned, this perhaps, is more important in the outpatient department than almost any other. While some facets of outpatient services are maintained separately from inpatient functions, they should be integrated physically, functionally, and from clinical and administrative standpoints as much as possible. The governing body and the hospital administrator should devote as much attention to prior organization, functions, budgets, utilization, and quality of services as for any other department. The director of the outpatient department should have full status as a department head and participate in policy and program discussions and decisions for the entire hospital in that capacity. He should be directly responsible to the administrator. The director needs to be cognizant of hospital and public health problems and programs, of individual and community needs and of economic, clinical and educational potential of his department. Tenure should be such as to provide clinical and educational potential of his department. The medical staff should be closely integrated with and a part of the hospital staff. The chief of a clinical service should give similar direction to its outpatient department extension or counterpart. This improves continuity of care. The staff should carry on the same type of medical audit in evaluation of quality of care as is indicated for other services in the hospital. HOSPITAL SUPPORTIVE SERVICES

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Educational Programs for interns, residents, nurses, and others are vastly enhanced by experience in the department. Such programs can also utilize to advantage these facilities for refresher courses for graduate practicing physicians in the region. The number of physicians and dentists on the staff will vary with the patient load, however, to give service approaching adequacy, none should be asked to handle more than two new patients and perhaps four or five returning patients per hour. The nursing staff will likewise vary with patient load and services offered. The staff will benefit by rotation between inpatient nursing units and outpatient duty, although continuity of supervision and concept of outpatient care are essential. Medical social services are an indispensable part of outpatient programs. Laboratory, X- ray, pharmacy, and similar services within the hospital should be integral parts of outpatient activities, the facilities and personnel being jointly used. Use of volunteer personnel, where adequate direction and supervision can be maintained may be of more advantage here than in many departments of the hospital. The health educator has an opportunity in the outpatient department which is not fully available elsewhere. Waiting rooms and clinics should be utilized to drive home facts about health, to a most receptive group, in effect, a captive audience. Posters, murals, pamphlets, and other display materials are readily absorbed by a receptive group. Competent staffing of the admitting and records office will go far in the establishment and operation of a smoothly functioning department. One of the most annoying experiences to the patient and a detriment to good public relations for the whole hospital is the seemingly interminable waiting for and between appointments. Expeditious handling of a workable appointment system and of records completion and transfer, contributes to efficiency and to staff and patient satisfaction. Records should be an extension, as a unit, of inpatient records insofar as possible. Additional and somewhat different forms will be required, and these are best developed for the specific hospital. 14

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PHYSICAL FACILITIES: Accommodations for outpatient services vary more widely than for any other hospital activity. Requirements are based on extent of services, and no two hospitals have exactly comparable problems and procedures. Indeed many hospitals have been planned and constructed with complete omission of outpatient facilities or have included them on such a limited scale that future development, and the tremendous increase in utilization by the public, have made the situation virtually intolerable. This always creates space and traffic problems for the entire hospital. A rough rule of thumb indicates that from three - fourths to one square foot for each annual outpatient visit expected will provide adequate space in the majority or instances, although design of the facility should be such as to allow for future modification or expansion. The location of the outpatient facilities should be such as to make for easy access for services. At the same time, traffic into the hospital proper must be held to a minimum. This means, for the average hospital, a location on the ground floor, with separate outside entrance from convenient parking areas. Ramps may be indicated. For the larger hospital, particularly one with an active teaching program, and requiring multiple floors, it has been found advantageous to have inpatient and outpatient departmental activities on continuous floors. Directional signs should be used freely throughout the department. The waiting rooms should provide about 8 to 10 square feet per patient visit and should be attractively furnished. Sub - waiting spaces for small numbers of patients in the immediate vicinity of the various clinics, have been found toexpedite patient flow and reduce congestion. Patients' toilets, lavatories, water coolers with paper cup dispensers, clocks, and public telephone, should be provided. A separate play area for children reduces noise and confusion. Acoustical ceiling is highly desirable. The information desk, records, appointment and cashiers' office open into the waiting room but should be so designed as to offer some degree of privacy. Admitting and social services offices open directly off the main waiting area and may require small adjacent waiting space. The number and arrangement of examining and treatment rooms will vary with services to be offered, with multiple scheduling, and other factors. There may be separate rooms or incubicle series, allowing for circulation of personnel. The typical room requires space for the examining table, lavatory with foot or knee control, small boiling water sterilizer portable light, stool, chair, small instrument table, nurses' call, and desk and chair for recording. HOSPITAL SUPPORTIVE SERVICES

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Special rooms which may be required include those for conferences and teaching, offices for the staff, minor surgery, dental suite, dark room for eye work, fluoroscopic room, small laboratory, shock or recovery observation room and the emergency room described below. THE EMERGENCY CLINIC: This is usually the most active of the outpatient units. As indicated earlier, it should be incorporated as an integral part of the physical facilities of the total outpatient department. It usually serves as the general outpatient unit during the hours when regular clinics are closed. If it is a separate facility it means duplication of staff and equipment. 1. The Emergency unit should be closed in an area easily accessible to the emergency patient entrance and away from the main hospital and general outpatient entrance. 2. The entrance should be well marked and illuminated, easily accessible from the street, without curbs or platforms, and sufficiently covered and enclosed to protect ambulance patients from the elements when unloading. 3. Space for stretchers and wheel chairs should be reserved immediately adjacent to the entrance. Stretchers should be sturdy enough to serve as examining tables, and ideally, should be X - ray permeable. 4. There should be waiting space, separated from the working area of the emergency clinic rooms and containing telephone, toilet, and drinking fountain. 5. Facilities to be considered, adapted to the program of the hospital, include: a) Examining and treatment rooms. b) Observation beds. c) Administrative offices. d) Doctors' call room e) Security room. f) Police, ambulance attendants, and reporters room. g) Family room. h) Nurses' station. i) Utility Room. j) Conference or teaching room. k) Admitting and Records office. l) Drug, supply, equipment, and housekeeping storage. m) Janitors' Closet. n) Staff Toilets. 6. X - ray and laboratory services should be available and easily accessible. 7. There should be facilities for equipment and supplies in or easily convenient to the emergency unit, or provision for efficient services from a central area. 16

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8. Facilities should be of sufficient size to accommodate the personnel, equipment and supplies for good, prompt patient care. Of utmost importance is that facilities permit good public relations. Congestion, delay, or apparent unsympathetic attention can never be justified by any explanation in the eyes of the injured patient and of distraught relatives. It is from this emergency clinic nucleus that the hospital must stand ready to fill a role which may vary from the simplest of complaints of an individual patient to a major accident or catastrophe as discussed in the chapter on fire, safety and disaster programs. AMBULANCE SERVICES: Adaptation of the ambulance to civilian use has developed only well within the past century, although its origin for military purposes is largely credited to Dominique Jean Larrey, a French military surgeon, in 1792. Primary responsibility for ambulance operation on the part of individual hospitals is decreasing, since it appears to be primarily a transportation service. Its major objective is to transport the sick and injured as quickly and comfortably as possibly as possible to a hospital where effective medical care can be rendered by qualified personnel. There is a wide variation in operation of ambulance services, from use of private or volunteer organizations, with or without contract, to the single municipal agency. There appears to be little correlation of costs with population, number of vehicles, calls per year, or type of service. The largest proportion of calls canbe expected to occur between three and six P.M. and traffic accidents usually account for at least a third of all calls. A word of caution is indicated concerning speed of ambulances. In the vast majority of cases there is absolutely no reason to exceed the legal speed limit of any other vehicle. The use of sirens is somewhat questionable. If used, they should be of a distinctive pitch to avoid collision with other vehicles.Although it has been found that the presence of a physician on all calls is notwanted, ambulance attendants should be prepared to administer first aid when indicated. Assistance in the training of such personnel is a role in which the hospital can play an important part, particularly as it relates to first aid, use of splints, and the transportation of fracture cases. Any treatment other than proper resuscitation measures and application of plain sterile dressings should not be undertaken by non-medical personnel. This applies particularly to the use of morphine.


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CHAPTER - 3

IN PATIENT DEPARTMENT A ward that section of hospital which has nursing station, the beds it serves and the necessary services, storage, work & public areas needed to carryout the nursing care. Patient admitted in the hospital spent there entire time of his stay in the inpatient ward a ward is not just the place for the care and treatment but it also serves as temporary home for the patients during the period of hospitalization. Important aspects of ward management 1. facility management/ Hospitality Services :a. Patient's living accommodation with beds, other furniture, toilet facility, lighting, ventilation, communication, housekeeping, dietary services, Physical safety. 2. Patient care Management :a. Medical Management:It includes doctor's visit to the patient, examination and assessment of the progress. b. Maintaining the case records for every patient. c. Discharge documentation & briefing of Patients and their relatives. d. Release of patients to home. Important Quality Parameters 1. Home comforts during the period of stay a. Good Standards of patient accommodation commensurate with room tariff. b. Good level of hygiene and sanitation. 2. Nursing Care:Helpful attitude and prompt and professional care by the nurses and other staff. 3. Medical Management:Timely visit, competent treatment, minimum essential investigation, prognosis, length of stay. 4. Result Expected :Minimum Possible Period 18

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5. Cost of care:Reasonable and affordable. Infrastructure:1. Building, Space, Layout a. Patient Accommodation, nursing Station, treatment area, bathrooms, toilets, storage, public areas to be as per the standard scale and layout. 2. Staffing :Requirement of doctors & nursing staff on the basis of bed occupancy of the hospital. The requirements of nurses would be 1:3 (day shift), 1:4 (Evening Shift), 1:5 (night shift) & in the intermediate care it may be 1:5-6 (morning shift), 1:7-8 (evening shift) 1:10 (night shift). It is important note that in wards with female patient adequate no of female housekeeping staff should be available in all the three shifts. 3. Equipment:The equipment (medical, non medical) shouldbe made available as appropriate for the type of patients and bed occupancy. 4. Materials:Medical as well as general stores supply should be timely, of high quality and in appropriate quantity. 5. Support Services :Supportive services such as diagnostic services, dietary services, pharmacy, housekeeping, linen and laundry, CSSD, admission, discharge, billing, hospital information systems, security and engineering support services, the performance of the services must be high quality.


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CHAPTER - 4

INTENSIVE CARE UNIT (ICU) Intensive care ward is the most important of inpatient areas as it deals with the critically sick patients. requiring intensive observation, nursing care and therapy. ICU may be classified as Medical / Surgical/ Coronary / Pulmonary / Neonatal / Burns ICU etc. ROLE: To provide an inpatient care unit with all the specialized facilities for intensive observation and monitoring round the clock, lifesaving procedures and specialized care and treatment by staff (nurses and doctors). FUNCTION: 1. Provision of inpatient services for the critically sick patients. 2. Continuous, intensive observation and monitoring of all the vital parameters for continuous assessment of the patient's clinical condition. 3. Specialized investigations and lifesaving procedures such as ventilator support (intubation/extubation), tracheostomy, peritoneal/haemodialysis. 4. Intensive and specialize~ nursing care required for the critically sick including the unconscious-requiring life-support, spinal injury cases, head Injury cases. Quality of-process 1. Protocol of designated-head of critical care services. 2. Protocol of quality for the department. 3. Documented policy for admission for ICU. 4. Clinical management of the patient. 5. Documented protocol for evaluation of the patient's condition. 6. Documented protocol for monitoring of patients. 7. Documented procedure for preventing medication errors. 8. SOPs for various procedures. 9. Documented procedure for-management of cardiac arrest. 10. Documented procedure for management of anaphylactic shock. 11.Documented procedure for blood transfusion and actions to be takenI in case 20

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12. 13. 14. 15.

of transfusion reactions. A well planned and seriously implemented program of infection control. SOP for barrier/reverse barrier nursing to prevent cross infection. Policy of segregating infectious from the non-infectious. SOP for bio-medical waste management asper the rules and correct

EVALUATIING INCIDENCE FOR QUALITY 1. Nosocomial Infection. 2. Death rate in ICU. 3. Response time of doctors. 4. Incidence of complications. 5. Bedsores SUMMING- UP ICU is that department of any hospital where critically ill patients admitted and treated. ICU is a zone where probability of error is zero %. So the quality of staff within the ICU, the level of care, the protocols of all procedures should be perfect, fully matched with the standards, efficient, well trained, alertness, promptness should be exist in ICU 's manpower. So that we can say we can reduce the chance of error in ICU and increase a level of survival.


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CHAPTER - 5

ACCIDENT AND EMERGENCY SERVICE Medical Emergency is defined as a situation where the patient requires, urgent and high quality medical care to prevent loss of life, limb or organ and initiate action for the restoration of normal healthy life. Functions 1. Reception should be prompt and active for handling of all emergency cases. 2. Immediate treatment of patient by life support treatment measures. 3. Starting treatment by the specialists concerned and if required calling other senior specialists 4. Ambulance services for patients. 5. Briefing the relatives about the condition of patient. Quality of Process: 1. Active assessment of patient's condition. 2. Documented protocol of each procedure. 3. SOP of all activities. 4. Disaster management of department. 5. Maintenance of equipment. 6. Mock drills. 7. Special protocol for death cases. 8. Audit 9. Bio medical waste management 10. Induction and training program for staff. SUMMING –UP For accident and emergency department quality of care is must. Because this is a department where only those patients come who are struggling with their life. So it is essential that the department is fully tuned to assessment and rapid resuscitation to save lives.

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CHAPTER - 6

DAY CARE SURGERY DEPARTMENT Day care surgery is totally different from out-patient surgery. In day care surgery patients need some degree of post-operative specialized nursing care necessitating post-operative observation for a few hours. All day care surgical patients essentially come early in the morning and after the surgery is over and the post-operative observation is uneventful, the patient is discharged home the same day. The concept of day surgery implies that patients come into hospital for their procedures and go home the same day. A Day Surgery facility refers to a specific operating complex for surgical treatment of patients who are admitted and discharged on the same day. Day-surgery is a cost effective and useful and is the best for healthy children undergoing minor procedures. Ambulatory surgery is increasingly being accepted and encouraged throughout the world by both government and private agencies. The reduction in cost to both the patient and community, coupled with the advantages of Day Surgery for both patients and their relatives. The monetary advantages of day surgery are many.Day surgery allows the treatment of large numbers of patients at less cost than in-patient surgery. Reasons for cost reduction include the following: 1. Staff and facilities not needed at night shifts , at week-ends or on public holidays. 2. Less staff is required for a Day Surgery facility in compare of in-patient surgery. 3. If an operation is suitable for Day Surgery is carried out as an inpatient, expensive hospital bed are occupied, thereby using up more capital equipment, patient and administrative time 4. The use of a Day surgery facility reduces the number of in-patient beds required. HOSPITAL SUPPORTIVE SERVICES

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Advantages to hospitals 1. The economic savings. 2. More attractive to nursing staff because of less shift work . Advantages to the patient 1. Pre-booking of dates and less chances of cancelation. 2. Shorter waiting lists and less waiting time . 3. Domestic arrangements 4. Mobilization. 5. Early recovery. 6. Reduce cross-infection 7. Less psychological disturbances in children 8. Lesser chances of cancellation due to pressures of emergency surgeries in a dedicated day care facility. Types of Day Care Surgical Centers Hospital Integrated Unit In this unit patients are admitted and discharged and preoperative evaluation and preparation are carried out. Hospital Autonomous Unit This unit is self-sufficient. This type of unit is located within the hospital, but operates totally independent of other portions of the hospital. Hospital Satellite Unit This is located away from the campus of the hospital but operated by hospital. Free-Standing Unit This unit is not geographically or administratively part of any other health care facility. SUMMING UP Day care surgery is an accepted modality of treatment for most surgical patients and it has multiple advantages to all the stakeholders as well as the patients, besides being an economically better option for the health sector which is beleaguered with scarce resources. So , creating more day care centers should be in the better interest of the patients and the nation as a whole Given the will, the majority patients, even in the developing countries, can undergo the majority of elective surgery procedures on a day stay basis and that there are facilities already available to cope with the initial expansion. 24

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CHAPTER - 7

MATERNITY SERVICES Maternity service would, perhaps be the most important service from public health point of view because an efficient maternal and infant health services are the very foundations of nation's health. Maternity serviceswould generally include1. Outpatient services 2. Inpatient services 3. Obstetrical 3. Outreach service ROLE: 1. Safe management pregnancy. 2. Safe conduct at deliveries. 3. Improvement of reproductive health 4. Training to the expectant mothers in mother craft. 5. Family, planning advice. FUNCTIONS OF MATERNITY SERVICES 1. Antenatal check up to ascertain the maternal and fetal well-being. 2. Administration of medication. 3. Medical termination of pregnancy services. 4. Safe-conduct of delivery by natural/surgical approach where indicated. 5. Post-natal follow-up and care of the mother and child. 6. Advice to couple. 7. Counseling regarding family planning. 8. Health education and training. 9. Out - reach services. 10. Investigation of concomitant disease. Quality of services: 1. Safe, full term delivery of a healthy baby through natural process (as far as possible) or surgical intervention where indicated. 2. No adverse effects of the hazards of pregnancy on the health of mother. HOSPITAL SUPPORTIVE SERVICES

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3.

Full protection of the mother and the child against all the attendant hazards/ dangers/complications. 4. Improved reproductive health of the mother. 5. Services rendered at a reasonable/affordable cost. 6. Quality manual for assurance of quality of services. 7. SOPs of each process. 8. Briefing and education of the couple. 9. Pain management. 10. Disposal of bio medical waste management. SUMMARY Maternal and neonatal death rates are, perhaps, the most important indices of quality of health services in a nation. Quality of maternity services is not much dependent upon sophisticated equipment. All that is required is arrangement for periodic antenatal checkup, correction of common antenatal problems and safe delivery by trained staff, under aseptic conditions and using standard protocols. If this much can be assured, the quality of services will improve and the maternal and infant death rate will come down.

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CHAPTER - 8

PHYSIOTHERAPY & REHABILITATION DEPARTMENT Rehabilitation, as defined by WHO , is the combined and coordinated use of medical, social, educational and vocational measures for training or retraining the individual to the highest possible level of functional efficiency and at enabling the disabled and handicapped to achieve social integration. Physical .Medicine and Rehabilitation department is responsible for providing rehabilitation services including all measures aimed at reducing the impact of disability and handicapping condition and at enabling the disabled for active participation in the main stream of community life. The department plays crucial role in disability reduction and restoration of physical activity in a wide variety of conditions. 1. Aid to physicians- in early ambulation of patients. 2. Aid to patients-improvement of scope of self-care activities. 3. Adjunctive and supportive treatment for many pathological conditions for speedy recovery. 4. Planning a fol1ow- up program after discharge. Functional Area: 1. Phyicaltherapy (physiotherapy) 2. Electrotherapy 3. Hydrotherapy , 4. Occupational therapy.

Facility / Equipment Available: 1. Short wave diathermy 2. Infra-red radiation

3. Ultraviolet radiation 4. Ultra violet stimulation 5. Radiant energy 6. Ultra sonotherapy 7. Hydrotherapy 8. Massage 9. Manipulation 10. Traction HOSPITAL SUPPORTIVE SERVICES

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11. Whirlpool- Hubbard's tank swimming pool 12. Wax bath 13. Exercises in the gymnasium 14. Latest, the laser therapy.

Space Requirement Requirement of space would depend upon the workload and facilities provided. About, 20% of allout-. Patients and 4.5% of total beds may require physiotherapy.

Layout 1. 2. 3. 4. 5. 6. 7. 8. 9.

Reception and waiting Doctor's office Examination room Office for the physiotherapist Treatment area (therapy cubicles, gymnasium, swimming pool) Patients' dressing/change ·room Store room Records room Toilets and showers.

Staffing The staff must be fully qualified and trained in various modalities of therapy and may be provided as per the following scale 1physiotherapist = 15 patiems per day. SUMMING UP: Physical Medicine, is the system of promoting the process of healing through various modalities of stimulation. It also uses exercise regimes to train and retrain the body musculature to regain the lost movements, relieve the pain and enable the patients to be self-reliant again.

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CHAPTER - 9

NURSING DEPARTMENT Good nursing services in the hospital result from and are a part of coordinated administrative and clinical planning. Needs of the nursing service and extent of the value of contributions made by it are based upon total clinical and administrative patterns, policies and practices, and the type of personnel employed. Patients look to the hospital for courteous, gentle and considerate care; for security; for skillfulness; for cleanliness; and for understanding personal interest. When they can attest to such care, the chances are good that all concerned with hospital matters will find satisfaction of their expectations and their desire for a job well done. The primary purpose of the nursing department is to give such comprehensive, safe, effective and well-organized nursing care to patients as to accomplish these ends. The department is responsible for teaching programs for nursing and auxiliary personnel; for patient education; for augmenting medical and allied research; and for maintaining the stability of the nursing staff. The nursing department constitutes the largest single group of hospital employees, averaging more than half of the total. Property administered, it is the mainstay of the organization from the standpoint of supporting administrative requirements, giving effective patient care, and promoting good public relations. While dependent upon all other hospital departments, it serves as a focal point for much of the administrative co-ordination required between departments. Nursing services must be under the direction of a competent nurse, responsible to the hospital administrator for the program and activities of nursing care of patients. Unlike most other department heads in the hospital, the nurse director has a dual role of responsibility. In addition to having administrative responsibility to the hospital administrator she has the role of coordinating professional activities of the nursing staff with those of the medical staff. HOSPITAL SUPPORTIVE SERVICES

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It is her duty to be oriented to the role of the hospital in the community so as to further its contributions along clinical, educational and economic lines. She administers the nursing program through proper planning of services, delegation of responsibility, giving general supervision and through determination of nursing policies and procedures in collaboration with the nursing staff. She gives the administrator the benefit of her counsel on nursing problems and interdepartmental activities which affect nursing. Her responsibilities include: 1) Evaluation and improvement of the nursing care of patients. 2) Keeping current the basic nursing service policies, procedures and functional organization. 3) Maintenance of a stable staffing pattern. 4) Procurement, selection, orientation and assignment of nursing personnel. 5) Maintaining effective relationship between the nursing department and the medical staff, and other hospital units. 6) Maintenance of adequate nursing records for clinical and administrative use. 7) Evaluation of nursing supplies and equipment, their preparation, distribution and care. 8) Preparation and adherence to the nursing service budget. In the larger hospital full-time assistance to the director of nursing is necessary to share these responsibilities to act the absence of the director. In the smaller hospital full-time assistance may not be required, although, in that event, some member of the staff must be designated for essential assistant functions. During the night shifts the nurse in charge acts as an assistant to the director and may be called upon to represent the administrator for certain functions which may be specifically delegated to her. The nursing department consists of the nursing units, or patients area, and such areas as the operating room, recovery room, labor, delivery and nursery suites, and perhaps, central supply room. Each of these is under the direction of a head nurse to whom is delegated the direct responsibility for administration of the unit and for the activities of the nursing personnel assigned to that area. The head nurse works under the general direction of the supervisor of the particular clinical division, such as medical, surgical, obstetrical, in which her unit is classified. Supervisors have general administrative and supervisory functions for the correlation of two or more nursing units, usually of the same 30

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clinical service. They may have clinical and instructional functions, even with a graduate staff, and are directly of nursing services. Titles of positions should designate, if possible, the functions of the positions. Detailed functions and assignment of individual duties may vary somewhat with hospitals of varying services and size. However, in any event a clearly defined functional organization plan is required if responsibilities are to be understood and properly discharged. Such a plan is necessary for efficient operation and good morale and should be set forth in writing and in as much detailed as possible. Focus on organization and administration of the nursing department should be well defined, but emphasis should not be so great as to preclude careful selection and appointment of well qualified head nurses and other supervisory personnel. Staff nurses skilled in beside care are essential but supervision provided in proportion to work load and employees is indispensable for providing consistently good quality care. As the utilization of practical nurses and other less highly trained personnel increases, the need for supervision increases. The establishment and smooth operation of the nursing department is dependent upon well-developed policies for administrative purposes and delineating standards, principles and procedures for patient care. For consistent interpretation and application of these policies, a nursing policy manual, available to appropriate personnel, is indispensable. PATIENT MONITORING One of the major, and spectacular, development is patient care in the past few years has been that of electronic monitoring. Such systems are rapidly from the initial cumbersome horse and buggy stages to extreme sophistication and complexity. Use of monitoring systems is still highly selective, with planning, programming, design, installation, and maintenance running through a very expensive range. Use of such system shows great promise and certain facets are becoming commonplace in many hospitals. Systems are in use today not only for patients in critical condition, but for routine observation and measurements of simpler diagnostic conditions for both bed patients and ambulatory individuals. HOSPITAL SUPPORTIVE SERVICES

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Monitoring systems do not reduce the number of personnel required for patient care; there is still no substitute for good nursing services. Requirements are for larger numbers of more highly competent personnel, including those for maintenance and repair. Orientation and training programs, from the initial concept and on a continuing basis thereafter for all personnel concerned, are a necessity for successful use of this addition to hospital procedures. In general, space requirements are considerable. Installation should not be undertaken without thorough exploration of all facets. In new design of areas in which monitoring is to be used, it is wise to include conduits for future installations when details are developed. Equipment may vary from small units for individual patients to very large and complex systems whereby multiple observations are delivered on control viewing panels, recordings on paper or tape, and to computers. Observations and measurements may be routine in relation to blood pressure, pulse, respiration, temperature and other physical and physiological conditions, or more complicated to meet sophisticated refinements. Built-in alarms are necessary to indicate critical changes in the patient's condition as well as for any failure in the system itself. PHYSICAL FACILITIES OF THE NURSING UNIT The best designed nursing unit will not operate satisfactorily unless the policy of operation is in keeping with the philosophy that governed the original planning. Therefore, in designing any area of hospital operation it is of paramount importance to plan function before architectural drawings are begun. Every nursing unit should be designed to serve certain functional goals. It should seek to achieve the following. 1. Provide for the highest quality patient care. 2. Be built at the lowest possible capital cost. 3. Be operated at the lowest cost. 4. Furnish the most desirable patient environment. 5. Achieve the highest degree of job satisfaction for the nursing and medical staffs. 6. Provide for needs of visitors. These six points refer to the nursing unit in question, but they also apply to all aspects of hospital planning. To achieve the aforementioned functional goals in a nursing unit for medical and surgical adult patients, many factors must be considered. They should be 32

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discussed un detail with the administrator, building committee, medical and nursing staffs, department heads and representatives, and the hospital consultant until there is a meeting of minds. Then the architect should be brought into the planning group and asked to suggest his methods of filling the prescription. OPTIMUM SIZE The optimum size of the general nursing unit is governed primarily by the number of patients and nursing staff that the nurse in charge of the unit can manage efficiently. The activity of the service, including bed utilization and degree of patient illness, naturally more or less establishes this pattern. In actual practice, minimum and maximum limits of 30 to 40 beds in each unit will probably be found to be best, with at least two such units on each floor. During the most active hours, 7 A.M. to 3 P.M., each unit would function more or less independently; in the less active shifts, staffing of the two units is combined. Ranges in size were formerly considered to be affected by the distribution of one-tow-and multiple-bed rooms in the unit. It was thought that with more multiple-bed rooms the larger unit was possible, due primarily to savings in walking-time by the nurse between patients. Present practice in most hospitals, as reported by the National League for Nursing, shows an insignificant difference in relative nursing time for one bed and multiple-bed rooms. Nursing units which are too small are even more expensive to build and maintain and are as unsatisfactory for service as those units which are too large. As an example, a ten-bed unit requires the same type of equipment, utilities and supervisory services as the twenty-bed unit. Design of the nursing unit, with proper arrangement of bedrooms and necessary auxiliary facilities, is of utmost importance. Such arrangement not only contributes to nursing proficiency but also to administrative economy and efficiency and, therefore, to patient and community welfare. Where possible, the nursing unit should be compact as to require the nurse to travel not more than about seventy-five feet to serve all patients. Efficiency of operation, economy of space and comfort of the patient are the primary considerations. This means orientation to a pleasing outlook, to ventilation or the prevailing breeze, and most hospital designers include provisions for as much sunlight as possible. Patients' rooms should be quiet, with service facilities located in the less desirable areas. Structural methods used should minimize transmission of sound, with use of acoustical ceilings in corridors and noisy areas. Service facilities requiring plumbing or venting should be arranged over each other in multistory buildings in order to reduce ducts, piping and stacks to a minimum. Complete air conditioning is desirable, HOSPITAL SUPPORTIVE SERVICES

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preferably with humidity control. PROGRESSIVE PATIENT CARE This is a dynamic concept applicable to hospitals of all types and sizes. While not an entirely new concept, having been used for centuries by the Japanese, by Florence Nightingale in the mid 1800's and by military hospitals for years, its application to hospitals in general is more recent. The elements usually considered under this heading include: Intensive Care: For critically and seriously ill patients who are unable to communicate their needs or who require extensive nursing and observation by those with special skills and training. All necessary lifesaving equipment, drugs, and supplies are immediately available. Form there to five per cent of medical-surgical beds can be used most effectively in such a unit. Intermediate Care : For patients requiring a moderate amount of nursing care- Emergency care and frequent observation are rarely needed; patients may be ambulatory for short periods of time, and begin to participate in caring for themselves. The terminally ill may be cared for here. Self Care: For ambulatory and largely selfsufficient patients, convalescents, or those that require only diagnostic or limited therapeutic procedures. Long-term ( extended ) Care : For patients requiring skilled prolonged medical and nursing care. Rehabilitation, physical or occupational therapy may be needed, along with instruction in learning to adjust to a disability. Home Care : For patients who can be adequately cared for in the home through the extension of certain hospital services. It is hospital based and coordinated with other community resources. PEDIATRICS UNIT: A brief description of physical facilities for such care is given here since they form part of nursing unit in the smaller hospital or constitute an entire nursing unit in those hospitals with a sufficient number of pediatric admissions. In the small hospital with a limited number of such patients, accommodations especially designed for the approximately 10 per cent of total admissions may be incorporated into the usual nursing unit. This may be one or more of the regular two-bed rooms arranged for child care by adapting as many of the features as possible of those described in the following paragraphs for the large pediatric unit. The point of emphasis is that a properly designed and equipped unit makes care much more efficient and contributes to the physical and emotional aspects which speed recovery. In the larger hospital with a separate pediatric nursing unit a series of two-bed rooms allows for more flexibility and reduces possibility of contagion. One or two four-bed rooms may be desirable 34

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for the older child. With the larger service, a somewhat higher proportion of pediatric admissions to total admissions may be found. As many as 12 to 15 per cent of beds may be required for pediatric patients. Corridors and partitions between rooms may have large window areas to permit better observation and supervision. Draw curtains are necessary. The larger rooms may require fixed partitions, approximately seven feet high, with curtain end closures. Curtained shatterproof glass is used above the thirty-six inch matters height. Cubicles should be wide enough to receive an adult size bed for larger children; hence the partition must extend seven feet from the wall. Projecting curtain rods will then permit a two foot working space between the foot of the bed and the curtain. Closets or lockers, as well as toy storage space, are necessary. If at all possible the room area should permit space for play and include a small table and chairs for dining. An elevated free-standing tub, accessible from all sides, with controls outside the reach of the child, is very useful. Finishes and furnishings should be colorful, decorative and appropriate for stimulation of child interest. ISOLATION ROOMS: All hospitals knowingly or unknowingly admit patients with communicable diseases. Without some limited special facilities, protection of other patients and personnel would be entirely dependent upon technique alone. Proper technique is a responsibility which can never be relaxed, but the usually overworked and sometimes insufficiently trained employee deserves to have all possible physical barriers established against possible lapses. Therefore, even though any patient's room could constitute an improvised isolation unit, additional safeguards are required. One and two-bed rooms designed for known infectious or communicable disease patients require separate sub utility may serve two rooms when placed between them. With its separate entry from the corridor, it may also serve similar rooms near-by. The isolation room is similar to other patients' rooms, but requires a hook strip for gowns near the door and an individual toilet with bedpan flushing attachment. Isolation rooms should be placed at the end of the corridor and should be available for use by other patients when not used for isolated patients. MEDICINE PREPARATION ROOM: The medicine preparation room must provide freedom from unnecessary commotion and interruption for the nurse while working in that area. It may be HOSPITAL SUPPORTIVE SERVICES

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located adjacent to the nurses' station or in another convenient area centrally located in the unit. Work space should be sufficient to accommodate trays for hypodermic preparation, collection of used syringes and the like; and for medicine glasses, medicine trays and directions for individual patient needs. A sink of acid-resistant material, locker space or cabinet for narcotics, and a small refrigerator for antibiotics are necessary. UTILITY ROOM: The utility room is another of the very busy areas in the nursing unit. It too should be centrally located. The self-closing door to this area should have a vision panel, push plates and arm hook. Work space, separated into clean and dirty sections, is required for the preparation of trays and care of materials, equipment and supplies used in the unit. All work and counter space should be covered at the background for ease in cleaning. Shelves and storage space of equipment used in the unit are needed with a locked cabinet for solutions including poisons. A clinical; sink, lavatory with knee or elbow control, bulletin board, good lighting and acoustical ceiling are needed. i) Ice for non-beverage purposes is stored here. ii) Bedpan flusher-sterilizer units may be placed here. ROLE AND FUNCTION OF NURSE ADMINISTRATOR The Principal Matron of the hospital will be responsible to the Nursing Head of the hospital for the following duties: Administration · Organizes, directs and supervises the nursing services both day and night. · Coordinates the general pattern of delegation of responsibilities and authority. · Formulates standing orders for the nursing care. · Ensures appropriate allocation of duties and responsibilities to all nursing staff working under her. · Formulates nursing policies to ensure quality patient care and adequate attention at all time. · Ensures that administration of nursing staff is carried out I accordance with the current rules and regulations of hospitals. · Responsible for efficient functioning of the nursing staff and enforces hostel rules and regulations and discipline. · Delegates the responsibilities to the assistant nursing superintendent. · Evaluates the personal performance of the nursing staff. Discipline · Ensure that standard of discipline of nursing staff is high at all times. · Maintain good order and discipline in wards / departments. 36

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· Brings immediately to the notice of the medical superintendent all matters concerning neglect of duty, insubordination either by nursing staff, patients or visitors or any un-towards incident, which comes to her notice for taking suitable action as required as per the orders on the subject. · Makes daily rounds of the Hospital in the evenings. · Ensures proper supervision of patients diet. Public Relations · Promotes and maintains harmonious and effective relationship with the various administrative departments of the hospital and related community agencies. · Maintains cordial relationships with the patients and their families. Office routine · Scrutinize the repots and returns and submits in accordance with existing orders. Confidential Reports · Initiates the confidential reports of nursing staff on due dates. · Responsible for the nursing budget. Education · Carries out in service training for all categories of nursing staff and Paramedical personnel and keeps the records of such trainings. · Conduct various update courses based on the needs. · Encourages the personnel to participate in the continuing education programme. Welfare · Responsible for health and welfare of nursing staff. · Ensures AME and periodical health examinations and maintenance of health records. Conferences · She will be responsible for organizing and conducting (quarterly) staff meetings of the nursing staff once in three months and monthly mess meetings. · Holds conferences to solve nursing care problems and discuss policies as regards to working conditions, working hours and other facilities and measures for motivation of personnel. Supervision · Supervises the Nursing care given to the patients and all nursing activities within the nursing unit. · Supervises the work of all Para medical staff of the hospital. · Makes evening rounds in rotation with other matrons, includes Sunday and holidays. HOSPITAL SUPPORTIVE SERVICES

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Records and Reports · Duty roster Nursing staff · Day Off Book · Personal Bio data · Leave plan · Casualty returns Book · Medical Category Book · Staff Conference Book · Releases File · Courses File MANAGEMENT OF NURSING SERVICE UNIT 3.1 INTRODUCTION Nursing profession is considered a caring profession to begin with; it was an art and a vocation. Now it is considered a scientific profession. Nursing Care: Nursing care is defined as the care of the patient with regard to nursing needs, with the ever increasing dimension of medical sciences quantitatively and qualitatively nursing care is becoming more and more complex with its management services. Definition of Nursing Services:WHO expert committee on nursing defines the nursing services as the part of the total health organization which aims to satisfy major objective of the nursing services which is to provide prevention of disease and promotion of health. ORGANISATION OF NURSING SERVICES:CHIEF NURSING OFFICER | NURSING SUPDT | DY. NURSING SUPDT. | ASSTT. NURSING SUPDT. | WARD SISTER-CLINICAL SUPERVISOR | STAFF NUIRSE ----? STUDENT NURSE 38

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OBJECTIVE OF NURSING IN WARD:· Maximum comfort and happiness by way of pleasant surroundings. · Qualitative/comprehensive care to the patient. · Care based on the patient's needs. · Accurate assessment of illness. · Adequate material resources at all times. · Health education to the patient and attendants. · Managerial skills as and when required. · Privacy at all levels. EFFECTIVE NURSING:An effective nursing is always based on nursing process which is an organized and systematic approach to nursing care that prioritizes patient assessment and management. Entire nursing process consists of four phases:· ASSESSMENT- not only initial but integral ongoing assessment of patient's condition is a component of the whole nursing process. · PLANNIG AND IMPLEMENTATION- in this the nurse formulates and implements the care. · EVALUATION- decides whether the action taken has met the identified needs or not. This is the final step of care. FACTORS TO BE CONSIDERED IN PLANNING HOSPITAL NURSING SERVICES:· Number and type of patient. · Number of beds and type of ward. · The services required. · Procedures/techniques necessary for care. · Number and type of personal needed to perform care effectively. · Physical facilities. · Provisional of equipment and supplies.


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CHAPTER - 10

PATHOLOGY AND CLINICAL LABORATORY DEPARTMENT The practice of medicine today requires more and more laboratory examinations. Physicians expect and the public has been educated to demand,better and more precise diagnosis. The importance of laboratory services cannot be overestimated, and the use of the laboratory by the hospital staff is an indication of thorough diagnostic procedure. It forms the basis for a true medical audit. It should serve not only the hospital but the practicing physicians and the health department in the community as well. FUNCTION: The functions of the laboratory service are: (a) to provide information to assist physicians in the diagnosis, treatment and prevention of disease; (b) to assist in training programs; and (c) to conduct research. There are some diseases which cannot be diagnosed without the assistance of the laboratory, such as diabetes, syphilis, endocrine disturbances and blood diseases. Diseases such as cancer and tuberculosis can be diagnosed much earlier with the help of the laboratory. The control and effect of treatment are aided by the laboratory as in the medical treatment of pernicious anemia, syphilis, chemotherapy and antibiotic therapy. The laboratory also provides essential information in surgical treatment, for instance in preoperative test such as urinalysis, blood counts, Rh typing, blood typing, as well as in examination of tissue removed at operation and in conducting postoperative tests. The necropsies performed by pathologists are necessary for medical education, continuing the medical progress which has been achieved to at and elevating the professional level of hospital work. Consultation on the proper test indicated to provide the most valuable information, evaluation of new tests as they are perfected and assistance in problems of sterilization are all part of the pathologist's duties. The laboratory personnel have an important role in the educational programs of hospitals. They participate in clinical pathologic conferences, training of interns and residents in pathology, and training courses for nurses, medical technologist, and others. The progress of preventive medicine has had valuable assistance from the laboratory through examination of food handlers, personnel and materials for delivery rooms, nursery and operating rooms; examination of 40

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intravenous solutions for sterility; examination of food, milk and dishes for possible contamination to prevent spread of disease. Research participate in by the laboratory may be clinical, experimental or medico-administrative. Physicians have need of diagnostic facilities, whether they practice in rural or in urban areas. One reason for the concentration of physicians in large cities is said to be the availability of such services, as contrasted with the lack of them in rural and less densely populated areas. This situation has caused physicians in many cases to rely on distant medical centers for diagnostic services. One solution to the problem lies in regional coordination of hospitals, a plan whereby the larger moderate-sized hospital cooperate with smaller hospitals in the surrounding area to increase the scope and dependability of their laboratory services. Tests for which the smaller hospital is inadequately equipped or staffed are performed by the larger hospital. Consultation on methods and proper technique is made available to the medical technological of the small hospital, and further assistance is given through periodic visits by a pathologist. The potential load on the facilities of the larger hospital so located as to offer such assistance to outlaying areas through coordination, merits full consideration by its planners. It is desirable, therefore, that the pathologist who is or will responsible for the administration of the laboratory be brought into the hospital planning program in the very beginning. ORGANIZATION AND ADMINISTRATION: THE PATHOLOGIST: Pathology and laboratory services should be under direction of a qualified physician, with special training and experience, preferably a diplomate of or eligible for certification by the M C I. He should be a regular member of the active medical staff, subject to its rules and regulations. Compensation of the pathologist is handled in various ways in different communities. Some work on a fee basis arrangement, some on a percentage, others as straight salary by the hospital. There are other variations or combinations. TECHNOLOGISTS: Medical technologist, under the supervision of the pathologist mentioned above, is responsible for the specific work of the laboratory. Too often laboratory work is done by improperly trained individuals who are vested with responsibilities beyond their ability. This tends to lower the confidence of the medical staff in reports made by the laboratory and could lead to results disastrous to the patient's welfare. The following are examples of the types of HOSPITAL SUPPORTIVE SERVICES

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examinations and normal duties performed by a medical technologist.: 1. Performs procedures embracing the fields of hematology, urinalysis, biochemistry, serology, histology, bacteriology and parasitology. 2. Performs basal metabolism test and takes electrocardiograms. 3. Makes out written reports of all completed procedures and maintains monthly and yearly records. 4. Checks all equipment and arranges for checking procedures against known standards. 5. Requisitions supplies and equipment; arranges for regular and periodic calibration of equipment. 6. Supervises other workers in the laboratory. PROCEDURE FOR REQUESTING LABORATORY EXAMINATIONS: Requests for examinations to be performed by the laboratory must be in writing and fall into several classifications: 1. Examinations for which the nurse or physician would be responsible for obtaining the specimen-urinalysis, blood chemistry, bacteriology, serology and pathology. 2. Examinations from which the laboratory personnel would be responsible for obtaining the specimen-blood counts ( red, white and differential), haemoglobin, blood typing, Rh factor and cross-agglutination tests. 3. Examinations performed by the laboratory personnel, with the patient sent to the laboratory or apparatus brought to the bedside of the patient by laboratory personnel ( e.g. basal metabolism and electrocardiogram ). The establishment of a time schedule for accepting certain types of specimens will facilitate the operations of the laboratory. Emergency requests are accepted at all times and always have priority over all requests. However, these should be kept to a minimum and be actual emergency examinations. When the medical staff or nursing personnel assign such priority falsely in order to have examinations done immediately when in reality then should have requested the examination the day before, the laboratory personnel naturally tend to lose respect for such emergency classifications. It is important that specimens be sent to the laboratory in proper containers. A list of commonly requested examinations indicating the proper time for taking the specimen ( fasting or non-fasting ), minimum volume necessary and the proper container, should be posted at the nurses' station together with a time schedule for sending specimens or requests to the laboratory. If there is any confusion or doubts in the minds of nursing service personnel the laboratory should be consulted ahead of time. 42

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PHYSICAL FACILITIES: PLANNING: Experience has shown that, as with laboratory examinations, space requirements tend to double every eight to ten years. This increase requires that adequate space be assigned in keeping with the importance of the functions to be performed. Such space must be flexible and permit early expansion. The pathologist, administrator, architect, and consultant, each with his own sphere of responsibility, are needed as close working team, to develop a written program for new or alteration of design and construction. This means an analysis of programs and translation into effective floor plans, equipment, organization, staffing and procedures. An outline suggested by the Public Health Service includes the following steps: 1. Determine which services are to be provided. 2. Determine space requirements to accommodate equipment and personnel in the following areas: a) Administrative. b) Technical. c) Auxiliary ( includes washing, sterilizing, storage and locker facilities). 3. Divide the technical area into functions or units, such as : Haematology; Biochemistry; Parasitology; Blood Bank; Bacteriology; Histology; Urinalysis; Serology. 4. Determine where the procedures are to be performed. a) Those to be combined in the same work area. b) Those to be done in completely separate work areas. 5. Estimate the volume of work in each area or unit, allowing for future increase in workload. 6) Indicate the number of personnel required a work station in each unit. 7) Describe the major equipment in each unit: a) If possible, indicate the linear feet of bench space required and how the space may be arranged. In many instances this can be determined only by an architectural study. b) List the equipment that requires utility lines and indicate the location. c) List the equipment, such as refrigerators, centrifuges, hoods, desks, that may be jointly used by technologists from different work stations. 8) Indicate the desirable functional arrangements. ( For example, the bacteriology unit may be located at the extreme end of the laboratory, to reduce the contamination hazard, and the washing area should be next to the bacteriology unit; hematology may be next to the waiting room, adjoining the examination and specimen area). 9) Indicate which work units may be expected to expand. ( It may be possible to HOSPITAL SUPPORTIVE SERVICES

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locate these areas at one end of the department to facilitate efficient, coordinated expansion ). 10) In the technical area, a standard module for the work areas is suggested (for instance, a module of 10 by 20 feet). This module can be worked out in collaboration with the architect. By using a standard module, the architect can accommodate more easily the laboratory within the fenestration and structural patterns of the building. A standard module will also facilitate future rearrangement of the department. 11. List the utilities to be provided and any special requirements for instruments such as electronic counters. Separate electrical circuits for some electronic instruments are necessary in order to avoid fluctuating voltage, which affects the accuracy of these instruments. 12. List environmental requirements, such as light, ventilation, color and isolation of equipment that may be noisy or may produce heat when used. LOCATION: The facilities must be planned in relation to the other services of the hospital, always keeping flexibility and expansion in mind. It is generally preferable that it be on a lower floor and so located as to be accessible to the patient area, medical staff, and to outpatients who may be sent to the laboratory. Since specimens from tec necropsy and operating room also will be taken to the laboratory for examination, it should be easily accessible to those departments. In larger hospitals, small laboratories for taking care of such routine tests as urinalysis and blood counts and for teaching purposes may be located in the nursing units. AREA The extent of laboratory service will depend on the size and type of hospital in which it functions. Laboratory facilities in hospitals of 50 beds and less ordinarily consist of one room in which urinalysis, hematology, limited bacteriology, serology and chemistry procedures are performed. As the volume of the work increases, more room is required for these laboratory procedures so that such services as sterilizing, glass-washing and culture media preparation are provided in separate facilities. The 200 bed general hospital is ordinarily the starting point for departmentalization of the laboratory. The bacteriology and serology laboratory examinations may be combined in one unit and a general laboratory unit provided for other procedures. When the bed capacity of the hospital is greater, it becomes necessary to provide separate units for each of the units which are necessary for complete service. Office space for the pathologist and a secretary should be located within the laboratory wing so that he will be 44

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in close touch with his staff for supervision and consultation. It is desirable in teaching hospitals and research laboratories to provide office facilities for department heads. It is not possible to establish any hard and fast rule for determining the space requirements for various size hospitals; each must be considered an individual problem. However, it is well to keep in mind that adequate working area is very important in attracting and retaining desirable personnel, and in maintaining a high quality of work. Although suggestions have been made, as a rule of thumb, of one square foot per each 25 to 30 yearly tests, certainly the square foot per bed ratio is not a valid approach because of so many variables. UNITS Maximum flexibility is desirable, and may be achieved by multiples of a modular arrangement, such as 10 by 20 foot areas and use of movable partitions. The Public Health service suggestions for a typical installation include: HEMATOLOGY-BLOOD BANK UNIT For the Hematology-blood Bank unit, a standard module is assigned. One half of its module is provided with a workbench for procedures such as hemoglobin tests, sedimentation rates, staining, and washing of pipettes. Knee space and storage cabinets are provided below the counter. In the other half of the module, a workbench is provided for technologists who are seated during tests. The micro-haematocrit centrifuge, because of its noise and vibration when in use, is placed in the general technical area along the interior wall directly opposite the hematology unit. The other equipment needed by this work unit, such as a refrigerator, centrifuge, and recording desk, is located conveniently opposite the unit, where it is shared with the urinalysis and the chemistry units If it is assumed that the laboratory will obtain blood for transfusions from other sources, needs are facilities for blood storage. a blood bank refrigerator is provided for this purpose in the examination and test room. A hospital which operates a self-contained blood bank should provide a separate bleeding room, processing laboratory, donor's recovery room, and an office available for preliminary physical examinations. URINALYSIS UNIT:The urinalysis unit is assigned one half of a standard module, with a workbench serving as the work area for the microscopic and chemical examinations. Five linear feet of the workbench and a knee-space are provided. The reminder of the workbench is used for the chemical examinations. A sink located at one end of HOSPITAL SUPPORTIVE SERVICES

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the workbench provides a continuous working surface for the technologists. BIOCHEMISTRY UNIT:The biochemistry unit requires an area that occupies one and a half standard laboratory modules. The half module is shared with the urinalysis unit and is used for the necessary preliminary procedures that are done prior to the actual chemical analysis. The adjoining module provides workbench area where a variety of chemical procedures may be performed and includes a fume hood for removal of vapors and gases. The reagent shelves are used to hold the chemicals needed during the procedures. Two utility sinks are provided, one in each chemistry work area. Apparatus used in this unit is cleaned by the personnel in unit; test tubes, pipettes, and flasks are sent to the central glass-washing area nearby. An instrument table 36 inches high is located along the interior wall opposite this unit where chemical apparatus, such a colorimeter, flame photometer, spectrophotometer, and carbon dioxide gas apparatus are placed. Adjacent to the instrument table is an analytical balance on a vibration free table or other type of support. A centrifuge, refrigerator, and desk are provided along the interior wall. The desk and refrigerator are shared with the urinalysis and the hematology units. HISTOLOGY UNIT The histology unit is assigned a standard module, separated from other units by a partition to prevent odors from spreading to other areas. It is located neat the pathologist's office since the medical technologist here works under his direction and supervision. An area is utilized by the pathologist to examine surgical and autopsy specimens and to select the tissues for slide sections to be prepared by the technologist. An exhaust hood is provided over this section. The remainder of the module is used for the processing and staining of tissues. Wall hung cabinets are provided for additional storage. A utility sink is provided at the end of the workbench. SEROLOGY-BACTERIOLOGY UNIT: The serology and bacteriology work is combined in one standard laboratory module, where a half module is assigned to each unit. Culture media for use in bacteriology are prepared in the bacteriology work area and sent to the sterilizing unit for sterilization. Parasitology may be performed in either the bacteriology or the urinalysis unit. A utility sink is provided for the personnel in both units, but the bacteriology unit also requires a sink for the staining of slides. A fume hood is provided to prevent the spread of possible infection to personnel when preparing specimens. The stool culture also may be prepared 46

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here to reduce the spread of odors to other work areas. A centrifuge, refrigerator, and incubator are provided along the interior wall within the unit. A desk is also conveniently located for the use of the personnel. This module is partitioned and separated from the other units by a door to reduce contamination of air and the hazard of infection to personnel in the other laboratory areas. ADMINISTRATIVE AREA: The administrative area is separated from the technical work areas so that the non-laboratory personnel need not enter the technical area. This is the central control and collection point for receiving specimens and is the reception area for the patients and the hospital staff who come to the laboratory. Waiting Room: A waiting area, with conventional waiting room furnishings, is provided for the ambulatory patients. In this area, a desk is provided for the clerk-typist. An intercommunication system between the technical areas for the laboratory and the clerk-typist is recommended. The pathologist's secretary sent to the laboratory. Venepuncture Cubicle: A venepuncture cubicle is provided where blood specimens are taken from the ambulant patients sent to the laboratory. Specimen Toilet : A specimen toilet is provided in this area for the collection of urine and stool specimens. Basal Metabolism Electrocardiography Room: A room is also located here for basal metabolism test and electrocardiograms, and when necessary, to obtain blood from donors. A desk is provided and a lavatory. Pathologist's Office: The pathologist's office is located so that he may have easy access to the technical areas of the laboratory, particularly the histology unit. This office is separated by a glass partition which permits the pathologist to observe the technical work areas. A draw curtain may be used when he desires privacy. those who wish to consult the pathologist have access to his office through an entrance from the administrative area. A table or working surface suitable for a microscope is provided so the pathologist may examine the tissue slides undisturbed. AUXILIARY SERVICE AREAS: The auxiliary service units are located adjacent to the administrative area and are easily accessible to the technical areas. Glass-washing and Sterilizing Unit: The glass-washing and sterilizing unit is close to the serology-bacteriology and the biochemistry units which will utilize such services more often than the other units. A separate doors leads directly into the serology-bacteriology unit so that contaminated glassware need not be transported through other work areas. Within this unit are located a water still, pressure sterilizer, sterilizing oven, and pipette, washer. Storage cabinets are also provided for stock items of glassware, HOSPITAL SUPPORTIVE SERVICES

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chemicals, and reagents. A hood over the sterilizers and water still is used to exhaust the heat generated by the equipment. Utility carts used to transport dirty glassware from the various laboratory units to this area are parked in this unit. Locker and toilet facilities for personnel are necessary. Some units use animals for conducting their tests and a smaller unit for housing animals, with facilities for operations and cage sterilizing should be convenient to them. Animal quarters for breeding purposes and exercise, when required, should be in a separate building constructed for this purpose. The morgue, necropsy and specimen museum facilities are operated by laboratory personnel and usually located in the basement, away from the traffic of patients and visitors. They should be convenient to the elevator, with an isolated exit to the service yard, if possible for the use of undertakers. Optional facilities, e.g., clinical photography, medical illustration, and research, will require additional space if they are to be incorporated into the program of the department. EQUIPMENT: Equipment requirements are based on the methods used, the types of examinations performed, the volume of work and the number of personnel employed. The pathologist should be responsible for requisitions are prepared. Modern scientific instruments are vital to the laboratory. Accurate, dependable laboratory reports cannot be made with poor equipment. Hospital administrators should familiarize themselves with laboratory equipment and its use so that they can appreciate the need for adequate equipment to provide good quality laboratory service. Good equipment soon pays for itself. This is particularly important in the light of increasing automation. Regular and periodic checking and calibration of laboratory instruments and equipment is a necessity. LIGHTING: Natural lighting should be used to the fullest extent. North light is preferable because of its uniformity, without direct sun. Microscopic work is particularly difficult where glare is present. Fixed equipment such as wall cabinets, refrigerators and centrifuges can be placed away from windows, and artificial light can be used if necessary to supplement the natural light. Portable lights with extension cords on the floor areas should be avoided. They are accident hazards. FINISHES: Finish materials for the laboratory areas should be selected on the basis of the type of work done in each area and the kind of wear that may be expected. The 48

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floors to the laboratory should be resilient, smooth and strain resistant. Greaseproof asphalt tile, rubber tile or linoleum could be used. The floor of the glass-washing and sterilizing room should be easy to clean, non-slip and resistant to heavy traffic. The wall should be coated with waterproof paint. They should be glazed or have similar finish to a point above the splash or spray line, and should be without cracks which may harbor roaches and ants. LABORATORY FURNITURE: Because of their flexibility to meet changing needs, the use of standard manufactured units is recommended for workbench installations. However, it is important to know exactly what tests will be done in a particular area in the laboratory so that the proper unit will be used. Where sedentary work is to be performed, ample leg room must be allowed. The usual height of workbenches used in sedentary work is 30 to 31 inches; for standing work, 36 to 37 inches. Wall units are 30 inches wide and center units are 54 inches wide. The minimum space between work benches or fixed equipment should be 3 feet 6 inches; the maximum to eliminate needless walking should be 5 feet. Small cup sinks and staining sinks might be built into the units at convenient points to avoid the necessity of using the large laboratory sink. Counter tops may be made of soapstone, wood (birch which has been acid - proofed), stainless steel, transit or heavy battleship linoleum. Wood is quite satisfactory for general use. In areas for glass washing and sterilizing, soapstone or a similar type of material is recommended because of the large amount of water and heat present. MECHANICAL AND ELECTRICAL: The provision of utilities (waste, cold water, hot water, gas, vacuum, compressed air, distilled water and electricity ) to the laboratory is a complex problem in designing the laboratory. The piping and wiring should be easily accessible so that time and cost may be saved in making repairs or changes to any existing arrangement. Placing the vertical utility lines along wise the structural columns which are located 16 to 20 feet apart in the exterior wall, seems to be the most direct and economical solution to the problem. This eliminates exposed piping at the ceilings and the cost of a dropped ceiling if the pipes are to be hidden. The vertical risers are available for connection to horizontal runs yet concealed behind removable metal panels at the piers. Dividing the vertical laboratory utilities into three groups and alternating them in consecutive piers will reduce the width of the piers. Acid-resistant piping is used for waste line. Laboratory sinks of soapstone or corrosive resistant materials manufactured for this specific use are preferred. Air conditioning is desirable for the laboratory because it obviates the necessity for opening HOSPITAL SUPPORTIVE SERVICES

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windows. This is especially true in a bacteriology department where air-borne bacteria are a source of contamination. For the same reason the sterile room or cubicle should be provided with mechanical ventilation. Similar provisions are helpful in the culture media, sterilizing and glass-washing rooms where odors and heat from the autoclaves and ovens are likely to make working very unpleasant in hot weather. The electrical requirements should be studied carefully in order that an adequate supply is furnished to the laboratory. A sufficient number of outlets in the work area are often overlooked. The planning and design of the laboratory in the hospital has been neglected to such an extent that many hospitals today are facing over crowed working conditions and a poorly functioning laboratory service. The increasing demand for the coordinated hospitals systems with emphasis on more adequate diagnostic service should be an incentive for a more careful consideration of the function and requirement of this rapidly growing service in the hospital. MORGUE: Every hospital should have a morgue. The location of facilities in the hospital should be such as to prevent unnecessary contact with the public. Hospitals under 50 beds may not require a morgue and facility for doing necropsies, if other facilities are available. The morgue should provide space for a mortuary refrigerator with a capacity for two bodies for a hospital of 50 to 100 beds and at least three-body capacity for a 200 bed hospital. Teaching and research hospitals will require larger capacity refrigerators according to their need. Small hospitals may include the mortuary refrigerator in the same room provided for the necropsy. It is better in hospitals of 100 beds and over to provide separate facilities for the morgue and necropsy. In addition provisions should be made for showers and toilets for personnel. The problem of storage facilities for gross specimens is a serious one for pathological departments in hospitals. These may well be provided adjacent to the room for necropsy or pathology lecture rooms. Space for a portable observation stand is needed. Exhaust ventilation is necessary in morgue area. Minimum ventilation of 10 room- volumes of air per hour, with no recirculation should be provided, with a negative air pressure. The floor and walls should be constructed of such material as may be easily cleaned. The walls should be titled to a height of five feet six inches. A floor drain should be provided so that a hose may be used for performing the necropsy. This should be carefully selected in consultation with the pathologist. Particular attention should be given to back-siphon all water connections to the necropsy table.

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CHAPTER - 11

RADIOLOGY DEPARTMENT The practice of modern medicine and surgery has increased the use of such specialized services as radiology, which has assumed a more and more important role as a diagnostic and therapeutic arm of the hospital. Functions of the radiology department are to assist in diagnosis and therapy through the use of radiography, fluoroscopy, and radioisotopes; and high voltage acceleration. Radiography and fluoroscopy constitute almost 90 per cent of the workload in the average hospital. The department also has a responsibility to engage in research essential to medical advancement, and to participate in educational programs for interns, residents, radiologists, technologists, and others. In relation to the total program of the hospital and the community, for example, one notes that in 1949, twenty per cent of all hospitals reported having an admission chest x-ray. This number has increased to almost 50 per cent today, and has served as a perpetual case finding mechanism, for protection of hospital personnel and the community. With present protective measures against overexposure to radiation, it is believed that the hazard is less dangerous than undetected tuberculosis. THE RADIOLOGIST: The department should be under the direction of a competent radiologist who is a graduate of a recognized school of medicine, licensed to practice in the State, and appointed as a regular member of the hospital medical staff. Further, he should have had special training in his specialty. In a small or rural hospital where competent full-time radiologist's services are not available, if a qualified individual is available within reasonable distance, he could be appointed with the understanding that he visits the hospital at least weekly, to go over the case histories with the physician in charge at specified intervals, and not simple review films received by mail. However, therapy, other than when under direct supervision of a full-time radiologist is usually discouraged. POLICIES: The following principles and policy guides should be given careful consideration: HOSPITAL SUPPORTIVE SERVICES

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1) Radiology services are to be available for inpatients and outpatients on an hourly and daily basis as required for good patient care. 2) The radiologist will have definite hours of attendance in the department, ample to permit examinations, interpretation, treatment, and medical consultations, as needed. 3) The radiologist will be solely responsible for all examination and treatment, including all x-ray interpretations and consultations. 4) Hospital requires that there be at least one registered Technician. One should be on call at all times. Under no circumstances should they attempt interpretations and diagnosis. 5) The radiologist will consult with the medical staff, of which he shall be a member, attend staff meetings, and observe rules and regulations applicable to staff members. 6) All records are to be signed by the radiologist. 7) Films and reports of examinations and treatments shall be made available to the referring physician. 8) Films are the property of the hospital. 9) Films and reports technically constitute a part of the medical record of the patient, and shall be subject to the same rules and regulations. The patient's record must contain data covering fluoroscopic examinations specifying date, site, roentgens per minute, exposure time, and operator (All fluoroscopes should have timers). 10) All films should be preserved for the period covered by statutes of limitation and not less than five to seven years for subsequent reference for clinical and medico-legal purposes. Those suitable for a film library and of value for research should be preserved indefinitely. Surplus old film may be sold for salvage. 11) All films must be legibly and permanently marked by appropriate methods. 12) There shall be established procedures necessary for the safe and proper use of all equipment and for handling of radioactive isotopes and or radium and its application and removal. 13) There shall be every provision for proper aseptic technique in the handling of patients and disposal of infectious material. 14) X-ray equipment, when permitted in the operating room, shall be provided with approved methods of eliminating electrostatic accumulation. All control devices and switches shall conform to requirements of the National Fire Protective Association. 15) Pre-employment and a complete yearly physical examination shall be made 52

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on all department personnel, with blood counts at six month intervals for those routine exposed to radiation. Reports of such examinations are to become a part of the permanent personnel record. 16) Accurate records, including a registry and diagnostic index shall be maintained, and appropriate clinical and administrative reports made as indicated. 17) The Atomic Energy Commission has jurisdiction over the use of radioisotopes, and its standards and regulations shall be adhered to. PHYSICAL FACILITIES: Due to the highly specialized nature of radiology services, equipment, and facilities, the radiologist must be called upon in the very earliest stages of planning for a new hospital or in remodeling or reorganizing an existing one. The program and anticipated use of the facilities will largely govern the size of the department, its staff, location, equipment and space. They must be planned in relation to other services of the hospital. Not only must inpatient requirements be taken into consideration, but also emergency and other outpatients, clinics , employee and students health programs, health department activities, surveys, referrals from private physicians, facilities in and relationships with other hospitals. A carefully planned department assures an efficient flow of service that may be scheduled promptly and expedited with a minimum of movement and distance for staff and patients. Allowance must be made, in every size institution, for future expansion. It has been said that space requirements have tended to almost double every eight to ten years over the past three decades. This means flexibility in the initial design. Remodeling is always more expensive than for most other hospital areas. It is preferable that the department be located on the first floor, as conveniently as possible for inpatients and for emergency and other outpatients. This is often difficult since it is desirable to eliminate through traffic and future expansion may be hampered. Full use of outside walls will reduce the expense of lead lining. The area required will vary from a minimum of 400 square feet for the smallest of hospitals, to 1,500 or more for the 50 bed institution and 2,000 or more for 100 beds. For larger institutions, and, indeed, for any size, needed space can be determined only in the light of the number and type of examinations, treatments and other facets of the program of the department. In addition to the waiting room, an office for the radiologist and a viewing room will be required although in the small institution those latter two can be combined. Larger hospitals, particularly teaching ones, will require considerably more space, dependent upon the workload. Filing of films always becomes a problem HOSPITAL SUPPORTIVE SERVICES

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sooner or later. Sectional units are available, each holding 650 films and are very practicable for temporary storage. Fire hazards have been greatly reduced since cellulose acetate films have replaced cellulose nitrate ones. Dressing booths, usually in units of two, are desirable. The radiographic room, with a door 3' 10'' leading from the corridor, should be of sufficient size to allow free adjustment of the apparatus and placing patients from wheel chair or stretcher. A minimum of 11 1/2 by 18 feet is desirable. Except in special instances, as in tuberculosis hospitals, fluoroscopy is done in this room; hence light -proof shades are required. A sink and toilet in the immediate vicinity are necessary. The dark room, improperly designed and operated, probably spoils more film than any other activity or situation. Film transfer cabinets between the radiographic and dark room are highly desirable. The area required varies from 38 to 100 or more square feet, determined by work loads and production peaks. A light-tight entrance is required, accomplished by a lock door, double or revolving door, or maze. There are advantages to each. Equipments and its arrangements can usually best be determined for a specific situation by the radiologist and the manufacturing engineer. Proper ventilation of the dark room is necessary not only for health and comfort of the operator but for best results with films. A dry bulb temperatureof 72 degrees F, and a humidity range of 50 per cent is the average zone of comfort and safety, with air movement of 10 feet per second. The room must have both white and safe light illumination. The wall finish should furnish the maximum safe light reflection; hence, while the ceiling may be white, the walls should be of warm ivory, cram, buff or pale shades of other colors. All wiring for the department should receive particular attention so as to conform to local codes and to the regulations of the Fire Service Department. If possible the power supply should be separate from other circuits to avoid voltage variations. Special storage facilities are required, including that for patient excretions. Disposal of radioactive material, particularly those of long half-life, creates difficult problems.

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CHAPTER - 12

BLOOD BANK Blood bank is a department that deals with collection, testing, processing, storage, preservation of blood and safe transfusion to the patients as requisitioned by the physicians. Functions of Blood Transfusion Services 1. Maintaining and recruiting records of voluntary donors, along with details of their blood groups, record of previous donations, and their contact numbers. 2. Collection, testing, safe storage and preservation of blood. 3. Separation, storage and preservation of blood components 4. Issue of blood/components after cross matching. 5. Counseling and motivation of donors. 6. Educating and advising the clinicians and nurses about the transfusion procedures. 7. Research activities. 8. Maintaining records of the blood units collected and issued. 9. Audit and submit periodic (monthly/yearly) reports to authorities. 10. Blood issue after cross check. The aim of blood bank is to supply good quality of blood to the patients and avoid any risk to the donors as well as recipients .Because of this reason strict quality control indicators are essential. QUALITY OF PROCESS 1. A documented policy and procedure for blood and blood products/components. 2. The staff of blood bank should be fully informed and educated about the policy/procedure. 3. Protocol for each and every activity held in department. 4. “Informed consent”. 5. Educate of patient and his/her family about the blood donation. 6. Strict aseptic conditions 7. Bio medical waste management. 8. Audit and periodic repot submission. HOSPITAL SUPPORTIVE SERVICES

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9. Ensure the quality procedure is followed. 10. SOP's of all system. . SUMMING -UP The uniqueness of blood is a therapeutic agent. It can cause serious damage, even death, if the quality of services and their reliability is compromised. It is therefore importance to ensure that there is no compromise on quality in any aspect and the blood supplied for transfusion is safe from all the hazards so that it can fulfill its intended purpose restoring life to the patient.

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CHAPTER 13

DENTAL SERVICES

Every hospital should offer at least the minimum in dental services, especially to care for emergencies. Whenever possible, the installation of a complete dental service should receive serious consideration. Without dental services in hospitals, the patient cannot receive a complete diagnostic analysis of his condition. Total treatment cannot be accomplished and potential causes of disability remain to permit future discomfort, illness, chronic diseases and immeasurable economic loss. Oral surgery for repair of injuries and for eradication of infections of dental origin requires the services of a competent dental staff. All hospitals may not need extensive facilities and equipment for complete dental services. If competent consultation is available in every hospital, much of the actual treatment, including surgical procedures, may be economically furnished elsewhere. This can be done through an efficient integration and coordination of hospital activities, through health clinics, by group or private practitioners. Such methods must be determined and applied in the light of local needs and policies by combined efforts of leaders in the medical, dental and hospital fields. DENTAL SERVICE OR DEPARTMENT: According to the procedure established for the appointment of the medical staff, one or more dentists may be appointed to the dental staff. Where more than a few dentists are so appointed a dental service may be organized. The organization of the Department of Dentistry shall be comparable to that of other services or departments. Whether or not the dental service is organized as a department, the following requirement shall be met: a)

Member of the dental staff must be qualified legally, professionally, ethically for the positions to which they are appointed.


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b)

Patients admitted for dental services may be admitted by the dentist either to the Department of Dentistry or if there is no department, to an organized clinical service.

c)

There must be a physician in attendance who is responsible for the medical care of the patient throughout the hospital stay. A medical survey shall be done and recorded by a member of the medical staff before dental surgery is performed.

BASIC STANDARDS OF HOSPITAL DENTAL SERVICE: The purpose of the "Basic Standard" is to provide hospital administrators, chiefs of dental service and dentists interested in the organization and conduct of dental service in hospitals with standards that have been approved by the Dental council of India for such a program. INTRODUCTION: The dental profession knows that the health care it renders is an essential part of a total health service. It has long recognized, as well, that its services must be well integrated with those of the other health professions in order to provide this total health service for the individual patient. The modern hospital, marshalling as it does many professions, services and facilities, provides a great challenge and opportunity for inter-professional cooperation in the service of the individual patient. FUNCTIONS: A dental service of a hospital should be operated on the basis of four main functions: Administrative: To conduct the affairs of the dental service in accordance with the established administrative procedures of the hospital. Consultative: To act, through customary channels, in an advisory capacity on all problems related to the dental health of the patient. Included in consultations required under these standards are those required under the rules of the hospital staff. In all cases where the patient is not a good risk and in all cases in which diagnosis is obscure, or when there is doubt as to the best therapeutic measures to be utilized , consultation is appropriate. The consultation note, except in emergencies, shall be recorded prior to definitive treatment.

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Clinical : To render professional services to patients in accordance with the concept of modern scientific dentistry and to evaluate these services periodically. Educational: To provide training for junior staff members in clinical diagnosis, consultations, restorative and surgical procedures and operating room decorum in all hospitals, to participate actively in the educational program of the hospital; to orient the medical and dental staff in the problems of oral health as it relates to the total health care of the patient; to engage, when facilities permit , in the teaching of graduate and postgraduate students who are preparing themselves for the practice of one of the specialties; and to provide an educational program for dental interns, dental residents, dental hygienists, dental assistants and both student and graduate nurses. ORGANIZATION AND OPERATION: In teaching hospitals and in larger hospitals, the functional division of the medical and dental staff into more than minimal departments or services is frequently desirable. In these instances, the organization of the department of dentistry or dental department should be comparable to that of other departments of the hospital. The dental department should be organized into sections to confirm to the areas of the recognized dental specialties consistent with available facilities and the needs of the community. The section on oral surgery should be administered as a section of the department of dentistry coequal with the other specialties of surgery with full consultative and advisory relations with the department of surgery. In smaller hospitals, and in those hospitals where the principal activity of the dental department is oral surgery, this service may be organized as a section of the surgery department coequal with the order surgical specialties. Chief of Dental Service: The chief of the dental service should be responsible for the dental service. He should be selected for his professional and executive ability. He should be designated by a little comparable to that of the chiefs of other services. He should have the same privileges regarding appointment to the medical board or executive committee as to chiefs of other services.


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Staff conferences and Meetings: The members of the dental service should attend and participate in general staff conference. They should also hold regular departmental meetings for the thorough and analysis of their clinical activities. Appointments and Promotions: All appointments to the dental staff shall be made by the governing body upon recommendation of the executive committee and credentials committee which should have a dental member. The terms and procedures of the appointment as established for the medical staff shall apply to the dental staff. The number of appointment and grades in rank available to the dental service will vary with the size and type of the individual hospital. The classification of appointments according to rank should be made in accordance with the standard nomenclature and the custom of other services in the hospital. Promotion in rank should be made on a basis consistent with that established for the other services in the hospital. Admission and discharge of Hospital Dental Patients: Dentists shall have the privilege of admitting and discharging patients for dental treatment. Medical survey of Dental Patients : An adequate medical survey by a member of the medical staff shall be required on each patient before oral surgery. Indicated consultations with the medical staff shall be required in complicated cases. Oral Examination of Dental Patients: Dental patients should have a complete oral examination by member of the dental staff as soon after admission as conditions permit. Dental outpatients should be afforded the same service when possible. Availability of Hospitals Beds: Hospital beds should be available to the dental service in the same manner that they are available to other services of the hospitals. Records: Careful records of all histories, diagnoses, therapeutic and operative procedures should be kept on the charts in accordance with the standard procedure of the hospital. Special clinical records may be useful as an aid in clinical research.

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Relation to School of Nursing: If the hospital maintains a school of nursing, it is desirable for members of the dental service to participate in the training of student nurses in the fundamental principles and practical knowledge of dental health. Rules: The dental service should establish rules for the conduct of its program comparable to the rules established by other service and not inconsistent with the rules of the hospital. Research : Research and investigation should be encouraged, and the hospital should make every effort to provide time for the investigation and such materials and assistance as may be needed. Library: An adequate selection of dental books and periodicals should be available in the hospital library. Physical Equipment: The space allotted to, the equipment, instruments and supplies of, the dental service should be adequate to carry out all services in accordance with generally accepted standards of practice. DENTAL SERVICES FOR HOSPITAL PATIENTS The extent of dental care provided for the hospital patients will vary with the size of the hospital, the type of hospital and the type of service rendered by the hospital. For example, in hospitals for crippled children or for those suffering from tuberculosis and mental diseases, more comprehensive dental service is necessary. The recommended program for hospitalized patients, and for outpatients when facilities permit, will include an oral examination based on a complete series of dental roentgenograms. Vitality tests, transilluminations, bacteriologic, pathologic and other types of laboratory test should be used where indicated. More specifically, the dental service should develop programs in the following areas in accordance with local needs and facilities:


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Dentistry for Children ( paedodontics ): In hospitals where children are hospitalized for an extended period of time, as the hospital for crippled children and for those suffering from chronic diseases, a paedodontic service is highly desirable. Consultation and treatment in orthodontics, should be available to all such hospital patients. Dental Imaging: In all hospitals there should be good facilities for dental imaging. In hospital where dental x rays are taken by another service, the dental service should be available for reading and interpretation of the films. Dental x rays should be made by persons specially trained in the technique under the supervision of the dental service. Technicians should be given complete instruction in safety precautions. Oral Hygiene: In all hospitals there should be an oral hygiene program whereby practical measures of mouth cleanliness should be an item of routine nursing. The volunteer and nurses aid programs in hospital appear to be a ready source or personnel to bring to the patient an effective program of oral hygiene. Oral Pathology: In hospitals where it is feasible, an oral pathologist should be available to the dental service because of the specialized nature of the tissues of the oral cavity. Oral surgery: In all hospitals there should be adequate facilities for the provision of oral surgical diagnosis and treatment. The scope of the specialty of oral surgery shall include the diagnosis, surgical and adjunctive treatment of the diseases, injuries and defect of the human jaws and associated structures within the limits of the personnel qualifications and training of the individual practitioner and within the limits of agreements made at the local level by the health team concerned with the total health care patient. An adequate medical survey, including physical examination, blood count, etc. shall be made for each patient before oral surgery and the indicate consultations shall be held in complicated cases. Periodontics: In all hospitals, it is desirable that patients have consultation and therapy available from a dentist qualified in the field of periodontics. Restorative Dentistry: In certain hospitals, such as those for patients suffering from tuberculosis and mental diseases, a restorative dental service is highly desirable. 62

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AMENDMENT OF EXISTING RULES: In order to comply with these standards it may be necessary to amend the rules of the hospital in order to include the words 'dentist' and 'dental service' in appropriate sections and to include such additional provisions as are necessary to permit proper functioning of the dental service. When necessary, the rules of the medical board should also be amended to obtain the same objective and to facilitate inter-professional cooperation. It is recognized that an ideal program would include a complete oral examination including a complete dental radiologic interpretation as a routine for hospitalized patients. Outpatients should be afforded the same service where facilities permit. However, with the present limitations of personnel and general development of dental departments, it appears necessary to postpone such a requirement as a minimum standard. Dental consultation should be made available by the department of dentistry of the several other departments in the hospital.


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SUPPORTIVE SERVICES

CHAPTER - 1

ADMINISTRATIVE DEPARTMENTS a. b. c. d.

Reception/Front Office & billing department Purchase & Store Department Accounts Department HR Department

Every hospital has a business side as well as a clinical side. The hospital's administrative department has responsibility to the community, to patients, and to the organization to keep an effective control over the hospital's financial picture and related matters. The ideal admin office is one that can temper the role of these factors with proper regard to good patient care. Some of the functions and responsibilities usually assigned to this office include: 1. Maintenance of an adequate accounting system for all income, expenditures and assets 2. Development, coordination and control of the budget 3. Credit and collection procedures 4. Banking procedures. Development of purchase procedures and stores control; in some hospitals, particularly large ones, purchases may be in a separate department in which event the admin office audits the inventory. 1. Maintenance of internal controls 2. Compilation of pertinent patient and departmental statistics in conjunction with the medical records office 3. Preparation of financial reports, an invaluable tool of the administrator and the board in the control of finances, switchboard and information services. Whether the hospital is large or small these functions must be performed. In the larger hospital the responsibility for carrying them out may be divided among many persons; in small hospitals a comparatively small group may share them. In any case, however, there must be direction, supervision and responsibility for coordinating all activities of the admin office to insure a competent organization capable of producing results in the most efficient manner. 64

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The admin office is the focal point for a number of interrelated functions, which can best be performed when grouped under a single head. Care in selecting a person qualified to assume responsibility over the telephone service, cashiers, bookkeepers and admin office, clerical staff will insure that these functions are property correlated. OFFICES The admin office, with its cashier's window opening into an alcove off the lobby, if possible, will be the central point of all clerical and business transactions, and a common complaint is that building design allows insufficient space. Business machines take an increasing amount of space and require initial planning if one is to avert units being scattered throughout the institution. There is a need for acoustical ceiling, good lighting and multiple outlets for business machines. Adjacent small private offices will probably be needed for the purchasing agent, chief clerk, and credit manager, as well as a major office for the director of the admin office functions. ACCOUNTING Accounting is probably the most overworked term in the field of hospital administration. Far too much stress is placed upon the role of finances and record keeping without proper relationship to care of the patient. Too often is the successful hospital considered to be the one with detailed knowledge of its business operations and a balanced budget. Unfortunately, all too many hospital trustees and administrators hold this concept. At the same time, it is one of the most important facets of any hospital. Good accounting is the one tool that can provide the necessary statistical data and information on operational details, income and expenses that are absolutely essential if management is to discharge fully its responsibilities to administration. It is not enough to know that a certain department spent more than was received from its operation. The reason for the expenditure must be known in order to permit analysis upon which administrative action may be taken to control effectively inefficiency or inadequacy. Adequate records are necessary, too for correcting possible shortcomings in methods of purchasing, storage and distribution of supplies. They provide an effective administrative device for checking on utilization of supplies and equipment resulting from fraud or failures by employees faithfully to discharge the duties assigned to them. With hospital operating costs slightly ahead of rapidly increasing general living costs, with reduction in income from bequests and contributions and with the increase in prepayment insurance plans, including Mediclaim, the hospital today must adopt an HOSPITAL SUPPORTIVE SERVICES

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adequate accounting system if it is to survive. PURCHASE AND STORES CONTROL Effective purchasing and stores control can obviate one of the most common financial drains on hospital, as well as contribute to patient care and employee utilization by assuring economical but quality products and services. In establishing purchasing policies administrators should explore the possibilities of joint programs with other hospitals in the region. Substantial savings can be made, on Coordination. Policies within the hospital must cover unification or centralization of purchasing authority of the purchasing agent, selection of vendors, quantity and quality of items, cost factors, such as utility, consumption and maintenance. Centralization of Purchasing: In any hospital, purchasing may be completely or partly decentralized. The hospital policy may permit departments, such as dietary, X-ray, laboratory and laundry, to buy their own supplies. Whether this is good or bad may depend entirely on the integrity and ability of the department head, on the controls established and on the traditions of the hospital. Often the dietitian may do better purchasing of foods because of her greater knowledge of food values than the purchasing because of her lack of time or knowledge of procedure. Each hospital must decide for itself to what extent the purchasing functions should be decentralized. Authority of Purchasing Agent: The extent of the authority of the purchasing agent, or agents, must also be set by a policy. In some instances, approval must be obtained from the governing board before certain items are purchased. In other instances, the budget may set the limit of expenditures; while in others, approval may be required only for such expenditures as large equipment; or a rupee limit may be placed on the buyer. Selection of Vendor: Giving preference to local suppliers, restricting the number of vendors to reduce accounting activities, weighing previous experience with vendors in trying time, buying on bids, using technical and advisory services provided by suppliers, maintaining one's own testing services and adhering to rigid specifications may be factors which set the policy in selecting vendors. What the role of the detail men, the vendor's salesmen and supplier's representatives will be decided by this policy. Quantity Purchased: Undoubtedly, the policies regarding quantities purchased cannot be the same at all times even for standard stock items. The policy may change with the trend of the markets, the stability of the items, the amounts needed on hand at all times, the speed with which the item may become obsolete, the current usage and the effects of changes in technique on this usage. 66

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Cost Factors: It is a simple matter to obtain the price that will appear on the invoice if an item is purchased. But this price is, of course, not the true cost of the item. Policy must be set for the purchasing agent which will indicate what other factors will be considered in determining the cost figure to be used. This might include such factors as cost or value of: accounting procedures; storage charges; personnel time in receiving, handling and using items with determination of time wasted, saved or added; esthetic values; testing; maintenance and repair; patronage refunds; transportation, and availability of outside repair service. The true cost of the item may become much greater or less when the valuation is made of the stability of the demand for and use of the item, the speed with which it becomes obsolete, the time and effort needed to train and supervise employees in using the item. Hospitals should check consistently to see that deliveries meet purchase specifications, standards of measurement and the guides, which are generally available. Some of the factors, for which appropriate procedures for tests, analyses, and evaluation need to be developed include camouflage, chemical content, color fastness, construction, general content, design, flexibility, heat resistance, measurement, odor, performance, shrinkage, size, specific gravity, strength, tensile strength, thread count, visual characteristics, wearing quality, weight and general safety features as well. STORES CONTROL Immediate control over storerooms should rest with one or two persons who should have the responsibility for receipt and issuance of supplies. The individual in direct charge should maintain records of quantities and value of supplies on hand, of quantities and value of supplies issued during a given period and of minimum and maximum levels of supply items. Such records should be audited regularly by admin office accounting personnel which would enable the administrator to exercise control not only purchases but also over all supplies issued. By requiring monthly reports he will be able to check on the economical use of supplies by employees. In placing orders for supplies, the person responsible for approving purchase orders would be in position to order more intelligently from his analysis of the inventory and stock-record control reports. A properly prepared stock-record card should contain the past and present prices so that in recording, the purchasing agent may analyze these fluctuations and regulate his purchases to coincide with favorable market conditions as to availability, price and quality. A system of stores control should provide for the following: 1. Quantities and value of all supplies should be set up on the records to HOSPITAL SUPPORTIVE SERVICES

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establish the initial inventories. 2. As additional items are received, their quantities and costs should be recorded. 3. Departments requiring supplies should order them by requisition from the storeroom. 4. As the storeroom receives requisitions, they should be promptly filled and delivered to the department requisitioning them. 5. Supplies issued on requisition should be recorded on stock-record control cards and the balance on hand shown in the column provided. 6. When requisitioned items are not on hand, the requisition should be returned to the department requesting them, showing that they are either on order or were never stocked and can only be ordered upon issuance and approval of a purchase requisition. 7. When the purchase order has been filled, the storeroom clerk should verify the receipt of the supplies and after checking the invoice for quantities, grade, price and extensions, should send it to the business or accounting office with a receiving report or a copy of the purchase order on which is entered the date of receipt and the approval of the storeroom clerk for payment. 8. A specific day should be set aside for the stockroom weekly requisition to reach the storeroom clerk. 9. Emergencies should be recognized and requisitions filled as they are received. 10. Employee must be educated as to the proper use of supplies to avoid waste or misuse. 11. Supplies received and issued must be carefully checked. A. Designate qualified person who will act as purchasing agent. B. Designate capable person who will act as storekeeper (receiving and issuing clerk) C. Establish centralized control over all purchases and issues. D. All requisitions for purchases shall be cleared through the office of the purchasing agent and purchase orders are issued only by the purchasing agent or other duly authorized individual. E. Install an adequate system of records. Suggested as essential 1) Purchase order. 2) Stores requisition. 3) Perpetual inventory system. 4) Suggested as desirable 68

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5) Purchase record. 6) Purchase requisition. 7) Quotation request. 8) Delivery receipt. 9) Record of goods received. 10) Return order record. 11) Overage, shortage and damage report. (F) Maintain an index of source of supply of items by categories. (G) Maintain a complete up-to-date catalog file. (H) Establish stores control system. 1) Personnel authorized to originate requisitions. 2) Approval of requisitions. 3) Issue periods. 4) Pricing of requisitions for departmental accounting systems. 5) Establish definite system for the platform receipt of merchandise and its inspection and storage. 6) Determine disposition of vendor's packing slips and bills of lading. 7) Study possibilities of joint purchasing with other hospitals. 8) Determine in conference with the administration the frequency of physical inventories. 9) Establish policy regarding sales of hospital supplies to physicians, employees and the public. 10) As much as possible develop standard specifications for equipment and supplies throughout the hospital using recommended simplified practices. 11) Check goods received against specifications or samples submitted. 12) Purchasing agent confers at frequent intervals with other department heads as to new equipment supplies, possible economies. 13) Purchasing department does not make major substitutions without consulting the department concerned. 14) All stores are centralized, with the possible exception of pharmaceuticals, food and engineer supplies. 15) All bank forms; records and other stationery are indexed and assigned a form number. 16) Stock is checked frequently to prevent obsolescence, deterioration and excess quantities. Old stock is moved first. 17) All long term purchase contracts are carefully investigated beforehand (with reference to changing needs and market trends ). HOSPITAL SUPPORTIVE SERVICES

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18) Arrange timing of deliveries of gas cylinders to reduce demurrage charges. 19)Check with state board of health, Red Cross, etc., to obtain any free supplies available. 20) Consider contract purchase of such items as the following. (1) Fuel. (10) Elevator maintenance. (2) Ice. (11) Machinery maintenance. (3) Milk. (12) Electric power, gas and water. (4) Eggs. (13) Anesthetic and therapeutic gases. (5) Ice cream. (14) Laundry service. (6) Telephone service (include switchboard) (15)Dietary services. (7) Surgical soap. (16) Housekeeping. (8) Commercial oxygen. (17) Grounds maintenance. (9) Parenteral fluids. (18) Business machines. 21. Remote warehouses are frequently checked as to storage conditions and are properly guarded. 22. All goods are stored in original, unbroken cases whenever feasible. 23. Policies with respect to purchases from local versus outside sources should be considered on a basis of transport cost, unit price, delivery lag, maintenance of optimum inventory and public relations. 24. Consider the appointment of advisory committees on purchasing (medical staff and nursing ) to meet with administrator and purchasing agent. 25. Study investment in inventory and keep it as low as possible by rapid turnover of supplies. Study possibilities of yearly contracts with regular monthly deliveries of such items as surgical gauze and dressings. The increased use of disposable items, still under continuing study in relation to efficiency and cost, is causing major shifts in purchasing and stores practices. The desirable perpetual inventory system is also undergoing rapid changes in the light of computer uses. FRONT OFFICE Admission procedures might well be the first chapter in any book on hospital management since activities in this area constitute perhaps the most important bridges between the public management and clinical services to the individual patient. Personnel responsible find themselves in one of the most difficult positions in the hospital in discharging duties involving public relations, business procedures and clinical matters. Of these three, the first - public relations - is most apt to receive the least attention; yet from the point of total community support, it is probably the most important. Patients and 70

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accompanying relatives are usually in varying degrees of emotional tension, and to them all hospital procedures are personal, never routine. Sympathetic, friendly reception and understanding tend to soothe these emotions, create an appreciation of the hospital which readily permeates the entire community and eases the transition into clinical care in a manner which hastens the patient's recovery. Patients, relatives and the community usually form rather permanent impressions of the entire hospital from their initial, though limited, contact with a departmental activity, which in a majority of instances is the admitting office. PERSONNEL In the larger hospitals, admitting functions may be specialized, in a separate department, with full-time personnel trained for specific duties. Smaller hospitals rarely find it possible to delegate all the details to a single individual, but divide them among the administrator, a clerk, the nurse or others. In this event it becomes even more important that procedures and responsibilities be set down in writing, so that sound, consistent techniques can be followed on a twenty-four hour basis. Any interviewer of patients at the time of admission should evoke confidence and understanding. Patient and relatives must be made to feel that personal problems will not be made public property. Such ability is a personal trait not necessarily related to age, although one would expect to find this quality more often in the mature employee. On the other hand, in going into the financial status of the patient, it has been suggested that the more mature employee is apt to be overly sympathetic in making allowances for ability of the patient to pay. The admitting officer is directly responsible to the administrator and should be a person who evokes confidence and understanding, but should not be unrealistic in making allowances for the ability of the patient to pay. Some policies involved in admitting include: Coverage, 24 hours a day, seven days a week Non-delay of any emergency patient to secure information Establishment of rotating system of staff doctors for the care of patients having no physician Having the patient who is refused admission for any reason examined by a physician and have reasons for non-admission explained by the physician and the administrator. Adoption of the use of pre-admission form Arrange for the supply of doctors' offices. Obtaining signature, on appropriate form, of any patient who insists on leaving HOSPITAL SUPPORTIVE SERVICES

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against his doctor's advice. Explanation of system of billing Deposit of patient's valuables in safe Maintenance of proper records One of the questions frequently discussed is the responsibility for refusal to admit a patient. This may be for reasons such as type of patient (communicable disease, mental condition or other), but most often involves legal and financial status. The governing board, with recommendations of the administrator and medical staff, must establish clearly defined policies in order to have a logical application of administrative procedures. It is usually best to have the patient who is refused admission for any reason examined by a physician and to have reasons for non-admission explained by the physician and the administrator. The responsibility should not be left to an admitting clerk. PROCEDURES The goal of good admitting practice would seem to be simplification of the process without impairment of efficiency in the hospital. A most annoying situation from the patient's viewpoint is that of having repeatedly to answer the same questions. Yet in all hospitals it is necessary that similar information be available to a number of departments. Data recorded upon admission should be automatically distributed to all areas of the hospital where it is needed, thereby increasing overall efficiency and reducing annoyance to the patient and his family. For scheduled admission much information often can be obtained from the physician or family at the time the reservation is made. For emergency admissions, one of the most annoying practices is tactless insistence upon details at a time of extreme stress. Rules and controls are necessary, but red tape is not. For every patient a record is necessary, but the manner of developing it requires adaptation to circumstances. The various forms necessary for completion by admitting personnel vary widely with hospital requirements and policies. Methods for compiling data vary equally as widely. Techniques vary from the simple cards and ledgers of the very small hospital to the very complicated machine handling of multiple copies. In most institutions multiple copies of at least portions of the record are necessary in order to coordinate admission, financial, treatment and discharge data. The admin office must be informed of certain information at the time the patient comes in so that the ledger may be posted and a whole series of records begun which involve the patient in a statistical and a financial way. 72

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Arrangements must be established to handle credit and collections. The nursing unit in arranging for clinical services needs data from the admitting office. Legally, multi-carbon copies have generally been held by the courts to be equally as acceptable as an original. Unfortunately, in the average hospital, each department desires the original because of the tendency of copies to become smudged. Forms and procedures should be reviewed and evaluated periodically, as there is a tendency to initiate a technique for a specific but temporary requirement and continue its operation long past its real usefulness. FINANCIAL DATA Good admitting requires a correct evaluation of the social and financial status of the prospective patient. It is at this point that admitting raises clerical details. No answer of pleasing personality, accuracy in recording information and love of fellowman will suffice unless the added ability property to appraise and correctly to judge is present. All too frequently patients are allowed to assume financial obligations, which they will never be able to meet. The information obtained in the admitting interview should guide the admitting officer in his decision as to the type of accommodation and manner of financial arrangement, which will be best for the patient and for the hospital. The referring physician is often above to give valuable information relative to the financial status of the patient. It is extremely important that the admitting personnel to thoroughly familiar with the various governmental, voluntary, commercial and industrial insurance plans. LOCATION: To the individual patient who approaches the hospital for admission, there are other factors affecting his impression of the institution besides the personality of admitting personnel and the efficiency of the organization. First impressions which are gained from the physical surroundings with which he is at once confronted play an important part. An attractive entrance tastefully and comfortably furnished will be long remembered. The admitting interview demands absolute privacy. No one cares to discuss his private affairs where conversations can be overheard. The Indian public is usually thought to be extremely gregarious and while it may prefer to buy groceries in a crowed store, it will bitterly resent having to reveal intimate personal and family details across a counter. Due consideration for the patients will usually yield better cooperation and assist in the development of sound public relations. The location should be convenient to the admin office and record room and, if there is an outpatient service, should be easily accessible to that department. HOSPITAL SUPPORTIVE SERVICES

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ELECTRONIC DATA PROCESSING & COMPUTERS IN HOSPITALS In Discussing the electronic data processing in this section does not imply that the admin office is the logical focal point for such functions. In the beginning, computer use was largely limited to accounting, payroll, and inventory activities. Increasing use is being made in areas contributing to broad and specific management decisions, master planning, medical records, laboratory, nursing activities, patient care, pharmacy, clinical and administrative research, total hospital information systems, and other applications. For these reasons, hospitals are finding that a separate department, as a staff function, with a guiding committee, increases the effectiveness and potential of automated or electronic information systems. The functions described here are being, and will continue to be, modified almost daily, hence are being changed almost faster than this subject can be written. Indeed, the computer process in hospitals, like most other chapters in this subject, could well be the subject of an entire subject, or books, in themselves.It is sufficient at this point to give a few highlights of trends and to emphasize that competent human minds still necessary to plan, program, and successfully utilize automation and other marvels of the electronics age. Installation of computers in hospitals is not to be looked upon as a status symbol, but when appropriate, on an individual or collective institutional basis, as a means of promoting efficiency and quality of patient care. Nevertheless, not since Norbert Weiner coined the term cybernetics have we been faced with such revolutionary action. Some of the following comments, with additions, are adapted from unpublished material by Jeff Steinert, Comptroller of the Greenville (S.C.) General Hospital System. Automatic connotes a characteristic of the electronic computer. The computeris automatic in that it provides for continuous operation under computer control without human innervations until the end results are obtained, subject only to having been given instructions and started. Computers are thus clearly distinguished from electro-mechanical devices in which electric power is used to activate mechanical components for the performance of operations. Electronic computers may have mechanical components, but their great speed is derived from electronic circuits. For the mere processing and storage of mass data, a sequential computer, usually of magnetic tape drives, provides speed with economy. The operator is responsible for these actions, and must correct any errors caused by data being out of sequence. To handle large quantities of data, or if it is desirable to retain data in memory to be processed from time to time, a random access computer is necessary, the availability of which was a major advancement in third generation hardware. Random access computers 74

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not only provide for programs to be maintained in memory, but for input of data as events occur and for the proper instructions to be applied. In effect, the computer instructs itself with human intervention, and sequence errors do not exist. Instead of an operator, a monitor is needed to handle any problems signaled by the computer, and to check that proper forms are in the output device, such as the card punch or printer. Computers are known for accuracy, to be impersonal and impartial. The errors in a computer operation are rarely small as the manipulation of data ordinarily magnifies small input errors into giant output results. Some such errors have become almost legendary, but their rarity is also well known, and the general public seldom questions the accuracy of a computer operation. Most familiar, as indicated, in the admin office where it was first used, the computer is rapidly becoming a valuable tool of management in relation to general accounting, accounts receivable and billing, payroll, inventory, patient statistics; procedures common to all hospitals, but automatic data processing enables them to carry out such processing many times faster, better, and more accurately, but, with an expensive tool. Automatic data processing is being increasingly programmed to record, control, and communicate various facets of patient care, services, and research, with financial data somewhat as by-products. As an example, the computer permits patient medical records to be kept in memory during his stay. Each physician order may be fed into memory, and the computer, at electronic speed, performs all the mental and paper work necessary for the order to be carried out and checks it against pre-established control. For instance, the nurse may enter a drug to be administered four times daily. The computer, properly programmed, will notify pharmacy of drug dosage, and administration, check to see, if the patient has a record of allergy or sensitivity, prepare a label, charge the drug to the patient's account, record the sale as pharmacy income, increase accounts receivable, reduce the drug inventory, expense the drug as cost of goods sold, and if necessary, notify the pharmacist to re-order stock. The computer will also put the drug into a schedule for the next administration time so the nurse will have time to prepare and administer it. If applicable, it will also automatically stop scheduling or remind the nurse to re-order. The computer will chart each medication. The only human task in relation to records is to insert input information and to keep output forms in the proper printing devices. Most hospitals have essentially the same data processing requirements, the differences being in volume or degree. Many of these do not necessarily require up-to-date minute processing, permitting fuller utilization of ADP equipment within the hospital, or that of other equipment within the community, or even in a distant city. HOSPITAL SUPPORTIVE SERVICES

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Communications are improving as fast as computers. This not only makes possible the sharing of a distant computer, but for the transfer of information from one computer to another at electronic speeds. With today's mobile population, such a file might be beneficial. Programming, i.e. instructing the computer, requires step by step planning of each procedure to be automated. Each completed program must be run in parallel with the current operation to ''de-but", or correct any errors in the programming. Some manufacturers are developing improved libraries of programs for hospital procedures, which may be adapted to the specific needs of a given hospital. Programming requires that policies be established and decisions made for all items if the computer is to make proper determinations. Where a human would make variable decisions, subjectively, the computer will always furnish the same determination for the same set of circumstances. Automatic data processing is not a panacea for all ills; it is no substitute for sound, scientific administration, and does not necessarily lead to marked savings under present systems, although it may well do so in the future. Programming is still very expensive, at times more so than the hardware. There is no doubt that all of this has, and will have, tremendous impact on hospital organization, administration, and services. It is possible that the admitting and admin offices, nursing stations and medical records department, as we know them today will disappear.

HUMAN RESOURCE DEPARTMENT The success of any hospital is more dependent upon the competency and attitudes of its personnel than upon almost any other factor. This applies individually to each one from the administrators to the least skilled worker. Sound personnel organization, with policies and procedures in writing, with competent supervision at all levels are the best of investments in the maintenance of efficient management, financial stability and quality of patient care. Industrial leaders and other students of management have long known that the higher the percentage of production is dependent on the efforts of people, as contrasted to machines, the more difficult management becomes. Attention to the causes, prevention, and cures of all kinds of physical and mental ills and the development and training of professional and nonprofessional people is the job of hospitals. This job is almost 100 per cent dependent upon personal effort. It follows, therefore, that the management function in hospitals is amost difficult one. Personnel management is the most complex of all facets of administration.

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ORGANIZATION: There must be a focal point for any activity. Diffusion of authority and responsibility for personnel more often substantiates the old adage that everybody's business is nobody's business. The director of personnel should be in a staff relationship with the organization and directly responsible to the administrator. His role is essentially advisory, to help analyze problems, to develop programs, and to assist department heads in carrying out personnel functions which are logically theirs. The staff necessary to execute the duties of the personnel department will vary with the program of the department itself and with the size, type, and objectives of the hospital. Comment has been made that, as a rule of thumb, one personnel worker for each 100 to 200 employees might serve as a basis. However, each hospital must determine its needs and program, including how extensive and dynamic an approach it will take, and utilize adequate quality of staff to get the job done. Where the hospital is so small as to feel it cannot afford a full time director of personnel, various combinations of duties have been utilized with varying success. If such dual responsibilities are necessary it is more satisfactory to join the duties with other administrative staff functions rather than a line operation. Hospital organization charts are not a depiction of any actual organization of people within the hospital. They are, rather, a statement of official policy about that organization. There are blocked relationships of official channels, studies of which would throw valuable light on the peculiar stresses of hospital organization. In the stresses and tension among individuals we find the key to stresses imposed by the hospital system or organization. In its relative way, one job in the hospital is as important to good patient care and to efficiency as is any other. Recognition of the status and relationships of the individual is necessary if the whole is to be effective. GENERAL POLICIES There must be a suitable environment for personnel philosophy, principles, and activities if success is to be achieved. It helps reflect motivation and the quality of the product of the hospital. The proper environment calls for identification of meaning, of concepts, philosophies and objectives of the hospital in relation to the community it serves. It also calls for an understanding of the roles and relationships of people who are to achieve objectives. It means integrity of top management and supervisors - people of principles with practical wisdom and fairness. Within such an environment the philosophy, concepts, goals of any successful organization and its components can and must be based on well developed, written policies, kept currently HOSPITAL SUPPORTIVE SERVICES

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consistent with problems and resources. It is not appropriate here to go into overall policies for the hospital, but to concentrate on some of those relating to personnel, realizing that one cannot separate them from the total. The American Management Association, many years ago, issued what it called "The Ten Commandments of Good Organization'', which were and still are applicable to hospital personnel management. 1. Definite and clean-cut responsibilities should be assigned. 2. Responsibility should always be coupled with corresponding authority. 3. No change should be made in the scope of responsibilities of a position without a definite understanding to the effect on the part of all persons concerned. 4. No executive or employee, occupying a single position in the organization, should be subject to definite orders from more than one source. 5. Orders should never be given to subordinates over the head of a responsible executive. Rather than do this, the officer in question should be supplanted. 6. Criticisms of subordinates should, whenever possible, be made privately, and in no case should a subordinate be criticized in the presence of executive of equal or lower rank. 7. No dispute or difference between executives or employees as to authority or responsibilities should be considered too trivial for prompt and careful adjudication. 8. The executive immediately superior to the one directly responsible should always approve promotions, wage changes and disciplinary action. 9. No executive or employees should ever be required, or expected, to be at the same time an assistant to, and critic of, another. 10. Any executive whose work is subject to regular inspection should, whenever practicable, be given the assistance and facilities necessary to enable him to maintain an independent check of the quality of his work. FUNCTIONS OF THE PERSONNEL DEPARTMENT In applying the principles of good personnel management at least ten basic elements can be identified. They can be easily compartmentalized, but are closely interwoven, from both policy and procedures standpoints. These ten elements are: 1. Policies 6. Orientation and Training 2. Job Requirements 7. Supervision 3. Qualification 8. Utilization 4. Recruitment 9. Compensation 5. Employment 10. Evaluation 78

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CHAPTER - 2

LINEN & LAUNDRY SERVICE While some hospitals have the control of linen under the direction of the laundry manager, many give this responsibility to the housekeeper, particularly if a central linen room is maintained. Decentralization is receiving more and more trial and experimentation, particularly though the use of linen carts which carry the entire requirements for a nursing unit. These carts are, in effect, linen closets on wheels, and appear to be efficient as well as space savers. Adequate control over issue must be maintained in any system, since there may always be the tendency towards hoarding. This applies not only to linens for nursing units but also to employee's uniforms. It is necessary that the linen supervisor be apprised of the daily patient census in order to plan for proper distribution. New linens should be marked promptly upon delivery, including, if possible, the date of receipt. A linen marker pays for itself many times over. For many of those items which are not easily marked, secure labels should be attached or, if feasible, as with blankets and towels, the name of the hospital woven into the manufactured articles. A sewing room, with competent personnel and equipment, should be provided for repair of linen so that full utilization is accomplished before discard or conversion to cleaning rags. Contaminated lines from communicable disease patients should be collected in separately identified canvas bags in which they remain through the first washing process. This will usually destroy pathogenic organisms. Ironing produces practically sterile lines. Distribution systems: 1. Laying down the standards for each unit of operation, for each ward or department. The linen for each unit must be marked separately. The linen is counted in the ward and it is counted again when returned from the laundry to check whether all the items have been correctly returned. 2. Another system is the one in which the sister-in-charge of ward has to place a daily requirement with the laundry for the following days HOSPITAL SUPPORTIVE SERVICES

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requirement. 3. Soiled linen is counted in the ward and sent to the laundry for exchange for clean linen. 4. In this system the linen is counted in the wards again on receipt in the laundry then at the time of issue from the laundry into the linen room and finally when it goes back to the ward. 5. This system includes the establishment of a central linen room in which case no reserved stocks are held in the wards. Central linen room system works as follows: 1. The laundry manager is responsible for the entire system of marking, sorting, washing, transportation, mending and replacement of usable articles. 2. The standard of linen per ward or department for daily usage is to be laid down. 3. Daily exchange of linen piece for piece under the direct supervision of a senior supervisor. 4. Procedure for disposal of items beyond use is to be clearly defined. 5. All new linen should be marked. Procedure for dealing with contaminated linen: 1. It is recommended that contaminated linen be placed in a double pack with a distinctive colour and sealed. 2. Contaminated linen should be laundered as soon as possible. 3. If it is to be transferred to a different building in a hospital outside all such linen should be put in a covered container 4. Only those who are essentially required to handle these linen should do so, indiscriminate handling should be prohibited. THE LAUNDRY: While most patient readily accept the professional services of their doctors and nurses with the minimum amount of criticism, they can and do judge the hospital by the personal care and attention given to them while they are confined to a hospital bed. Criticism of the linen service by both patients and personnel is one of the most frequent complaints heard in the hospitals. The major share of this criticism can be avoided by properly planned linen and laundry services. Such attention to the personal needs and comfort of the patient is as important as the physician's orders for medication or for appetizing food served promptly and with attention to eye - appeal. 80

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Necessary to this service is an adequate supply of clean linen sufficient for the comfort and safety of the patient and the personal appearance and dress of all personnel who have the responsibility for attendance on patients. Pleasant, neatly attired employees in fresh crisp uniforms do much to sell the hospital to the public. Intelligent planning for the linen and laundry services, essential to good hospital care, is not possible without knowledge of the types of services that the hospital contemplates. They must be planned in relationship to the total bed capacity, the allotment of beds to the various services, the diagnostic and therapeutic facilities, the extent of service facilities, including the dietary department, mechanical and other services. Also necessary is a detailed knowledge of plans for a school of nursing and quarters for personnel. The average amount of circulating patient linen has been found to be a minimum of four times the complete complement of that in use at one time. This allows one set to be in use, one set at the laundry, one available for immediate use and one for stand - by and emergency purposes. To this expected daily load of patients linen must be added the daily load from other sources, such as the dietary department, operating room, delivery room, outpatient department, clinics, emergency room, and employees' uniforms. The amount of bed and room linen for students and other employee residence must be taken into consideration. Some institutions also do personal laundry for employees. Individual items for these various services, while not required in the same ratio as the given for patients' linen, will amount to a sizeable part of the laundry load. The total laundry load is usually expressed in pounds of soiled linen per day. The average figure ordinarily used for general hospitals is from 12 to 18kg of soiled linen per patient each day, plus 25kg for each operation or delivery, and which usually includes both the direct (patient service) and indirect (employee and other) linen usage. For chronic disease hospitals, i.e. tuberculosis and mental diseases, this average will be from 6 to 9 kg per patient per day. Even with use of disposable items, in a hospital with an average of 100 patients the amount of linen expected per day would be approximately 1,500kg. This figure is computed on the basis of 15kg of soiled linen per patient per day. At an average of two pieces to the pound, the daily workload would then be approximately 3,000 pieces. For hospitals with more than 50 beds, the consensus appears to be that it is usually more economical and more satisfactory for the hospital to operate its own laundry. For hospitals of less than 50 beds, opinion is divided and the problem has not been sufficiently studied to provide the answer at this time. HOSPITAL SUPPORTIVE SERVICES

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Should the linen be sent to a commercial laundry, approximately 20 per cent larger linen inventory must be maintained to forestall delays in delivery. Dependability of the service, including possible increased damage to linen,must be taken into consideration in reaching a decision. Some hospitals rent linens. The comparative costs of handling work in the hospital's laundry or sending it out must be figured on a per kg or per piece basis. In making these calculations, losses, repairs and the necessity for setting up a checking in and out system need to be considered as well as the operating costs. Costs can be materially reduced if the hospital laundry is efficiently operated and equipped with modern labor - saving machinery. LOCATION: Present design practice is to centralize the mechanical services of a hospital in one location and in conformity with local building codes and laws. The services grouped are usually boiler and pump room, maintenance shop, laundry and garbage. Such centralization will result in less initial investment for building and equipment. It is a major factor in lowering operating costs and promoting efficient operation. It also has considerable administrative value. The occasional disadvantages, such as excessive heat during the summer and the increased use of supplies owing to infiltration of dirt from the boiler room, where coal is used for fuel, can be corrected by adequate ventilation and screening. Ideally, all the mechanical services of a hospital should be installed in a separate building located as far as practicable from the patient service areas in order to reduce noise and dirt. However, it is the exceptional community that has sufficient funds to permit the construction of a detached building for housing these services. Most hospitals of less than 100 bed capacity locate these services in the basement and at rear of the main building. Hospitals of more than 100 beds more often can afford expenditures for a separate service wing. Traffic to and from the laundry should be routed to keep entrances into administrative and patient areas at a minimum. Space requirements: No. of beds Sq. ft per bed 100 12.5 200 11.5 400 9.00 500 8.00 82

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Special features of a laundry: Ceiling: It should be moisture proof, sound proof and have a high light reflection factor. The height should not be less than 11 feet from the floor. Floors: They should be rust-proof, smooth and of concrete or equivalent material, with a sufficient gradient to provide easy flow of water. Walls: They should be hard surfaced preferably light tiled and light colored. Windows: Maximum light and maximum ventilation should be allowed. They should at least open 50% and be easy to maintain. Lighting: Correct lighting should be used after consultation with an expert. Workload and Staffing: The average load is approximately: Hospital linen= 55%, Hospital Staff= 35%, House hold= 10% The turnover estimated is approximately 4500 articles per week for every 100 beds. The expenditure estimated is: Material= 10%, Labour= 60%, Fuel, Light, Water= 30% 9 pounds of soap required for 1000 articles 18 pounds of soda required for 1000 articles Equipments and supplies: Particulars Nos. Size Washing machine 22 32" * 54"33" * 72" Hydro-extractors 32 30"26" Ironing 3 120" Drying Apparatus 4 10" * 12" Garments Pressers-rollers 22 36"52" Hand ironing boards 4 60"


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CHAPTER - 3

HOUSE KEEPING SERVICES Good house keeping is an asset, no hospital can afford to be without not only because of its public relations and psychological effects upon patients, visitors and employees, but because from the standpoint of maintenance, economy it is good business. While the direct budget for housekeeping may be only 3 per cent of the total, other departments are helped to carry out their tasks more efficiently when full value received for the amount spent for housekeeping. A common practice has been for the housekeeper to be the head of that department, responsible directly to the administrator. Suggestions have been made that these functions be under the direction of the plant operations superintendent or engineer. However, few engineers in hospitals today have the qualifications to assume such a role. The housekeeper should be schooled in the fundamentals of home economics and those physical sciences essential to her duties. She should know the characteristics and qualities of cleaning agents, their selection and proper use. Since she will direct a fairly large staff of what are ordinarily unskilled workers she should be capable of carrying on a continuous training program. The primary activities of the housekeeping department include the routine cleaning, dusting, mopping, waxing, removal of trash, window and wall washing and related domestic duties involved in maintaining a high standard of cleanliness in the institution. They should include bed making and other functions required in preparing a vacated room for occupancy by another patient. Some hospitals contract for window washing, and on occasion for all housekeeping functions. General sanitation, including vermin and rodent control are among the most important duties. Housekeeping employees are in the best position in their daily, intimate hours of duty, to assist all employees, particularly the engineer, nursing staff and administrator, to establish and maintain many aspects of an adequate safety program. The housekeepers act as an inspectors for and reports to the engineer any repairs needed, such as damage to floors or walls, peeling paint, cracking plaster. She may intimate requisitions for repairs of these and 84

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for various items of equipment and furniture. Routine work schedules should be coordinated with those of other department in order to provoke a minimum disruption of all services, Supply centers for cleaning and housekeeping supplies should be established and issuance made upon schedule. Schedules, with procedures, should be in writing for the proper care of all types of floors, walls, windows furniture and other equipment for which housekeeping employees are responsible. Such details reduce the loss of efficiency due to indoctrination of new employees. Duties and responsibilities of house-keeping department: 1. developing policies and setting the objective of the department correlating with the policies and objectives of the hospital. 2. having two way communication with hospital administrator regarding the working of the department 3. To assist in quality health care and patient care programmes. 4. Different precautions in controlling cross infection. 5. Up keeping and maintenance of hospital property 6. To enhance the environment and develop the aesthetic value 7. Appointment of manpower, induction programme, training and orientation. 8. To develop proper use of cleaning procedures. 9. Ensure proper use of cleaning agent and equipments 10. Maintenance of records. 11. Making duty roasters, attendance registers, stock registers. 12. Attending to patients complaints 13. Supervision for quality maintenance and infection control 14. Development and standardization of newer and improved method of cleaning for better results 15. Experimenting with new techniques and equipments for cleaning 16. Co-ordination and co-operation with other departments. Housekeeping task and procedures: 1. It involves routine cleaning, mopping, dusting, waxing, removal of trash, window and wall washing and related domestic duties involved in maintaining a high standard of cleanliness in the institution. 2. General sanitation, including rodent control are among the important duties of house-keeping. 3. It must include bed making and other functions required in preparing a vacated room for occupancy by the next patient. HOSPITAL SUPPORTIVE SERVICES

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4.

5.

The housekeeper acts as an inspector for and reports to the engineer about any repairs needed. She may initiate requisitions for repairs of these and for various items of equipment and furniture. Schedules, with standard procedures, should be in writing for the proper care of all types of floors, walls, windows, furniture and other equipment for which house keeping employees are responsible.

Housekeeping Manual should contain: 1. The organization and brief outline of the hospital 2. Rules like work, leave, lunch, locker rules, safety rules etc 3. Special rules like training for specific areas. 4. Methods of supervision, efficiency rating etc 5. Housekeeping procedures like sweeping, mopping etc 6. Equipments and supplies, when to use, how to use, amount to use and care of equipment.

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CHAPTER - 4

CENTRAL STERILE SUPPLY DEPARTMENT In modern hospitals, due to increasingly sophisticated treatment modalities and emergence of complex diseases (some whose etiology was unconfirmed earlier but is now possible due to modern gadgets), it is necessary to completely disinfect and supply totally sterile material to departments like OT, ICCU/ICU etc., Thus it is vital to have a department whose main responsibility is focused on cleaning, sterilizing and maintaining many lifesaving articles and equipment. Functions of CSSD: 1. To process and provide sterile equipment and supplies 2. Distribution of sterile and distilled solutions 3. To supervise and provide sterile treatment and procedure trays and packs 4. Processing and Sterilization of rubber gloves, catheters and other similar items 5. Receiving, storing and distribution of sterile equipments not processed or manufactured by the hospital 6. Receiving, maintaining and issuing portable equipments, as well as suction apparatus etc 7. Maintenance and replacement of all equipment and supplies indicated above 8. Finding new products Location and Area: Wherever possible the department should be situated in the central part of the building, convenient to lifts and preferably with its own dumb-waiter service to expedite deliveries. The department generally consists of four-six different areas, which may or may not be provided with partitions. These areas are: receiving, wash-up, solution and work areas or rooms, sterile supply and storage. In addition, there should be space for built in sterilisers. Space: Beds(including bassinets) Sq. ft Basic Sq. ft Comp HOSPITAL SUPPORTIVE SERVICES

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75-99 8 13 100-149 7 11 150-199 6 10 200-249 6 9 250-300 5 9 300 up 5 7 Ventilation: Adequate ventilation is essential in this department, not only from the stand point of comfort and health of the personnel, but also for the efficient operation of the autoclaves. Windows alone are generally not sufficient, exhaust fans are needed in addition to the regular fans. The most desirable method would be air-conditioning. Distribution and collection: The distribution and collection of supply in a hospital may prove a big problem owing to lack of physical facilities for holding and transmitting supply to the point of use. 1. Quota System: here the predetermined stock level for each user is established and maintained by the C.S.S.D through a regular delivery programme. 2. Clean for dirty exchange: Here every article that is given in a dirty state is returned in a corresponding clean one. 3. Regular complete stock system: this is a double container issue in which complex needs of a user for a specified time period are placed in a container. This is replaced at the specified periods by a similar container irrespective of whether the items in the original are used or not. 4. Required issue: here the demand is placed for and item of and as required basis. Record keeping: 1. Materials received from stores and vendors stored in their original form until issued 2. Materials which are not expendable, issued from and returned to the department 3. A master stock record should also be maintained 4. Daily, weekly and monthly production records should be available for efficiency rating to assess production standard, cost control and staffing requirement. C.S.S.D committee: It is advisable in the interest of good management and planning to appoint a 88

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committee consisting of an administrator, a surgeon, an anaesthetist, a pharmacist and a Matron. This committee will prepare a written programme for the department covering the following subjects: 1. Objectives of the department 2. Functions of the department 3. The departments to be served 4. The services to be rendered, including a list of the major supplies and equipment which will be provided also the estimated quantities of these supplies and equipment 5. A detailed description of how the work will be done, including the specific methods to be used in performing the operations 6. An outline of work stations and workflow methods including all essential processing equipment required to perform the operations 7. An estimate of duties that may be assigned to the department in the future and other anticipated changes 8. The administrative structure and the organization of the department including the estimated number of personnel for the department and their needs. Patterns of the organizational set-up include: 1. The C.S.S.D forms part of the nursing services with a senior nurse appointed as a supervisor under the matron or director of nursing 2. The C.S.S.D and the operating room is under a trained nurse. This set-up will obviously be the logical one in a hospital having one or two theatres 3. The C.S.S.D forms one division of the O.T. complex and is under a seniornurse who reports to the superintendent or the supervisor of the complex. 4. The C.S.S.D is under a supervisor who is directly responsible to the administrator 5. The C.S.S.D is under a pharmacist with possibly an assistant who is a registered nurse. The pharmacist reports directly to the administrator or through his doctor. Central supply supervisor: The supervisor should have the skills to handle his department as well as skills of industrial management. He must have the ability to use modern techniques of time and motion study production, planning and control work simplification. He must have the ability to lead effective changes. He must have good inter-departmental communication. He must be able to maintain efficiency, records and quality of products. He must maintain proper inventory levels of all supplies. HOSPITAL SUPPORTIVE SERVICES

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CHAPTER - 5

BIOMEDICAL ENGINEERING DEPARTMENT Physical facilities and their maintenance are keystones in medical care of patients. In planning a new hospital the building itself is often overemphasized because of its tangibility, without enough thought being given to functions and services. In the existing hospital the situation is too often reversed. Not enough attention is given to the importance of the plant, its operations, efficient staffing, management and general value to patient care and personnel activities from practical, psychological and economical viewpoints. The hospital will fail in its responsibilities if the plant operations department fails just as if any other department failed, whether it be clinical or administrative. SCOPE OF MAINTENANCE 1. 1.1. 1.2. 1.3. 1.4. 1.5. 1.6. 1.7. 2. 2.1. 2.2. 2.3. 2.4. 3. 3.1. 3.2. 3.3. 3.4. 3.5.

GENERAL MAINTENANCE DEPARTMENT CIVIL: BUILDING AND ROADS DOORS, GATES, WINDOWS AND INTERIOR FITTINGS GENERAL AND HOSPITAL FURNITURE (WOODEN/ METAL) VEHICLES [GENERAL + AMBULANCES] LIFTS [PATIENT/PASSENGER] & DUMB WAITERS LAUNDRY, KITCHEN & HOUSE-KEEPING EQUIPMENT BUILDING AUTOMATION SYSTEM AIR CONDITIONING HVAC: CHILLER PLANT, AHU, FCU BLOOD BANK COLD STORAGES FRIDGES & WATER COOLERS MORGUE ELECTRICAL ELECTRICAL PANELS, WIRINGS AND FITTINGS (FAN, LIGHT ETC…) TRANSFORMER, GENERATORS AND UPS SOLAR AND NON-CONVENTIONAL ENERGY SYSTEM INCINERATOR FIRE ALARM

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3.6. 3.7. 3.8. 3.9. 3.10. 3.11. 3.12. 4. 4.1. 4.2. 4.3. 4.4. 4.5. 5. 6. 6.1. 7. 7.1. 7.2. 7.3.

NURSE-CALL SYSTEM/ CALL BELL SYSTEM PUBLIC ADDRESS SYSTEM CCTV TV AND SATELLITE CABLE TELECOMMUNICATION [DIRECT LINES, EPABX & PCO/ STD BOOTHS] ATTENDANCE SYSTEM [SWIPE CARD] PHOTOCOPIER & SIMILAR ELECTRONIC EQUIPMENT PLUMBING GENERAL PLUMBING: TANKS, PLUMBING LINES, FITTINGS AND PUMPS WATER FILTERS BOILER SEWAGE TREATMENT PLANT FIRE FIGHTING [SMOKE DETECTORS / SPRINKLERS / FIRE HYDRANT] MEDICAL GASES MANIFOLD BIOMEDICAL ENGINEERING DEPARTMENT BIOMEDICAL EQUIPMENT IT DEPARTMENT COMPUTER HARDWARE & PERIPHERALS DATA NETWORKING & INTERNET CONNECTIONS AUDIO-VISUAL AIDS (+AUDITORIUM STUDIO)

PHYSICAL PLANT AND MAINTENANCE: Locally, the competent plant operations superintendent engineer should begiven status equal to other departmental heads. The trend, with many advantages, is towards having a graduate professional engineer. He should attend general staff conferences and be consulted prior to purchase of major equipment or to building alterations. Under his direction are all those areas involving maintenance of physical facilities and related functions. These include: 1) The maintenance, repair and operation of all equipment, machinery and distribution lines concerned with the following: a. Steam and hot water. b. Plumbing (including waste disposal) c. The electrical system (power and lighting, including emergency lighting) d. Fire detection, prevention and fire-fighting methods and devices. e. Carpentry (including furniture repair) HOSPITAL SUPPORTIVE SERVICES

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2) 3)

f. Painting and decorating. g. Vertical transportation equipment (elevators, dumb-waiters). h. Communication and mechanical messenger systems. Grounds maintenance and landscaping. Safety.

MECHANICAL SERVICES: Initial cost of installed mechanical and electrical equipment of a hospital may exceed 40 percent of the total cost of the building. The cost of operating and maintaining this equipment is far greater than for all other parts of the building. Without modern emphasis on environmental conditions such as air conditioning, proper lighting, color, heating, ventilation and the use of automatic and labor saving equipment, mechanical services and proper maintenance have become one of the most important aspects of any hospital. In the plant operations department the engineering responsibilities include the provision of efficient, economical and continuous utility services such as heat, light, hot and cold water conditioned air, steam, electric power, gas, refrigeration, compressed air, communications and transportation both within and without the hospital, and whether these services are originated within the hospital, purchased or both. It is difficult to discontinue many hospital mechanical services without serious disruption of clinical and administrative activities. To provide as nearly continuous services as possible in an efficient manner requires a high degree of supervision and an intimate and practical knowledge of needs and maintenance requirements. It is of prime importance that the engineer has in his office a set of working drawings and floor plans of the hospital (as originally actually build, and incorporating any charges). Such drawings, preferably on linen, must show foundation plans, wiring and plumbing layouts, elevations, structural framework of buildings, sanitary and storm sewer lines, ventilating system and essential wiring and piping diagrams of major items of equipment. From the admin office he will want a detailed list of all purchased equipment, such as furniture, fixtures, sterilizers, x-ray equipment, master-clock system, fire fighting equipment, motors, boilers, refrigeration, air-conditioning equipment, and all the mechanical appliances used. He will need to know their original costs, installed costs, instruction for operation and up keeps, so he may set up an equipment record file posting to each major piece repair costs as they occur. He must work with the admin office in the maintenance of cost records such as 92

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steam and laundry production, departmental repairs and other items on a monthly basis. Even in the most soundly designed and constructed hospital, use, abuse, and action of the elements all act against planned efficiency to a point which might have dire consequences if proper maintenance services are not established. The ''baling wire'' engineer and patch system of maintenance are costly. They mean a maintenance organization inadequately staffed in quality if not also in quantity in relation to the workload. Usually there is a shortsighted starvation budget, no adequate work locations and no systematic inspection of buildings and equipment. Maintenance and repair costs under such a system will usually be double or treble that under an efficient system. Cost reports likewise would be of doubtful value, since they probably could include only direct labor and materials. It would be impossible to show the excessive indirect costs of interruptions to service, idle time and inconvenience of personnel, temporary repairs and unnecessary early replacements due to lack of servicing. Preventive maintenance is a far better answer and is just what the term implies. Preventive maintenance anticipates wear and tear, deterioration of buildings and equipment, and protects the original investment by an intelligent, planned program of inspection and upkeep. Work is planned to take advantage of the seasons. A regular schedule of outside repairs to roofs, gutters, windows, doors, walks and painting is set up. Boiler and power plant repairs are scheduled to take advantage of the summer months when the heating lead is at a minimum. In addition, preventive maintenance searches out the causes of breakdowns of equipment and permits their correction. Emergency calls, almost a daily occurrence under the ''patch system'', are reduced to a minimum by systematic inspection and prompt attention to minor repairs. Such attention is required lest through neglect serious breakdowns result. Lost time by the nursing staff and other highly paid professional or technical personnel, caused by failure of equipment or service is reduced. Most important of all is that service to patients is rarely interrupted. Equipment and supplies should be standardized as much as possible to reduce inventories and simplify repairs and replacements. For special equipment such as electronic, x-ray, elevators and similar items, outside contract repair and maintenance services can often be secured at a saving. The importance of having a reliable source of adequate electrical power is to be stressed.


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SANITATION There are many aspects of sanitation involved in hospital design, construction of operation. Detailed study and advice by competent public health engineers should go into all phases. It would not be pertinent to attempt to give here the technical details on design and construction, but it is pertinent to emphasize the importance of the subject, since it will affect markedly the appearance, safety and maintenance of the institution. As an example, it might be noted that it is far more satisfactory to have rat-proof and vermin-proof construction than to be forced to carry on a perpetual but too often losing battle of control measures. From an operational standpoint, the majority of sanitary practices fall within the scope of housekeeping and engineering and are discussed under that heading, with limitation at this point to water supply, plumbing, refuse and sewage disposal. Periodic visits to the hospital by the sanitary engineering staff of the state health department are to be encouraged. Importance of the subject, as well as tangible results, are immediately apparent in that factors relating to the physical plant constitute a major portion of state hospital licensure procedures. WATER SUPPLY AND PLUMBING It has been estimated that water consumption by a hospital will approximate 400 to 600 gallons per bed day varying with air conditioning, fixtures, laundry, and other factors. The supply should be taken from a public system wherever one is available and can meet the maximum demand. The state health department or other recognized agency should determine the purity of the water supply. If it is found unsuitable for drinking, provision should be made for a treatment plant. Two water services should be brought into the building from two street mains, if they are available, to provide an emergency service in case one fails. Separate portable and non-portable water supply systems are objectionable, as cross connections that would contaminate the drinking water are possible. Should the pressure in the street main not be sufficient to supply the fixtures on the upper floor a tank with duplicate pumps may be necessary. At times it is advisable to supply the laundry and first floor fixtures from the street main and pump the water for the upper floors. Where a public water-supply system is not available, water wells should be considered in preference to the use of surface water would require a treatment plant and constant supervision. In all such cases the state health agency should be consulted. It is obviously ridiculous to 94

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protect the water supply from its original source to the building and to subject it to various hazards of contamination from a poorly designed and installed plumbing system. Field studies have proved conclusively that it is not a result of breaks, shutdowns and drainages for repairs, or inadequately sized pipes. Strangely enough, few plumbing codes have included provisions for the proper sizing of the distribution system which require consideration of the pressures available in the supply main, the characteristic of the water from the standpoint of corrosion or caking of the piping materials, future installation of fixtures (a common occurrence in most hospitals) and the hydraulics of the system. Sole dependence cannot be placed on pressure alone to protect against backflow of waste material form plumbing fixtures or devices but it does minimize the hazard. In addition,adequate pressures are necessary for proper operation and maintenance of the fixtures in a sanitary condition and for reduction of noise caused by the flow of water in the system, which is particularly objectionable from the viewpoint of the patient. Since vacuums can and do occur, it is essential that the water inlets to the fixture terminate a safe distance above the highest possible water levels in the fixture. In instances where this is not possible, back-flow preventers must be used. These devices are mechanical and, therefore, subject to failure. Overhead drainage lines should be located so that leakage will not cause serious consequences. Such lines should never be exposed in food handling and storage areas. Sterilizers, dishwashing machines, refrigerators, foodhandling equipment and similar devices should not be directly connected to the building drainage system because of the possibility of a stoppage in the drain resulting in the backing up of sewage or waste material. One other point peculiar to hospitals is the need for protection of certain types of equipment against possible contamination by the portable water supply. This necessitates the use of leak-escape proof values on the various types of water supplied sterilizers. Unfortunately, too little attention is paid to the location and type of fixtures provided for the accomplishment of specific tasks in the hospitals. Inadequate hand washing facilities in patient and work areas may result in break of technique or unnecessary loss of time. These facilities should have the proper type fitting, wrist, elbow or knee action controls, to prevent the fixtures from becoming a vehicle for the transmission of pathogens. Proper location and number of fixtures will permit more effective use of time of hospital personnel. Present accepted practice provides for the installation of lavatories in the HOSPITAL SUPPORTIVE SERVICES

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patients' rooms and in a wall recess in the hall of each nursing unit. In this connection, consideration should be given in any hospital survey to the adequacy both in number and convenience of location of the toilet and restroom facilities for all personnel. HOT WATER SYSTEM It is advisable to have two combination hot water heaters and storage tanks with horizontal submerged copper U tube heaters. One tank should normally be used for the laundry, dishwashers and kitchen, and the other, for the hospital fixtures. A maximum temperature of 120 degrees is recommended at fixtures. Through the use of booster heaters, the water for the kitchen and dishwashing may be taken from the lower temperature service. The tanks should be cross connected so that either can be used to supply all fixtures during cleaning or emergency repairs. This arrangement requires two systems of hot water piping, but the additional cost is not great because the mains to the laundry and kitchen are usually short. For a general hospital, the minimum hot water requirements that may be expected are 4.5 gallons per bed per hour for the laundry, 4 gallons per bedper hour for the kitchen, both at 180 degrees, 6 1/2 gallons per bed per hour at 125 degrees for the hospital. The storage capacity should be not less than 80 percent of the heater capacity. REFUSE AND GARBAGE DISPOSAL Methods to be used by the hospital for disposal of garbage should be reviewed by local health officials and the state health department. The hospital administrator and his maintenance staff should request periodic inspections from these officers in addition to routine observation and control. Total refuse from a hospital, exclusive of ashes, may amount to several points per day for each individual. Of this, food wastes will constitute one - half to three - quarters of a pound. Storage of garbage pending disposal by means other than by grinders' poses a problem not too often satisfactory solved. A number of hospitals, particularly in the warmer climates, have found it to be highly advantageous from both the seminary and nuisance standpoints to install walk - in refrigerated facilities adjacent to the can - washing room. The can washing room should be located at the service entrance, as near the kitchen as possible. The room should be provided with a floor drain, and hot water and steam outlets for sterilizing 96

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garbage cans. Disposal has more health implication than the disposal of such material from an ordinary building or community. In addition to the usual garbage and refuse will be included such things as infected dressings, discarded surgical specimens, food scraps from patients' dishes which should be considered infected and similar material. All of this latter class of refuse must be disposed of by incineration with the exception of the food scraps which may be disposed of in the sewer if a garbage grinding device, such as is discussed later, is provided. In some cases it may be practicable to use the central heating plant for incineration. On the other hand, especially in rural areas, it may be desirable to provide an incriminator for the disposal of all garbage and trash. If a separate incinerator is provided to burn all refuse including organic wastes, it probably will be necessary to make provision for forced draft and auxiliary fuel as it will not be in service at all times, but will be started each day. All combustion gases should be passed through a furnace temperature of 1,400 degrees F. Average and 1,250 degrees. F. Minimum to prevent odor and smoke nuisance. As the design of incinerators conforming to these specifications is a specialized field, it is suggested that the unit be purchased from a reliable manufacturer. If a separate incineration is to be provided for readily combustible materials only, a suitable incriminatory may be readily built. The disposal of garbage through the sewerage system as is done where one of the garbage grinding devices is used is a satisfactory method of disposal. If this method is used and the hospital has its own sewage treatment plant, this additional load on the plant must be considered in its design. Certain localities do not have sufficient digesting facilities for the additional garbage load and will not permit the use of the equipment. Garbage can be disposed of at various points of collection, thus minimizing the use of garbage cans. It certain localities the hog feeding methods is used for disposal of garbage. However, before the garbage is fed to the hogs, boiling should sanitize it. Where large feeding stations are provided, the boiling sterilizers can be located at the feeling grounds. Where the garbage is given to several feeders, the boiling sterilizers should be located at the hospital under the supervisionof hospital personnel. The method of feeding the hogs requires considerable supervision to prevent a nuisance problem. The amount of garbage fed to the hogs should be removed from the feeding area and disposed of through the sanitary fill method. Sanitary fill methods are recommended only where proper equipment and personnel are available for buying the garbage; otherwise these fills will become a nuisance problem. HOSPITAL SUPPORTIVE SERVICES

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Disposal of garbage on an open dump is very undesirable. SEWAGE DISPOSAL: Should a community sewer system not be available, it becomes necessary to treat sewage from the hospital. The objective of sewage treatment should be to prevent contamination and possible infection of a source of water supply; to prevent possible spread of disease by rodents and insects, to prevent a nuisance condition; and to prevent destruction of aquatic life. Hospital sewage often differs from domestic sewage in that it contains a much greater proportion of laundry wastes. Interference with the biological processes usually employed in domestic sewage treatment is more likely. Likewise, hospital sewage is more likely to contain infectious material. A competent sanitary engineer should be employed for the design of the reatment plant, and the design should comply with the regulations or policies of the state health agency. Generally, effective setting and disinfections should be considered the minimum treatment of hospital sewage when it is discharged into a surface watercourse regardless of the dilution available. Additional treatment will be required when location and available dilution demand. The quantity of sewage from even a small hospital is to large that disposal by subsurface irrigation is not practical except under very favorable soil conditions. Ordinary biological processes of sewage treatment will usually be applicable, although when the water supply is heavily mineralized, interference with biological processes is a possibility. In such cases, consideration should be given to separation of wastes containing organic matter from inorganic wastes, such as water softener discharges, backwash water and boiler blow-off water. The latter contain no pathogenic organisms and are not putrescrible; so final disposal is usually not a serious problem. In locating the disposal plant, orders must be taken into account. If the plant is located close to the hospital or other built-up areas, all units should be housed and all openings should be well screened. Additional precautions against odor, such as provision for chlorination, may be necessary. In as much as ordinary biological treatment of sewage does not destroy all bacteria, it much be assumed that the effluent from such plants will contain pathogens. Therefore, final chlorination of the effluent is indicated in all cases where the receiving stream is used as a source of water supply or for swimming or any other recreational use. Final chlorination may also be necessary where sewage is discharged into a watercourse, which is dry during part of the year. 98

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Most local regulations prohibit the discharge of storm water into a sanitary sewer system. Should it be necessary to use sewage treatment plant for the hospital, such storm water drainage should not be admitted to the sanitary sewers. It would be uneconomical to construct a treatment plant for storm water load and this water would complicate operation of the sewage treatment plant. In checklist form, the following are highlights of items for evaluation of the hospital physical plant and its maintenance in regard to quality and safety of care: 1) The hospital is so located that objectionable environmental factors are reduced to a minimum. 2) Design and construction of buildings are such as to be classed as acceptably by state and local inspection and licensing agencies. 3) The buildings and premises are subject at all times to inspection by a representative of appropriate state and local building and fire authorities. 4) Patient areas are arranged in units consisting of that number of patients who can be safely and effectively supervised, treated and cared for in one general location, according to acceptable medical, nursing and administrative principles. 5) Patients' rooms are so arranged and constructed that each patient is provided with ventilation, light and temperature control commensurate with acceptable standards of environment and hygiene. 6) Each patient's room has an outside exposure with satisfactory amount of natural light and good ventilation and communicates directly with a corridor without passage through another patient area. 7) Privacy is provided for all patients by means of curtains or other suitable screening devices. 8) A solarium, dining room and other common facilities for patients are provided as necessary to meet medical and rehabilitative needs of patients. 9) There are rooms for the care of patients requiring segregation because of physical or mental condition. 10) Rooms, adequately equipped, are available for the isolation of patients having or suspected of having communicable or infectious diseases, which are either subject to legal quarantine or may endanger the health or well-being of other hospital patients and personnel. 11) There is a sufficient supply of bedside equipment to render proper, individual care to all patients and the rooms furnishings are arranged to facilitate nursing care and to avoid the transmission of infection. 12) There is a nurses' station, properly equipped, located and arranged, for HOSPITAL SUPPORTIVE SERVICES

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13)

14) 15)

16) 17) 18)

19)

20) 21) 22) 23)

100

each nursing unit. Suitable provision is made for the safe and convenient preparation of dosages and treatments, including provision of ample light, running water, refrigeration, work area, and storage space assuring security for drugs and medications. There is refrigeration for thermo labile drugs and biological, separate from that provided for food, drink and infant formulate. There is at least one well illuminated and ventilated utility room on each floor of the hospital where patients are accommodated, conveniently located and arranged for efficient and safe conduct of work. Facilities are provided for convenient and safe emptying and care of bedpans, urinals, emesis, and wash basins. There is provision for safe and sanitary storage of patients' clothing and personal articles. There is provided, on each nursing unit, adequate storage areas for linens, nursing supplies, wheel chairs, litters, administrative supplies, and other materials in constant or frequent use in the unit. Well ventilated storage and work space for supplies and functions associated with daily housekeeping and maintenance of the unit are provided. Diagnostic and therapeutic facilities are conveniently available to the medical and surgical services. Dressing rooms and locker facilities, designated and planned for the purpose, are provided for employees and physicians. Treatment rooms, conference rooms and offices are provided in the number required for patient care, medical and hospital staff. Adequate space is available for administrative and clinical departmental and functional activities, including: 1) Administration. 2) Nursing units have a minimum of: a) 100 square feet per bed in single rooms. b) 80 square feet per bed in multi-bed rooms. c) 40 square feet per bassinet in nurseries. d) Rooms and wards are of sufficient size to all adequate floor space per bed and adequate space between beds so as to provide necessary room of nursing procedures and to prevent the transmission of infection. (3) Operating suites. (4) Delivery suites. SCHC


24.

25. 26.

27.

28. 29. 30. 31. 32. 33.

(5) Laboratory. (6) X-ray. (7) Pharmacy. (8) Medical records. (9) Library. (10) Dietary. (11) Outpatient services. (12) Central supply. (13) Isolation. (14) Physical medicine. (15) Personnel facilities. (16) Public facilities. (17) Other. All corridors are wide enough to permit the easy passage of two hospital beds with an increased width provided at elevator lobbies and other place where complicated traffic conditions may demand more clearance. All doors are wide enough to permit the entrance of an occupied hospital bed. There are space and facilities for the proper storage of all drugs, supplies, linen and equipment. Equipment necessary for the functioning of the facility as planned is provided in the kind and to the extent required to perform the desired service. All mechanical equipment and installations are equipped with recognized safety devices and controls. Wall finishes are smooth and washable, ceilings reflect light efficiently and have a finish which is readily cleaned, and floors have smooth, waterproof surfaces. The physical layout is designed to avoid conflicting traffic of patients, staff, and visitors. All entrances and rams are wide enough to permit passage of stretchers and chairs. Elevators are adequate in number and properly located. Stairways are adequate in number and properly located. Directional signs are adequate. Facilities for employees include: (1) Auditorium or assembly room. (2) Adequate rest rooms, locker rooms. (3) Suitable dining area. (4) Adequately ventilated and illuminated working areas.


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34.

35.

36.

37. 38.

39.

40.

41. 42. 43.

44.

45. 102

(5) Housing for personnel. The hospital is equipped with sufficient heating units to maintain a temperature adequate for the comfort and safety of patients at all times. Heating facilities are adequate to insure higher temperatures in surgery, obstetrical suite, and nursery. No open flame heating device is used for heating any room in the hospital. All direct fired heating units are designed so as to permit the discharge of the product of combustion into a flue or vent, and in addition all such units are properly ventilated to a vertical flue or chimney leading to the outer air above the high point of the roof. Direct fired heating units are not permitted in any operating room or in any other room where combustible vapors are present. The high-pressure steam boiler, hot water generator and connecting ping are so designed and maintained as to provide sufficient capacity for the demands of the hospital as to hot water of suitable temperature and sterilizing requirements. All parts of the heating system are constructed and maintained so as to eliminate fire hazards. All furnace or boiler rooms have a direct entrance from the exterior of the building. Should there be an entrance to the furnace or boiler room from the interior of the building, such entrance is protected by fire-resistive material. The heating system, piping, boilers and ventilation are furnished, installed and maintained to meet all requirements of the local and State codes and regulations. Chimneys, flues and pipes connected with the heating facilities are check and cleaned periodically. Fire resistant materials are used wherever contact with heating facility presents a fire hazard. The fuel supply is handled and stored in accordance with local and State codes and regulations. Buildings are adequately ventilated at all times. Outside ventilation is provided in accordance with all applicable local and State codes for all patient's rooms, kitchens, bathrooms, toilet rooms, and other service rooms. The location and ventilation of kitchen, bathrooms, toilet rooms, and other work areas are such as to prevent offensive odors from entering patients' rooms and other parts of the building. Whenever necessary, mechanical means are provided to remove excessive SCHC


46. 47. 48. 49. 50. 51. 52.

53. 54.

55.

56. 57.

58. 59.

heat, smoke, moisture, objectionable odors, and dust, explosive or toxic gases. Basement rooms used for shortage are ventilated to the outside air with intake and discharge ducts. (This does not apply to cold storage rooms.) Draft deflectors are installed on all windows where a patient's safety or comfort requires them. The hospital ventilating system is so designed and regulated so that objectionable drafts will not be created. Re-circulation of untreated air is not permitted in any air conditioning system. Refrigerants used for air-cooling or for any other purpose in the hospital are non-toxic, non-irritant, and non-flammable. Adequate precautions are taken to prevent the introduction of dust-laden air into operating, delivery and emergency rooms. Operating and delivery rooms are provided with a supply ventilating system with heaters and humidifiers which supply fresh filtered air, humidified to prevent static. Sterilizing rooms and adjoining operating and delivery rooms are furnished with separate exhaust systems. Nurseries are provided with mechanical equipment capable of maintaining a desirable balance between temperature, air movement, humidity, and germ-free atmosphere. The installation of electrical work and equipment complies with the National Electric Code and the regulations of the local utility companies with the National Electric Code and the regulations of the local utility companies govern service connections. Lighting fixtures and all wiring and equipment are periodically tested to show that they are free from grounds, shorts or open circuits. There is provided and maintained an adequate call system at the bedside of each patient and at all other points where patients will require such facility. Pilot or signal lights associated with the call system are distinct and different from lights associated with exists. Each patient's room has an outside window and artificial lighting adequate for reading and other uses as needed. All entrances, hallways, stairways, inclines, ramps, cellars, attics, storerooms, kitchens, laundries, service units and other rooms or areas have sufficient lighting to prevent accidents and to promote efficient service.


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60. Lighting fixtures are selected and located with a view to the comfort and safety of patients and personnel. 61. All service or working centers such as medicine cabinets, or nurses charting desks are adequately lighted. 62. Emergency lighting and power facilities are available in at least the operating, delivery, recovery, emergency rooms and stairwells. 63. In other areas battery lamps and flashlights are available. 64. At least one person familiar with the operation of the hospital's electrical and lighting system is readily available at all times. The location of switches and fuse boxes should be known to this person. 65. An adequate supply of water under pressure, which is of safe sanitary quality, suitable for human use, is provided from a public or independent water supply system approved by the State Department of Public Health. Samples of water, other than from the public supply, are submitted periodically to the State Department of Health for bacterial examination. 66. Bottled water and ice meet standards established by the State Department of Health. 67. All interior water supply piping is installed and maintained in conformance with State plumbing codes, municipal ordinances, and with the rules and regulations of the State Department of Health. 68. The plumbing system (including facilities for the sterilization of utensils and instruments) is free from cross-connections and interconnections between a safe water supply and one which is subject to contamination, or between a sage water supply and sewage, waste water, drainage, condensate, previously used water, contents of plumbing fixtures, or any other contaminated material. All plumbing fixtures are also designed and installed as to prevent the backflow or back siphon age of any material into the water supply. 69. Toilet facilities in a reasonable ratio, to the number, type, and sex of patients cared for in the institution and to the number of personnel are provided. 70. Toilet rooms do not open directly into any room in which food, drink or utensils are handles or stored. 71. There are adequate hand washing facilities with knee, foot or elbow control throughout the institution, especially in operating, delivery and labour rooms, in the nursery, in examining and treatment rooms. In main and diet kitchens, in utility and service rooms, and in rooms are used for the isolation of patients. 104

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72. All sewage and liquid wastes are discharged into a municipal sewerage system where such a system is available; otherwise, the sewage is collected, treated, and disposed of in an independent sewerage system which conforms to the minimum standards of the State Department of Health. 73. All drainage and other arrangements for the disposal of excreta, infectious discharges and institutional and kitchen wastes conform to the State plumbing code, municipal ordinances and to the regulations of the State Department of Health. 74. Incineration facilities or other approved methods for the disposal of infected dressings, surgical and obstetric wastes, and other similar material are provided. 75. All means necessary are taken for the exclusion and control of files, mosquitoes, other insects, rats, and rodents. 76. All buildings, equipment and services are maintained in accordance with State and local standards, ordinance, regulations and laws. 77. The responsibility for the repair, maintenance and safety of the entire physical plant is local standards, ordinances, regulation and laws. 78. Provision is made in the annual budget for adequate funds to maintain the hospital plant and equipment in good condition at all times. 79. The number and variety of maintenance personnel are in keeping with the needs of the institution. 80. All new personnel are thoroughly oriented in the peculiar problems encountered in maintaining engineering programs in patient care facility. 81. The chief engineer is provided a complete set of all pertinent blueprints, specifications maintaining engineering programs in a patient care facility 82. The hospital structure and all its component parts and facilities are kept in good repair and maintained with consideration for the safety and comfort of the patients and personal. 83. Effective routines are established for periodic inspections, repair and maintenance of all parts and areas of the hospital physical plant to assure that it is kept in a good condition of good repair and free from all hazards to the health, safety and comfort of patients, personnel and the general public. 84. There is a formal preventive maintenance program and complete records are kept regarding the maintenance of all items of equipment requiring such services.


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CHAPTER - 6

MEDICAL RECORDS Introduction The hospital is built and maintained for the benefit of the patient, and failure to maintain complete and accurate records means failure in duty to the patient and in many ways to the family, the community and general public. Medical records are of vital importance clinically for immediate diagnosis and treatment and for future welfare of the patient, and in some cases become the deciding factor between life and death. Medical records are of importance to the hospital for evaluation of its services, improving its efficiency through lowered mortality and morbidity, and better patient care. Morale of the staff with concrete evidence of a job well done is enhanced. Records serve as a resource for education, training and post-graduate study for physicians and others. The records are the basis for successful research. Clinical research often has its origin in the laboratory, but is never completed until proved through application to patients. To be effective, it requires scientifically recorded observations as reflected in the medical record. The same may be said for epidemiological work. The value of complete and accurate records for legal purposes is well established. The basic principles involved in obtaining adequate medical records and maintaining a smoothly functioning medical record department are similar in all hospital regardless of size. Large teaching hospital supporting training programs for interns, residents and nurses usually find it necessary to elaborate on the basic records to fit their needs. It should not be assumed that medical records are of lesser value because the hospital is small. The primary reason for record keeping is to improve the care of the patient. There can be no disagreement that the patient in a 30-bed hospital is just as important as one in a 1000-bed teaching hospital. In all cases the record should be complete to the extent that it presents a comprehensive picture of the patient's illness, together with the physical findings and special reports, such as x-ray and laboratory. Such a record substantiates the diagnosis, warrants the treatment and justifies the end result. Three of the basic principles of medical records are that they must be accurately written, properly filed and easily accessible. Otherwise they become simply an expensive nuisance. Service to the professional staff is the primary function of the Department of Medical 106

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Records. The problem of completing records is a very real one for the already overburdened physician. Therefore, every hospital must periodically evaluate the service the record department renders. Careful planning of time and judicious use of personnel and mechanical aids may well be the answer to the problem of incomplete records. In hospitals where the records clerk has multiple responsibilities that do not permit him/ her to help the doctor during his leisure time, the use of dictating equipment may prove to be deciding factor between complete or incomplete records. Medical records are the memory of the medical audit and act as the mouthpiece of the hospital activities. It is the performance barometer of the hospital. The data collection begins with patient and not with physician. The information recorded comes from the patient, relates to patient, is held on behalf of patient and is important for patients and the hospital. Thus it serves a vital link between hospital and public through accurate and complete compilation of clinical, scientific and administrative data. This data helps in generating various efficiency and activity ratios which are used in retrospection. It also helps in improvement which is essential for the progress of the hospital. Definition of a Medical record: It is a clinical, scientific, administrative and legal document relating to patient care in which sufficient data is recorded by trained observers as per sequence of events to justify the diagnosis and therapy, giving the results thereof are in accordance with reasonable expectation of present day scientific medicare. DEFINITION AND FUNCTION: 1. The medical record is a document which contains statements by trained observers of conditions found and results of treatment. It indicates whether or not the efforts of the physicians supplemented by hospital facilities are in accordance with reasonable expectations of present day scientific medicine. Medical records provide material for analysis of the immediate results of hospital service, the reason therefore, and the quality and quantity of work done. 2. The functions and responsibility of this department include: a) Planning, development, installation, and continued direction of a medical records system, which includes not only the patients' original clinical records but also the primary and secondary records and indexes related thereto in the central record room and in each of the clinical services, adjunct departments and outpatient department for the hospital. b) Planning, development, installation and continued direction of procedures for assuring proper flow of records and reports among the various clinical HOSPITAL SUPPORTIVE SERVICES

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services, adjunct departments, and the outpatient department clinics. c) Planning, installation and direction of the basic statistical reporting system, which includes the ward census, consolidated daily census, outpatient department clinic activities, the adjunct department services such as radiology, clinical - pathological laboratory, pharmacy, and physical medicine. d) Preparation of vital records of birth, stillbirths, and deaths, reports of communicable and other notifiable diseases. e) Direction of the coding and recording of medical data to a variety of indexes, such as the diagnostic index, index of operations, and special therapy index. f) Determining action to be taken in medical legal activities related to the release of medical information in a variety of situations, which involves determination of the legality and conformance with regulations as well as of the ethical appropriateness in each case. ORGANIZATION AND ADMINISTRATION: 1) The medical record department shall be under the supervision of a competent, qualified person, and preferably, a trained medical record librarian who is responsible to the administrator. 2) Records of patients are the property of the hospital and shall not be taken from the hospital property except under subpoena. 3) All hospital records shall be preserved either as original records or microfilmed in accordance with the needs of the hospital and the legal statute of limitations. PROCEDURES: 1. Accurate and complete medical records, sufficient to justify the diagnosis and to establish the basis upon which treatment was given shall be written for all patients. 2. There shall be written policies, procedures, and rules for the completion of the record, the nomenclature to be used, the use of records including the release of information for the guidance of the medical record librarian and hospital personnel. 3. A member or committee of members appointed by the medical staff shall be responsible for the maintenance of complete and up - to - date medical records and the review and analysis of the clinic all experience in the hospital. 4. Medical records shall be filed in an accessible manner in the hospital. 5. Proper indexes shall be maintained in order that medical records may be available for all purposes. 108

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6. Records of operations, obstetrics, anesthetics, roentgenograms, and clinical and pathological laboratory findings shall be properly classified to permit ready reference. 7. Records for inpatients and outpatients shall be correlated. 8. Medical records shall be regarded as privileged communication as specified in statutes and regulations of the state and local community. 9. Each case of communicable disease, poisoning, epidemic outbreak or other unusual occurrence which threatens the welfare, safety or health of any patient, as well as each case of notifiable disease shall be reported to the local board of health having jurisdiction case of notifiable disease shall be reported to the local board of health having jurisdiction of the patient, or to the state department of health as may be required by state, statute and regulation. 10. Hospital records shall contain data to permit a basis for a complete audit of professional service given, and for gathering statistical information. 11. Proper recording methods and procedures shall be maintained to assure compilation of data for proper administration of services. 12. A summary of hospital services shall be compiled periodically for presentation to medical staff conferences. 13. Vital records shall be maintained and statistics compiled as required by state, statues and regulations. PHYSICAL FACILITIES: 1. An accessible medical record room should be conveniently located with adequate space, equipment and supplies. Satisfactory safe storage facilities shall be provided in all hospitals. 2. The medical record room should be conveniently located with adequate space, equipment and supplies. Satisfactory safe storage facilities shall be provided in all hospitals. Characteristics of a good medical record: 1. Complete: It must contain sufficient data written in sequence of events to justify the diagnosis and warrant the treatment. 2. Adequate: Complete progress note written by attending doctor. 3. Accurate: To justify its purpose. 4. Comprehensive: to the point and easily understood. 5. Economical: Should not be an economic burden on the administration to maintain. 6. Properly planned: In sequence, easy to understand and in order. HOSPITAL SUPPORTIVE SERVICES

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7. Timely: Space for time to time entry regarding investigation diagnosis treatment and follow up of the patient. Classification of medical records: 1. Vital records 2. Important records 3. Useful records This is done so that the records can be easily analyzed, compiled and stored. IMPORTANCE OF MEDICAL RECORD : Medical records are as necessary for the practice of medicine as medication for the effective treatment. Medical Record is useful for: 1. Patients: It is used to identify the patient with the history of his illness, the physical findings and the treatment given to him as a particular individual. M.R. assists patients in obtaining improved continuous medical care. It also serves as evidence in medico-legal cases and in insurance and other claim cases. 2. Hospital Administration a) Furnish information on all aspects of patient care, clinical and managerial quality and quantity. b) For working out economic aspects of medical care. It serves as a means for analyzing and appraising quality as well as volume of the medical service given by the institution c) For evaluation of patient care and proficiency of medical and other staff. d) Protect hospital and staff n legal matters. e) For budgetary allocation, determining distribution of the medical facilities and rationalization of staff allocation according to the demand of medical care facilities. f) Serves as an effective managerial tool for planning future programmes and facilities. 3. Medical and allied education: · Helping in education and research · Providing data for self-evaluation · Providing base for medical audit · Providing detailed clinical information on past cases which helps in · Future diagnosis and therapy. 4. Medico-legal purposes: Any MR may become evidence in accordance with Indian evidence Act. 110

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_ _ _

_

_

_

_

5.

Insurance and other claims settlements. Medical certificates such as fitness for employment sickness certificates etc Workmen's compensation Act: The clinical data recorded by medical practitioner to indicate the extent of injury and the degree of disability of the individual is taken as documentary evidence to settle the claims for payment by certain classes of employers to give their workmen, some compensation for injury arising out of and in the course of his employment under the Workmen's Compensation Act. Patients Will: Medical record gives the day to day progress of the patient as by the clinician and then indicate whether the patient was of normal mental state or not at the time of making his will. For the settlement of personal injury suit: The medical record is used to obtain the required data regarding extent of injury, the type, amount and length of treatment given in order to settle the claim made by an individual for damage sustained as a result of injury which were due to the fault or neglect of another. The malpractice suit: Medical record protects doctors and the hospital if action for damages be brought against hospital by demonstrating that there was no negligence involved and the treatment was scientific, adequate, proper and prompt. Criminal cases: Medical records play an important role in investigations of murders, assault, rapes and dowry deaths. Authorization for operation: Consent is required for operation. In case of children, parent or guardian. In case of persons of unsound mind, the person in whose custody and care the patient has been lawfully committed have to give necessary consent. The consent of the husband is required in the case of a proposed operation on his wife if the operation may or will result in sterility. Research: It provides data base for clinical research, community health. Control of diseases and for managerial research including organization, staffing and future expansion.

Main Components of Medical Records: 1. Social data: It consists of general information regarding patients identification such as name, age, sex, community, religion, residential address, occupation, marital status etc. 2. Administrative data: It consists of patients OPD registration number, name of the OPD, name of the unit head, X-ray registration number and other investigations reference number. If patient is to be admitted in the hospital, his indoor registration number, date & time of admission, patient HOSPITAL SUPPORTIVE SERVICES

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accompanied by whom, his relation with patient and his signature along with the admitting officer's signature. 3. Clinical data: It is collected at two levels: OPD: It consists of; 1. Complaints 2. Past history of illness 3. Physical examination 4. Provisional diagnosis 5. Laboratory investigation/x-ray reports 6. Special investigations 7. Treatment 8. Final diagnosis 9. Advice 10. Follow up ü Ward: Along with the above information, it consists of; 1. House officer's note 2. Registrar's note 3. Honorary medical officer's observations 4. Operation note 5. Nurses beside record 6. Discharge summary 7. Recommendations Basic requirements of Medical Records Department: 1. Trained Staff Medical record officer must be a graduate with knowledge of administration, record keeping, statistics and orientation to medicine and medical diseases. Medical record department consists of Medical Record Officer, Medical Record technicians, Registration Assistants, Clerks with other supportive staff like patients guide, hamals, sweepers, cycle peon etc. Trained personnel not only do work but also can involve themselves into it to get better information in an easy, non-complicated way. They play an important role in efficient record keeping. MRD Staff Pattern: Staffing should commensurate with the actual work-load rather than the bed strength alone though the two are roughly interrelated. A thumb rule is to provide one MRT for every 50 beds. The following pattern is Recommended: Category of Staff Hospital size 100 beds 250 beds 500 beds M.R. officer - One One M.R. Technician One Two Four 112

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M.R. Assistants (Clerks) Two Four Eight Staff One Two Four 2. Space It should be centrally situated. However it can be separated if so required with good communication service between various departments and medical record department. Registration counter for outpatient which is part of medical record department is always situated at the entrance and forms key role of the department. Depending upon the hospital policy, working flow, record department can be placed as required but it should convenient from patients and staff point of view. Space required: Capacity(no. of beds) Space in sq.ft 50 175-200 100 240-300 400 500-600 500 1000-1200 Admitting office = 125-175 sq. ft Admitting office cum enquiry= 250-350 sq. ft As the bed strength of the hospital increases, more space is required. 3. Equipment and furniture: At registration counter: 1. Writing desk with various drawers to keep different forms. 2. Chairs with proper height for easy communication with patients at registration counter Telephone and intercoms to communicate with various departments, wards and outside the hospital whenever necessary placed at the desk. Medical Record department: 1. Racks and Shelves for storage of medical records 2. Cupboard to keep important documents 3. Tables and chairs for staff 4. Telephone and intercom for communication. Duties and responsibilities of medical record officer: 1. Overall control on MRD 2. General supervision over the working and organization of the out patient registration section and indoor registrations. 3. Responsible for completion and compilation and disposal of records as necessary. 4. proper preservation of records. 5. Making records available for research, education and medico-legal purpose. 6. Responsible for medico-legal cases such as issues of certificates to police, HOSPITAL SUPPORTIVE SERVICES

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receiving summons served on institutional doctors and arranged to depute them to the respective courts with records, attending court and arrangement for production of records in the court. 7. Forwarding visceral samples and stomach contents to the chemical analyser, receiving reports from chemical analysis and filing depositions in the Coroners court. 8. Correspondence regarding medico legal cases with police, coroner of Mumbai etc. 9. Issuing various medical certificates such as accident, insurance, injury, compensation, life insurance etc. to the patients' relatives and L.I.C. India. 10. Preparation of monthly bulletin and administrative reports for the year. 11. To attend complaints of the patients and relatives and report to higher authority as and when required. 12. To give permission for taking dead bodies outside the greater Mumbai. 13. Convener of the meeting of the advisory board of the medical record committee. 14. To prepare agenda for the monthly meeting and distribute it and minutes of the meeting to the concerned. 15. Sanction casual leave for the staff of M.R.D. and make substitute arrangements. 16. Other duties that are entrusted by the authority. Duties Of Medical Record Technician: 1. Scrutinizing the discharge paper of the patients for completeness. 2. Coding of diagnosis and coding of operations as per W.H.O. classification. 3. Preparation of the diagnostic and operation index. 4. Assisting medical record officer to prepare the yearly administration report. 5. To collect clinical and statistical data from various wards and departments. 6. To prepare daily reports of the activities in the hospital under the supervision of the medical record officer. 7. To prepare monthly bulletin of services given by the hospital under the medical record officers supervision. 8. To furnish the information to short notice questions received from committee section, government, and state government. 9. Preparation of a list of operation and distributing to the concerned wards and O.Ts. 10. Sending intimation to coroner, police station in case of dearth of the patient in the hospital. 11. To supervise the work of registration assistance and other subordinates. 12. Maintain and preserve records in the proper manner with the help of 114

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subordinate staff. 13. Maintain the various registers up to date. 14. Help doctors, Researchers to get the medical record for references. 15. Any other duties entrusted by the superior. A records committee appointed by the staff can, if active, be of immeasurable help in obtaining and maintaining records of high quality and through them maintain high standards of medical practice. Member of this committee, together with the administrator, will solve the problems of incomplete records, release of information and general policies concerning the records department. The problem of the incomplete record rears it head with relentless regularity. Librarians and records clerks have gone to limitless ends to cajole staff members, particularly the older ones, into keeping records current. While this is often the best way to accomplish desired results, failure becomes a direct responsibility of the records committee, the staff, the administrator and the governing board. The privilege of practicing in a hospital is limited to certain physicians and surgeons who agree to abide by the rules and regulation of the hospital. The staff member who is treating too many patients to have time for keeping adequate minimum records is probably too busy to give adequate care to his many patients. The committee, staff, administrator and governing board must be strong enough to face this fact, since, in the end, the position of the entire hospital is lowered. The medical records librarian cannot be expected to assume these responsibilities alone. There are not nearly enough competent medical records librarians to staff the hospitals in this country. Training of more able medical secretaries will be the only answer for many hospitals, particularly the smaller ones, for some time. REGISTERS AND OTHER MEDICAL RECORD MAINTAINED BY HOSPITALS Hospitals are also to maintain the following registers: 1. O.P.D register 2. Indoor register 3. Operation theatre register 4. Delivery register 5. Birth & Death register 6. Lab register 7. Radiology including imaging register 8. Nurses GOB register & night report 9. MLC (Medico Legal Case) registers HOSPITAL SUPPORTIVE SERVICES

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10. MTP (Medical Termination of Pregnancy) registers 11. Family planning device register Various certificates issued by the doctors also form part of medical record. FORMS: There are many types of record forms in use today. Forms have frequently been made up to satisfy individual doctors interested in one special branch of medicine. These forms serve the purpose for which they were intended but are not designed for general use. The following clinical record forms have been designed to meet the basic needs of the non-teaching hospital. Many of these forms will serve a dual purpose since an attempt was made to keep to a minimum the number needed. BRIEF SHEET: This is called the Brief sheet because it contains in brief pertinent facts concerning the patient's stay in the hospital. This is the form used in admitting the patient and becomes the face sheet of the clinical chart. Sociological and identifying data should be carefully selected and if these facts are fully and accurately obtained on admission of the patient, the record will contain all non medical information needed for the admin office, insurance companies, as well as the information required for birth and death certificates. The information is filled in by the admitting clerk at the time of admission. Space may be provided for the signature of names and serves as a check against signatures received later for purpose of granting release of confidential information. The date and hour of admission and discharge are entered on the form, together with the total number of hospital days. The lower half of the page has space allocated for final diagnosis, operation performed and condition of patient on discharge. The non medical part of this record is the responsibility of the records department. The recording of the medical date (i.e. diagnosis, operation, condition on discharge ) is the responsibility of the attending physician and should be recorded and signed by him. It may be recorded or typed on this page by the records clerk at his direction but it must be singed by the attending physician. It is recommended that the following statement be printed above the space for the physician's signature, ''I have reviewed this record and find it to be completed and accurate''. This will eliminate the need to sign the separate pages in the chart with the exception of the operation report. When the operation is performed by other than the attending physician, the report should be signed by the surgeon. The physician should review the entire chart and make any additions or corrections before he signs the Brief Sheet. 116

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MEDICAL HISTORY FORM: The History form included in this series has at the top a list items pertaining to family history. These items are of such a nature that they may be obtained and recorded on the form by a clerk, as part of the admission procedure. The remainder of the form, the narrative history of past and present illness, should be written or dictated by the physician attending the patient or by the referring physicians. PHYSICAL EXAMINATION: Those who wish to tick their findings may do so on a preprinted form and use a blank space for elaboration of abnormal findings. Others may prefer to write or dictate full physical findings. The latter is preferable. LABORATORY REPORTS: These reports are designed as a backer for laboratory and x-ray forms. Laboratory forms may be in duplicate with a carbon inserted to serve both as the request for laboratory work and for the report of findings. The technician's recording of the findings on the original is reproduced on the duplicate. The original is returned to the nursing station and the copy is retained for the laboratory files. The original ( stapled or gummed ) is fastened to the backer and any subsequent reports are put on the same backer, until the page is filled. If stapled, a fine wire staple should be used to reduce the bulk and weight of the record. X-RAY REPORTS: The same procedure may be followed for x-ray reports as for laboratory reports. It is recommended that laboratory and x-ray forms be purchased with intricate one-time carbon. The slight additional cost of such forms is more than offset by the saving in personnel time consumed in inserting and withdrawing carbons. OPERATION REPORT: This form is designed to cover information usually included on the anaesthetic report, such as pre-medication and condition during anesthesia, as well as the usual items of diagnosis, time of operation, name of surgeon and nurse, surgeon's findings and description of operation performed. The surgeon should state whether the operation was major or minor. TISSUE EXAMINATION: Tissue removed during an operation an operation or specifically removed for HOSPITAL SUPPORTIVE SERVICES

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biopsy should be submitted to the pathology laboratory together with a request for examination and report. Since this form is designed to serve both as the request and the report of findings it should be made in duplicate and sent with the specimen. Where the examination is done in the hospital the laboratory should keep the duplicate report in its files. When sent to an outside laboratory, the original will be returned to the hospital to be attached to the clinical record. The examining laboratory may desire to keep the duplicate. A space for accession number is provided for the laboratory to record its identification number of the specimen. DOCTOR'S ORDERS: It is recommended that all treatment and medication ordered by the physician be recorded on a separate form rather than in an order book or on the progress report form. All orders should be written by the attending physician and signed by him. Telephone orders recorded by the nurse must be confirmed by the signature of the doctor when he next visits the hospital. PROGRESS REPORT: The attending physician should not be the progress of the patient, unusual trends, infection of surgical wounds, results of medication, and treatment and any abnormal findings not observed on admission. These notes must be dated and signed. A brief and comprehensive note should be made at time of patient's discharge, summarizing the case. Specific statements by the physician relative to the course of the disease, special examinations made, response to treatment, new signs and symptoms, complication, and in surgical cases, removal of drains, splints and stitches, condition of surgical wound, development of infection and any other data pertinent to the course of the disease are also recorded. The frequent use of general statements, such as '' condition fair'', ''general condition good'' and ''no complaints'', is unscientific and valueless. This may appear to be an added burden on the doctor but very frequently it serves as a time saver, because it eliminates the necessity for repeated inquiries to obtain information for completion of the numerous forms now needed to certify fitness for duty in industry and for insurance claims. In addition to this the progress report may be used for several purposes. Requests for consultation and report of consultant may be written on this form appropriately identified by heading. Report of blood transfusions, giving information concerning the type of blood and the amount given may be reported here. Electrocardiography tracings can be mounted and the interpretation recorded on the progress sheet. 118

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GRAPHIC CHARTS: This chart is for the use of nursing personnel in recording the patient's temperature pulse, respiration in graphic form. Space is provided on the form for entering blood pressure readings, summary totals of fluid intake and output and daily and cumulative totals of special medications NURSE'S NOTES: This is for the use of nursing personnel in recording their observations. It provides separate columns for the date, medication and treatment (which may also include diet) and general observations. The hour is recorded in the appropriate entry column rather than in the date column in order to make maximum use of the space. 'Nurses' entries should be limited to information and observations concerning the patient's reactions, condition and significant items of care. Entries concerning routine care, such as bed baths, or observations that ''had a good night'' add little to the record and should be Omitted. OBSTETRICAL AND NEWBORN RECORDS FORMS: It is probable the special forms for obstetrical cases and new born infants will needed. It has been useful in many instances to provide the physician with pregnancy record forms on which to record in duplicate the prenatal history and observations made during office visits. The doctor keeps one form in his office and sends the other to the hospital when the patient is admitted for delivery. This procedure tends to result in better obstetrical records. ALL FORMS - GENERAL CHARACTERISTICS: All of the forms discussed above are standard full size forms except the laboratory and x-ray report forms. The name of the hospital may be preprinted at the top of each form. If the forms are purchased from a record supply company, and it is felt desirable to avoid the cost of overprinting, the name of the hospital on the Brief Sheet is sufficient to identify the chart as long as it remains in the hospital. If it is released from the hospital, as it may be for presentation at court in the event of a lawsuit, the records clerk should stamp the name of the hospital on each sheet and number the pages in sequence. note should be kept in the file indicating the total number of the pages in sequence. A note should be kept in the file indicating the total number of pages present in the record when it was released from the records room. When the chart is returned, the pages should be checked to insure that the record has been returned intact. On most of the forms the title is printed in the lower right hand corner, thus HOSPITAL SUPPORTIVE SERVICES

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making it easy to locate. Space is also provided at the bottom of all forms for the name of the patient, ward or room, and the registration number. This convenient location will promote more accurate filing. Many forms are designed for use on both sides of the sheet to keep record bulk to a minimum and thus conserve filing space. It is recommended that all forms be punched at the assembled for filling after the patient's discharge, it is suggested that they be fastened on a backer or in a folder with a light built in fastener. SHORT FORMS: A short form medical record is acceptable in certain treatment and diagnostic of a minor nature which require less than 48 hours hospitalization. Short forms may be appropriate for such conditions as tonsillectomies, cystoscopies, plaster casts, removal of superficial growths and accident cases held for observation. The short form should at least include identification data, a description of the patient's condition, pertinent physical findings, an account of the treatment given and any other data necessary to justify the diagnosis and treatment. The record should be signed by the physician. RE-ADMISSIONS: If a patient is re-admitted within a month's time for the same condition, the previous history and physical examination with an interval note will suffice. SIGNATURES: 1. In hospitals without house officers, the attending physicians should separately sign the history and physical examination, operative report, progress notes, drugs and other orders and the summary. Standing orders should be reproduced on the record, and signed by the physician. 2. In hospitals with house officers, the attending physician should countersign at least the history and physical examination and the summary written by the house officer. Aside from the fact that this is a legal requirement in many states, it is a protection for the individual physician. It is not considered necessary to countersign progress notes or drug and treatment orders written by house officers. In all instances a physician should sign the clinical entries which he himself makes. Senior residents defined as third, fourth or fifth year residents need not have their histories, physicals and summaries authenticated if they are licensed physicians and the medical staff has voted to allow them this privilege. Senior residents, as defined above, may be given the right to authenticate histories, physical and summaries written by externs, interns, first and second year residents, if the senior residents are 120

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licensed physicians and permission has been given to do this by vote of the medical staff. 3. A single signature of the physician on the face sheet of the medical record does not suffice to authenticate the entire content of the record. 4. The use of rubber stamp signature is acceptable under the following strict conditions: a) The physician whose signature the rubber stamp represents is the only one who has possession of the stamp and is the only one who uses it. b) The physician places in the administrative offices of the hospital a signed statement to the effect that he is the only one who has the stamp and is the only one who will use it. 5. Initials in place of a full signature are acceptable provided that the initials can be recognized as having been placed there by a particular physician who can be identified by those initials. CERTIFICATES The various certificates that are issued by the doctor in his professional capacity are: 1. Admission / Discharge certificate 2. Emergency admission certificate 3. Birth record certificate 4. Medical Termination of Pregnancy certificate 5. Maternity certificate 6. Leave certificate 7. Injury certificate 8. Disability certificate. 9. Medico legal case certificate 10. Unsoundness of mind certificate 11. Vaccination certificate 12. Insurance certificate Giving a false certificate is a criminal offence. Death certificates Death certificates are extremely important documents and while issuing a death certificate certain precautions have to be taken. A doctor should not issue a death certificate unless he has attended the deceased at least once during the seven days preceding death. One should be very sure of the diagnosis before giving a death certificate. In case of a doubt, it is always better to ask for post mortem examination. While giving a certificate it is important to identify the HOSPITAL SUPPORTIVE SERVICES

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person concerned and even to note identification marks on the certificate. The certificate should also contain day, date & diagnosis, advice given, signature, name and registration number of the doctor. It is a good practice to keep a duplicate copy of any certificate issued. A doctor is not entitled to charge fees for writing a death certificate. He also can not delay or refuse on the grounds of non receipt of professional fees. A doctor can refuse to give death certificate if 1. He is not sure of the cause of death 2. It is a sudden death 3. There is suspicion of foul play 4. The death is caused by any violent or unnatural cause, drug, medicine or poison 5. There is suspicion of starvation, exposure or neglect. In such situation one to has report to police authorities before the body is removed for cremation. Signing of a blank death certificate in anticipation of death is not only illegal but is also violation of medical ethics. INDEXES: Just as the items in a catalog are alphabetically listed or ''indexed'', so indexes are kept in hospitals to tell where to locate either the clinical records in the department or various kinds of information contained within those records. There are generally four types of needs to locate records. Each is met by a specific index. Name Index (also known as master index and patient's index): To find the record of a patient by name, a perpetual name index is maintained. This is usually a card index, one card for each patient. The information on the card should be for identifying purposes only. This will include: (a) full name of patient (last name recorded first), (b) registration number , (c) address, (d) date of birth, (e) date of admission, (f) date of discharge. The card should be completed through item (g) at time of admission and held in a ''current inpatient file'' or ''house file''. At time of discharge it is withdrawn and the discharge date tied or stamped and the card filled in alphabetical sequence in a master file. The term ''master file'' indicates that the file contains the name of each patient admitted regardless of the year of admission. Readmission should be recorded on the original card. At the time of a patient's admission, the name file should be screened for previous admission and the card of a readmitted patient pulled the master file, the subsequent date of admission entered and the card placed in the ''current inpatient'' file and processed in the same manner as on original admission. Any change of address should be noted on the card at this time. In order to conserve valuable hospital space, it is recommended that a 122

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small size index card be used. Disease Index: To find groups of clinical records of patients having the same diagnosis, a disease index is maintained. The final diagnosis as recorded on the Brief Sheet by the doctor at time of patient's discharge is the source for recording in this index. The primary reason for keeping such an index is for convenience in producing charts of patients with like diagnosis. It is not used for compiling statistics of hospital activity. The index should be well planned to fit the needs of the individual hospital. Care should be exercised to keep only the information needed. It is recommended that this index be kept on cards, probably 3x5 in size, of lightweight index stock. The card should be carefully designed for ease of posting, with the number of columns limited to a few significant items. The minimum entries should be : patient's register number, date of disposition ( i.e., discharge or death ), hospital days, sex, age, death and autopsy. It is advisable to have one blank column for the occasional indexing of items of special interest such as manifestation of a particular disease. There are two common types of equipment for the disease index, the vertical file and the visible file. Either is satisfactory and selection is entirely a matter of preference. The comparative expense should be considered in relation to the type and frequency of use made of the index before deciding on the equipment. There are other methods of maintaining this and other hospital indexes, such as to rotary file, or by the punch care system. The latter is used occasionally in large teaching hospitals but its use in the non-teaching hospital is not practicable. The Standard Nomenclature of Diseases and Operations is most commonly used for diagnostic terminology and coding. The International Classification of Diseases used broader groupings and is said to be quicker more satisfactory for coding purposes in most hospitals if physicians continue to use standard terminology. Discussion of systems in sufficient details to make it possible to set up and maintain them in a implified manner is of sufficient importance and complexity as to require separate treatment. It is advisable to secure the technical assistance of a qualified Medical Records Librarian to help plan and install the system and train clerk. This is of particular importance in light of increasing automation. Operation Index : To find groups of clinical patients who have had the same operation an operation index is kept. The source of the information for this index is the completed Brief Sheet or the operative record. Physician's Index: To group the patients who have been attended by the individual physician a Physicians' Index is kept. This is only one of the indexes other than Patients' Name Index that necessarily lists the name of the patient. The index is maintained to serve the administration with figures which may be of interest in future staff assignments. It is often used to locate patients of an individual Physician. HOSPITAL SUPPORTIVE SERVICES

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LEGAL ASPECTS: Medico-legal problems often concern records department personnel. Policies governing the release of confidential information should be clearly by the administrator. The policy should be formulated on the basis of these principles: As a personal document, the record is used to identify the patient with the history of his illness, the physical findings and the treatment given to this one individual. The information is confidential and may not be released to anyone without the patient's permission. It is advisable before releasing information (as authorized by the patient) that the attending physician also be notified of the request and that he, too, sign the release for information. If a second physician is called to care for a patient, that physician is regarded as having the patient's permission to review the record. It is giving one physician, information secured by the other but this privilege is reciprocal. It must be recognized that if a record is subpoenaed it must be produced in court. Usually a member of the records department represents the hospital in producing this record in court. As an impersonal document, the records may be used for review of the work of the hospital and for research purposes. In such instances the record of the individual loses its identity as a personal document and only the record number is used and so it is unnecessary to obtain permission. If the record is used for research purpose, and publication is intended, courtesy demands that the physician who attended the patient should be advised in advance and his consent obtained. The medical record is legally the property of the hospital. Thompson, in an excellent presentation of various aspects of legal problems of interest to all, but particularly the medical records librarian, states: Her contact with consent of operation and treatment will be negligible. If it is the policy of the institute to obtain consent for operation, it will be her responsibility only to ascertain that such consent slips are a part of the record and are legally sound. Her knowledge of the factors qualifying consent for operation must be sufficient for her to interpret the policy established and to permit her to determine whether the absence of a consent slip is justified and whether the supporting evidence justifying the absence of a consent slip is a part of the clinical record and is sufficient. If any doubt arises, she should refer the discussion to her immediate superior, usually the administrator or medical director. Similarly, her contact with consent for autopsy will be negligible, as it is not her responsibility to obtain such consent but only to ascertain that consent is properly a part of the clinical record whenever an autopsy has been performed. In the event of autopsies performed at the direction of the coroner or medical examiner, it is her responsibility to ascertain that the clinical record has the proper notations to substantiate and justify the autopsy. In regard to 124

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consent for treatment, her contact will usually be limited to check of the presence of a duty signed and witnessed release form responsibility if the patient leaves the hospital against the advice of the physician. In the event the patient has refused to sign a release, the clinical record should contain a statement by the physician and duly witnessed, setting forth the circumstances, reasons and warning against the premature department. Problems involving the right of privacy and privileged communications will arise almost daily in the medical record department. Knowledge of the basic principles involved and of the many qualifying factors will aid the medical records librarian in arriving at proper solutions to the problems. The medical records librarian may use as a guide the following general and specific comments: Nonprofessional information, such as name, address, date of hospitalization etc. is not considered privileged and may usually by divulged with impunity. All professional information is to be considered privileged and not be released without a properly signed and witnessed consent. No information should be given over the telephone at any time except in an emergency and then only after verification of the patient of the information as one who is entitled to the information. No one may see a clinical record without the consent of the patient. There are certain exceptions to this general rule: 1. Those individuals who have been responsible for the inclusion of the professional information may review the record. 2. Clinical records may be used for study and research purposes in which case the individual using the record is legally and ethically prohibited from divulging any information which may be used for publication of scientific papers, etc. if the identity of the patient is not revealed. 3. The administrative authority has the right of access to clinical information in the interest or the protection of the patient, patients of public, but in any such case, it is incumbent upon that administrative authority to protect the interest of the patient and safeguard them from embarrassment or exposure. 4. Clinical information, of course, may be divulged in a proper court, tribunal, etc., when subpoenaed through the legal service of a subpoena deuces tecum. 5. Professional information may be furnished to those governmental authorities responsible for the protection of the general health of the community but only in sufficient detail to permit the authority to protect the general public, and of course, always be conformity with statues or local ordinances. In all other cases, it is considered advisable to obtain consent for release of information duly signed and witnessed prior to the furnishing of any professional or clinical information. HOSPITAL SUPPORTIVE SERVICES

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BEST EVIDENCE: Best evidence is regarded as the evidence which is original, not copied or duplicated. Hence, clinical records, should consist of the original of each form or sheet and not the copies. While this practice is almost universal in hospitals, yet occasionally clinical records are found in which the face sheet is a duplicate, and the laboratory, x-ray and other reports are also duplicates, the originals being field in the department originating the form. This is not an acceptable practice and may cause embarrassment or inconvenience to medical records librarians on presentation of clinical records in courts. Recently some courts have ruled favorably upon the acceptance of microfilmed records, but it is considered advisable for each medical records librarian to ascertain the status of microfilmed records in her jurisdiction. Ditto copies and Photostats are accepted as meeting the requirements of the best evidence law. An additional duty frequently added to the many already assigned to the medical records librarian is that of ''watch dog'' for the legality of consents. As watch dog, she should remember that the forms of consent for operation, autopsy and release from hospital must be legally executed. To ascertain this, she must know that the signature is that of a person not since deceased, for the authorization invalidates the document. However, this factor will usually only enter the case when the consent is for the release of privileged communication. The consent should also be duly witnessed and by an individual not implicated in the consent or the action authorized in the consent. For the own protection and for the protection of the institution for whom she works, the medical records librarian must clearly understand the implications of liability for her own tortious acts and for the tortious acts of others, particularly if she functions in a supervisory capacity with administrative authority over assistants, stenographers, clerks and others. While recognizing her own responsibility, she should instill into her employees a similar recognition and administer her departments in such fashion that tortious acts do not occur. Her assistants and subordinates will look for guidance in problems concerning privileged communications and other matters, and she must by advice, instruction and example set a pattern of action which will at all times conform to ethical and legal requirements of human relationship. From time to time, the medical records librarian may appear in a court before a compensation commission or other tribunal in response to the service of a subpoena ducestecum as the custodian of the record. It is her responsibility to obey the subpoena if legally served, and it is not her responsibility to question the use of the record for purposes of evidence, it is suggested that she refer the matter to the hospital's attorney through her administrative superior. Unless the hospital attorney can 126

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secure and injunction restraining the use of the record prior to the date of appearance in court, she is legally obligated to obey the subpoena under penalty of contempt of court. After the legal service of a subpoena, the individual ordered to appear must obey unless duly informed that the subpoena has been cancelled or an injunction issued to restrain the action of the subpoena. The latter will rarely happen, but it must be recognized as a possibility. Medical Record is a confidential report of the patient &can not be released without patients permission. Any information from the patients medical records should be released on written request by the patient e.g. to employer or to insurance companies. Police authorities and courts can summon medical records. How long to preserve the case papers; Limitation period for filing a case is maximum up to 3 years under the Limitation Act (2 years according to Consumer Protection Act) However, this limitation period starts only after the patient comes to know the effect of the alleged negligence on part of the doctor. An extreme example can be given of the obstetrician who was sued by the child who was delivered by him and suffered birth injury after 21 years i.e. within 3 years the child becoming major according to the law. Maharashtra government has issued a resolution (G.R. No. JJH-29 66/49733.) which states that OPD paper should be kept for 3 years, indoor for 5 years, and papers of Medico Legal Cases for 30 years. Filing of Records / Preservation of Medical Records: There are two common methods of numbering and filling records. One is the assignment of a new register number to each patient at time of admission. This is known as serial numbering and chart may be filed either separately under numbers as assigned to together under the most recent number. The latter is a modified of ''brought forward'' serial system. The second methods, called ''unit numbering'', is the assignment of one number to a patient on first admission, using that same number of subsequent admissions. With this type of system all records of a patient are kept together in one jacket regardless of the number of admission of the patient. There is varying opinion regarding unit records. There is no question as to their superior usefulness and value. The main question relates to the practical possibility of operating a unit record system. The major problem is one of space and this should be sufficient for an activity period of at least 5 years. Where sufficient space is unavailable and records must be retired to secondary filing space within a matter of months, it would be preferable to assign a serial number on each admission and bring forward the records of previous visits. There is merit in both plans and choice of one should be predicated on individual hospital facilities, staffing, patient populations and related factors. However, the unit records system reduces HOSPITAL SUPPORTIVE SERVICES

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work. Increase efficiency in statistical reporting and eliminates duplication of entries on the disease and operative index cards. Before a unit record system is installed, careful study should be made of: 1. Percentage of readmissions. 2. Activity of records (how often and over how long a period the records are used, or drawn from the files after permanent filing) 3. Average size of charts (the thickness of charts or the average number of pages in a chart). 4. Location of master name file for quick reference to previous admissions. Where a unit record is kept it is necessary to have this file conveniently located for the admission clerk. If a unit number is given and retained permanently for all read missions it becomes necessary to ascertain the number of charts that can be housed, then figure the percentage of readmission within the period it is planned to keep current records and determine the number of records allotted to each filing area. The major trend is towards terminal digit filing of records. This system facilities sorting, filing, and retrieval by being more accurate, faster and easier. Storage on open shelving is far preferable to the old methods of filling cabinets, making records more easily available and occupying less floor space. Microfilming of records has long been endorsed in most states as being legally acceptable. Its major advantage is that of saving storage space, in instances to such a degree as to offset costs of microfilming procedures. There are other advantages, but in the average hospital without heavy teaching and research activities, physicians still prefer reviewing the original record rather than using the microfilm reader. It has been reported that in the average hospital more than half of the records of former patients are seldom, if ever, recalled for study. Some of the contents of records, perhaps 50 per cent, are not worth microfilming, but it is usually cheaper to copy than to expend professional time in selecting pages for discard. A through review and detailed planned program, with expert assistance, is indicated before embarking upon microfilming efforts. With this the move should more than worth while. As stated earlier, the use of the computer, automatic data processing and other innovations will speed the revolution in records and record-keeping for hospitals, including medical information. The chances are good that in time may be no records as we know them today. THE HOSPITAL LIBRARY: Every hospital should have a good library. The real value that can be obtained from library services is dependent upon the interest that can be created by and 128

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among the medical and administrative staffs. Use of the library is usually proportional to the desire for self-improvement and for betterment of the hospital. Interesting and stimulating staff meetings and clinical conferences by the medical staff, and comparable study, review and presentation of subject matter on pertinent problem by nursing, supervisory, administrative and departmental personnel, will give all a feeling of pride in growth and accomplishment. Bibliographies and review of current literature inappropriate fields can be valuable contributions to better staffs, hospitals and patient care. Medical libraries are required in all hospitals approved for internship and residency. A library for nursing personnel, with or without a school of nursing, is of equal import, as in an administrative library for personnel in that and supervisory capacities. Library services for patients are always desirable, of course. These four groupings, with proper organization and supervision add immeasurably to the quality of hospital services. The organization of the hospital library and the services it will render are inseparably related. The medical section may provide a catalogued library of current textbooks and monographs; bound volumes of journals; various indexes, such as the Quarterly Cumulative Index Medicus, and special lists. Other services which should be provided are editing, abstracting and translating, as well as maintenance of card catalogs, complication of references routing of references materials and journals and the collection of reprints. The library committee of the medical staff assumes the responsibility for development of this service, in close co-operation with the librarian. The extent and content of the medical library will vary with programs, needs, and interests of the staff. Hospital Libraries - Objectives and Standards, reissued in 1963 through the American Library Association, indicates that a general hospital of 100 or more beds should have at least 1000 volumes of high quality, a large majority of which should have been purchased within a decade. The library should have a minimum of 25 periodicals of current value, and appropriate indexes. The library for nursing personnel, student and graduate, will follow a similar pattern. It should provide material for professional advancement, of general educational items, and administrative and clinical texts and journals and recreational reading. Educational institutions, state and national organization have suggestions for such libraries. The third library grouping and one that is too often entirely inadequate is a planned service on administrative and management matters. The hospital administrator has the responsibility to see that he has for himself, the governing board, departmental heads and all employees having supervisory and operational duties, access to literature on HOSPITAL SUPPORTIVE SERVICES

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pertinent subjects. The American Hospital Association issues a Cumulative index a Hospital Literature which is extremely valuable. Periodic review of all library content and elimination of obsolete material is necessary. The fourth grouping is the patient's library, which is of particular value in hospitals with longer than average patient stay. The patient's library can furnish a scope literature for those who will benefit, as well as material having educational value. The librarian who makes the rounds to learn patient's tastes in reading will find them as different as individual personalities, but most patients want literature that will stimulate and cheer. The Library Association suggests the basic number of volumes should not be less than eight books per patient in general hospitals up to 300 beds in size, decreasing to a minimum of four books per patient in extremely large hospitals of 1,100 - 1,500 beds. Special or long stay hospitals, with exception of the larger mental hospitals, will require up to half again as many more. Supervision of the hospital library should be by a full-time trained librarian. However, except in the larger teaching hospitals the extent of utilization of library services generally has not developed to the point which requires the full-time services of the professional librarian. In the average hospital with only limited library services, the medical records librarian is often given the responsibility by design or default. Professionally trained medical records librarians have included in their courses some instruction in general library technique. Unfortunately the medical records librarian is usually too burdened with other duties to give the library the attention it deserves, and which she would like to give. Where the time of the librarian does not permit sufficient attention, consideration might be given to joint employment of a professional librarian by two or more hospitals. Exchange of books and periodicals might also be an advantageous arrangement In some cities affiliation with the public library has provided trained supervision, books and special services for the local hospitals. Exchange of books and periodicals might also be an advantageous arrangement. In some cities affiliation with the public library has provided trained supervision, books and special services for the local hospital. Volunteers and auxiliary organizations are often willing and enthusiastic assistants in carrying library services.

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CHAPTER - 7

BIO-MEDICAL WASTE 7.1 INTRODUCTION Medical care is vital for our life, health and well being. But the waste generated from medical activities can be hazardous, toxic and even lethal because of their high potential for diseases transmission. The hazardous and toxic parts of waste from health care establishments comprising infectious, bio-medical and radioactive material as well as sharps (hypodermic needles, knives, scalpels etc.) constitute a grave risk, if these are not properly treated/disposed or is allowed to get mixed with other municipal waste. Its propensity to encourage growth of various pathogen and vectors and its ability to contaminate other nonhazardous/ non-toxic municipal waste jeopardises the efforts undertaken for overall municipal waste management. The rag pickers and waste workers are often worst affected, because unknowingly or unwittingly, they rummage through all kinds of poisonous material while trying to salvage items which they can sell for reuse. At the same tim e, this kind of illegal and unethical reuse can be extremely dangerous and even fatal. Diseases like cholera, plague, tuberculosis, hepatitis (especially HBV), AIDS (HIV), diphtheria etc. in either epidemic or even endemic form, pose grave public health risks. Unfortunately, in the absence of reliable and extensive data, it is difficult to quantify the dimension of the problem or even the extent and variety of the risk involved. With a judicious planning and management, however, the risk can be considerably reduced. Studies have shown that about three fourth of the total waste generated in health care establishments is non-hazardous and non-toxic. Some estimates put the infectious waste at 15% and other hazardous waste at 5%. Therefore with a rigorous regime of segregation at source, the problem can be reduced proportionately. Similarly, with better planning and management, not only the waste generation is reduced, but overall expenditu re on waste management can be controlled. Institutional/Organisational set up, training an d motivation are given great importance these days. Proper training of health care establishment personnel at all levels coupled with sustained motivation can improve the situation considerably. The rules framed by the Ministry of Environment and Forests (MoEF ), Govt. of India, known as 'Bio-medical Waste (Management and Handling) Rules, 1998,' notified on 20th July 1998, provides uniform guidelines and code of practice for the whole nation. It is clearly HOSPITAL SUPPORTIVE SERVICES

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mentioned in this rule that the 'occupier' (a person who has control over the concerned institution / premises) of an institution generating bio-medical waste (e.g., hospital, nursing home, clinic, dispensary, veterinary institution, animal house, pathological laboratory, blood bank etc.) shall be responsible for taking necessary steps to ensure that such waste is handled without any adverse effect to human health and the environment. Definition : 'Bio -medical waste' means any solid and/or liquid waste including its container and any intermediate product, which is generated durin g the diagnosis, treatment or immunisation of human beings or animals or in research pertaining thereto or in the production or testing thereof. The physico-chemical and biological nature of these components, their toxicity and potential hazard are different, necessitating different m ethods / options for their treatment / disposal. In Schedule I of the Bio-medical Waste (Management and Handling) Rules, 1998 (Annexure II), therefore, th e waste originating from different kinds of such establishments, has been categorised into 10 different categories (as mentioned in the box below) and their treatment and disposal options have been indicated. Components of Bio-medical waste (i) human anatomical waste - (tissues, organs, body parts etc.), (ii) animal waste - (as above, generated during research/experimentation, from veterinary hospitals etc.), (iii) microbiology and biotechnology waste, -such as, laboratory cultures, micro -organisms, human and animal cell cultures, toxins etc., (iv) waste sharps , hypodermic needles, syringes, scalpels, broken glass etc., (v) discarded medicines and cyto -toxic drugs (vi) soiled waste, such as dressing, bandages, plaster casts, material contaminated with blood etc., (vii) solid waste (disposable items like tubes, catheters etc. excluding sharps), (viii) liquid waste generated from any of the infected areas, (ix) incineration ash, (x) chemical waste. H ealth hazards associated with poor management of B-imoedical waste (i) Injury from sharps to staff and waste handlers associated with the health care establishment. (ii) Hospital Acquired Infection(HAI)(Nosocomial) of patients due to spread of infection. (iii) Risk of infection outside the hospital for waste handlers/scavengers and eventually general public. (iv) Occupational risk associated with hazardous chemicals, drugs etc. 132

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(v) Unauthorised repackaging and sale of disposable items and unused / date expired drugs. The environmental hazards are mentioned at 7.4.2. 7.1.1 Linkage of Bio-medical Waste Management with Municipal Waste Management At present, the role of the civic body with respect to the management of biomedical waste is not clearly efined, leading to confusion and laxity either side. . Since majority of the health care establishments are located with in the municipal area, their waste management naturally has a close linkage with the municipal system. At the same time, the ci vic authority is responsible for public health in the whole of the municipal area. Therefore, the health care establishments must have a clear understanding with the municipality regarding sharing of responsibilities associated with this issue. . Studies have shown that about three fourth of the total hospital waste is not hazardous / infected (provided strict segregation is practised) and can even be taken care of by the municipal waste management system, e.g., waste generated at the hospital kitchen or garden, the office or packaging material from the store etc. . Such practices of strict and careful segregation would reduce the load and the cost of management of the actually hazardous and infected bio-medical waste (collection, transportation, treatment and disposal). . Since, it would not be possible for each and every health care establishment to have its own full fledged treatment and disposal system for bio-medical waste, there would be need for common treatment and disposal facilities under the ownership/supervision/guidance of the civic authority (discussed in para 7.9). From the above mentioned issues, it is clear that the success of the biomedical waste management program depends on proper in-house management (within the health care establishment) and co-ordination and co-operation amongst the various establishments themselves as well as with the civic authority. Hence this chapter discusses both these aspects. 7.2 ASSESSMENT OF CURRENT SITUATION An assessment of the situation obtaining within the individual health care establishments as well as the town/city as a whole is necessary before making any attempts for improvement. Essentially this involves three steps : . survey of waste generation HOSPITAL SUPPORTIVE SERVICES

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. documentation of prevailing practices . allocation of responsibilities 7.2.1 Waste Generation Qualitative as well as quantitative survey of the waste generated is the goal of this step. This needs to be broadly carried out for : (i) Health care establishments - as units and (ii) The whole town / city 7.2.1.1 Health Care Establishments Each establishment has to chalk out a programme for qualitative as well as quantitative survey of the waste generated depending on the medical activities and procedures followed by it. In order to asses the current situation, the following have to be included (as applicable) in the survey as per the time frame indicated : Table . A HOSPITAL WASTE CLASSIFICATION DIFFERENT STREAMS OF WASTE PRODUCTION Office House Kitchen Clinical Areas Keeping Human laundry Food From Wards Resources Purchasing Services Public Lab Gift Shops Radiology Receiving & Pharmacy Shipping O.T. I .C.C.U. Security Post Mortem Infectious Hazardous Recyclable Reusable Municipal Recyclable Body 15% 5% S.W.M. Vermi-Culture 80% 20% HANDLING HOSPITAL WASTE HOSPITAL WASTE INFECTIOUS NON-INFECTIOUS (A) (B) (C) SHARP NON KITCHEN CARD BOARD NEEDLES SHARP WASTE BOXES. ETC. 134

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SCALPEL BLADES (D) CONTAMINATED LABORATORY WASTE WASTE, RELATED SECRETIONS EXCRETIONS (E) (F) (G) (H) PLASTICS, PVC. PEPET NON PLASTIC SPECIMEN PATHOLOGY PP ETC. COTTON (BLOOD & TISSUES (SOFT PLASTIC, BLOOD GAUZ BODY FLUIDS) ANIMAL BAGS, I .V. CATH LINEN CARCAS RESPIRATARY EQUIPMENTS A = Dispose in puncture proof containers containing 1% hypochlorite solutions (destroy needle in cutter / burner depositing in container) B = Dispose off in black bags – (1) biodegradable (2) non biodegradable. C = Collect in big boxes or bags – for selling to Raddiwala or to scrap dealer. D = Secretions excretion – decontaminate – drain. Containers – decontaminate – autoclave E = Blood bags – autoclave under supervision and incineration. Plastic tubing – I .V. put in sodium hypochlorite – shred – recycle. F = Cotton gauze – Incineration Linen – decontaminate dip in 5% sodium hypochlorite wash in hot soap water – laundry. G = Lab. Specimen – microwave Culture autoclave – general waste Fluids – decontaminate – drain H = Pathological tissue formaline – incineration Animal Caracas – incineration. The concerned medical establishment should constitute a team of I ts experts, concerned personnel and workers (doctors, chemists, laboratory technicians, hospital engineers, nurses, cleaning supervisors/inspectors, cleaning staff etc.). If such expertise is not available, it may take the help of external experts in the field who can help them carry out the survey work . A third alternative is possible if expert agencies are available who carry out the whole work on contract as a package. In either case, the medical establishment has to earmark a suitable placewhere the qualitative and quantitative tests can be carried out. This place should be an enclosed space. Depending upon the requirement, it can be a large room or a hall or at least a covered shade with proper fencing. Unauthorised entry to this space should be strictly restricted. It should be well HOSPITAL SUPPORTIVE SERVICES

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lighted. The place should be washed and disinfected daily and preferably dry and clean. The waste generated by all the departments has to be collected according to the prevailing practices of collection but due care has to be taken to see that no portion of the total waste generated is missed out from this survey. The waste so collected (except the liquid waste and incineration ash) has to be sorted out into the different categories according to the Schedule I of the Biomedical Waste (Management and Handling) Rules, 1998 (as applicable). If an incinerator is operating within the hospital campu s, then the incinerator ash produced every day has to be weighed. This can be done once a day. At the same time the total aste incinerated every day has also to be recorded. The liquid waste may be divided into two components : (a ) liquid reagents/chemicals discarded and (b) the cleaning and washing water channelled into the drain. The first component can be easily measured by a measuring cylinder or other suitable measuring device before discarding each ti me and keeping suitable records. The second component can be derived from the total water used in the hospital or by using appropriate flow metres. The survey needs to be carried out at least for 3 days a week in continuation followed by similar exercise for 4 weeks (preferably alternate weeks for better reproducibility of the data). The result is then compiled for both quantitative as well as qualitative data. 7.2.2 Current Practices The current practices in relation to waste management in the particular health care establishment need to be recorded with respect to the following activities for each unit (i.e., wards, operation theatres, laboratories etc.) : . Storage of waste at the point of generation. . Whether one container is used for all waste or different containers are used for different types of waste ? . How frequently the waste material is removed and to where ? . Is there any intermediate storage of the waste before it is moved in bulk outside the hospital campus ? . Who removes the waste material from the points of generation ? . Whether any measures are taken to deter further unauthorised reuse of the discarded items, such as cutting/ mutilating needles, plastic tubes, gloves etc. ? . Is there an incineration plant in the hospital ? If yes, what are the materials incinerated and what happens to the ash/ clinkers? 136

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. What happens to the waste once it is removed from the health care establishment - can it be tracked ? . Is there any strategy/plan and administrative support for tackling this issue? 7.2.3 Allocation of Responsibilities The administrative head of the health care establishment should carry out an exercise of documenting the current allocation of responsibilities with relation to waste management within its premises. In large establishments, specialised services of consultants/experts should be sought. Each departmental head should be involved in the exercise. Organisational chart indicating specific accountability of staff at each level in each department needs to be prepared. 7.3 BASIC ISSUES Health care waste is a heterogeneous mixture, which is very difficult to manage as such. But the problem can be simplified and its dimension reduced considerably if a proper management system is planned. Therefore it is important to take a brief look at the management issues. 7.3.1 Management Issues of Bio-medical Waste Management The management principles are based on the following aspects : . Reduction/control of waste (by controlling inventory, wastage of consumable items, reagents, breakage etc.). . Segregation of the different types of wastes into different categories according to their treatment/disposal options given in Schedule I of the Rules mentioned above. . Segregated collection and transportation to final treatment/disposal facility so that they do not get mixed. . Proper treatment and final disposal as indicated in the rules. . Safety of handling, full care/protection against operational hazard for personnel at each level. . Proper organisation and management. 7.3.2 Current Issues in Management of Health Care Waste There are two main issues at present : the recent legislation by the Govt. of India and . implementation of the same at individual health care establishments level as well as whole town / city level. The recent legislation has fulfilled a long standing necessity. No w this sector has got clear cut guidelines which should be able to initiate a u niform standard of practice through out the country. It would be necessary to implement proper HOSPITAL SUPPORTIVE SERVICES

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bio-medical waste management system for each and every hospital, nursing home, pathological laborator y etc. Comprehensive management system for each and every health care establishment has to be planned for optimal technoeconomic viability. At the same time the final disposal for the whole town must not be lost sight of. Since there are a large number of small and medium health care establishments, com mon treatment and disposal facilities are essential. 7.4. LEGAL ASPECTS AND ENVIRONMENTAL CONCERN Indiscriminate disposal of infected and hazardous waste from hospitals, nursing homes and pathological laboratories has led to significant degradation of the environment, leading to spread of diseases and putting the people to great risk from certain highly contagious and transmission prone disease vectors. This has given rise to considerable environmental concern. The first standard on the subject to be brought out in India was by the Bureau of Indian Standards (BIS), IS 12625 : 1989, entitled 'Solid Wastes- Hospitals- Guidelines for Management' (Annexure 7.1) but it was unable to bring any improvement in the situation. In this scenario, the notification of the 'Biomedical waste (Management & Handling) Rules, 1998' assumes great significance. 7.4.1. Bio-medical Waste (Management and Handling) Rules, 1998 The Central Govt. has notified these rules on 20th July, 1998 in exercise of section 6, 8 and 25 of the Environment (Protection) Act, 1986. Prior to that, the draft rules were gazetted on 16th October, 1997 and Public suggestion/comments were invited within 60 days. These suggestion were considered before finalising the rules. The text of the rules( English version) is annexed (Annexure-7.2). Scope and application of the Rules These rules apply to all those who generate, collect, receive, store, transport, treat, dispose or handle bio-medical waste in any form. According to these rules, it shall be the du ty of every occupier of an institution generating bio medical waste, which includes hospitals, nursing homes, clinics, dispensaries, veterinary institution, animal houses, pathology laboratories, blood banks etc., to take all steps to ensure that such wastes are handled without any adverse effect to human health and the environment. They have to either set up their own facility within the time frame (schedule VI) or ensure requisite treatment at a common waste treatment facility or any other waste treatment facility. Every occupier of an institution, which is generating, collecting, receiving, storing, transporting, treating, disposing and/or handling bio-medical waste 138

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in any other manner, except such occupier of clinics, dispensaries, pathological laboratories, blood banks etc., which provide treatment/service to less than 1000 (one thousand) patients per month shall make an application in prescribed form to the prescribed authority for grant of authorisation to carry on the work. Whenever an accident occurs on cerning bio-medical waste, it has to be reported to this authority. Each State and Union Territory (UT) Government shall be reqired to establish a prescribed authority for this purpose. The respective governments would also constitute advisory committees to advise the Govts with respect to implementation of these rules. The occupier or operator can also appeal against any order of the authority if they feel aggrieved to such other authority as the Govt. of the State/UT may think fit to constitute. Prescribed Authorities, so far established by various State Governments are listed at Annexure 7.3 and the time limit as per schedule VI of the 'Bio-Medical(Management & Handling) Rules,1998. 7.4.2 Environmental Concern The following are the main environmental concerns with respect to improper disposal of bio-medical waste management: . Spread of infection and disease through vectors (fly, mosquito, insects etc.) which affect the in -house as well as surrounding population. . Spread of infection through contact/injury among medical/nonmedical personnel and sweepers/rag pickers, especially from the sharps (need less, blades etc.). . Spread of infection through un authorised recycling of disposable items such as hypodermic needles, tubes, blades, bottles etc. . Reaction due to use of discarded medicines. . Toxic emissions from defective/inefficient incinerators. . Indiscriminate disposal of incinerator ash / residues. 7.5. WASTE IDENTIFICATION AND WASTE CONTROL PROGRAM FOR THE HEALTH CARE ESTABLISHMENTS In facwtaste identification is an important tool of waste control programme. The necessity of segregation has already been mentioned. The use of colour coding and labelling of hazardous waste containers prov ides great assistance in waste separation. Without opening a container one can easily know about the contents. Therefore, in addition to segregation, separate transportation and storage is also facilitated.


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7.5.1 Identification of Various Components of the Waste Generated The Bio-medical waste (Management and Handling) Rules, 1998 says that such waste shall be segregated into containers/bags at the point of generation in accordance with Schedule II of the rules prior to its storage, transporantation, treatment and disposal. This would help in easy identification f the various components of health care waste. All containers bearing hazardous material must be adequately labelled according to Schedule IV of the Rules (Annexure 7.2). 7.5.2. An Exercise in Waste Control Programme For larger health care establishments such as hospitals, a comprehensive exercise needs to be carried out for evolving its own waste management plan/programme, consisting of the following steps: 1. Documenting the medical/bio-medical practice/procedures carried out by the particular health care establishment by enlisting categories of waste generated as per schedule I of the rules. 2. Assessing current practices and responsibilities (as mentioned earlier). 3. Assessing current costs for hazardous waste management. 4. Developing an effective bio-medical waste management policy/plan according to the Rules and 5. Implementation of the plan. It is important to identify the current costs associated with waste management. Purchasing and inventory practices, for example, must be closely examined to identify the costs related to the disposables, recyclables etc. All associated materials (e.g. gloves, boots, brushes, disinfectants etc.), cost of fuel (for incinerator, vehicles), electricity etc. as well as man hours should be accounted for. Based on these results, a comprehensive policy has to be framed in consonance with the govt. rules so that compliance is achieved. An official statement incorporating all practices from the segregated storage through transportation, treatment and final disposal should be repared and wide ly circulated after due approval. 7.6 WASTE STORAGE Storage of waste is necessary at two points : (i) at the point of generation and (ii) common storage for the total waste inside a health care organisation. For smaller units, however, the common storage area may not be possible. Systematic segregated storage is the most important step in the waste control programme of the health care establishment. For ease of identification and 140

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handling it is necessary to use colour coding, i.e., use of specific coloured container with liner / sealed container (for sharps) for particular wastes. It must be remembered that according to the Rules, untreated waste should not be stored beyond a period of 48 hours. 7.6.1 Recommended Labelling and Colour Coding These have to be in accordance with Schedule II of the notified rules(Annexure 7.2). A simple and clear notice, describing which waste should go to which container and how frequently it has to be routinely removed and to where, is to be pasted on the wall or at a conspicuous place nearest to the container. The notice should be in English, Hindi and the predominant local language. Preferably,it should have drawings correlating the container in appropriate colour with the kind of waste it should contain. 7.6.2 Segregated Storage in Separate Containers (at the Point of Generation) Each category of waste (according to treatment options mentioned in Schedule I of the rules) has to be kept segregated in a proper container or bag as the case may be. Such container / bag should have the following property : . It must be sturdy enough to contain the designed maximum volume and weight of the waste without any damage . It should be without any puncture/leakage. . The container should have a cover, preferably operated by foot. If plastic bags are to be used, they have to be securely fitted within a container in such a manner that they stay in place during opening and closing of the lid and can also be removed without difficulty. . The sharps must be stored in puncture proof sharps containers. But before putting them in the containers, they must be mutilated by a needle cutter, placed in the department/ward itself. The bags/containers should not be filled more than 3/4th capacity. Attempts should be made to designate fixed places for each container so that it becomes a part of regular scenario and practice for the concerned medical as well as nursing staff. The specification for the containers is mentioned in chapter 4 of this manual. 7.6.3 Certification When a bag or container is sealed, appropriate label (s) clearly indicating the following information (as per Schedule IV of the Rules) has to be attached. A water-proof marker pen should be used for writing. They should be labelled with the 'Biohazard' or 'cyto-toxic' symbol as the case may be according to HOSPITAL SUPPORTIVE SERVICES

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Schedule III of the rules (Annexure 7.2). . The containers should bear the name of the department/laboratory from where the waste has been generated so that in case of a problem or accident, the nature of the waste can be traced back quickly and correctly for proper remediation and if necessary, the responsibility can be fixed. . The containers should also be labelled with the date, name and signature of the person responsible. This would generate greater accountability. . The label should contain the name, address, phone/fax nos. of the sender as well as the receiver. . It should also contain name, address and phone/fax nos. of the person who is to be contacted in case of an emergency. 7.6.4 Common/Intermediate Storage Area Collection room(s)/intermediate storage area where the waste packets/bags are collected before they are finally taken/transported to the treatment/disposal site are necessary for large hospitals having a number of departments, laboratories, OTs, wards etc. This is all the more important when the waste is to be taken outside the premises. Two rooms - one for the general and the other for the hazardous waste are preferable (details at 7.14.1, 5th point). In case of shortage of rooms, the general waste (non-hazardous) can be directly stored outside in dumper containers with lids of suitable size. Arrangement for separate receptacles in the storage area with prominent display of colour code on the wall nearest to the receptacles has to be made. When waste carrying carts/containers arrive at this area, they have to be systematically put in the relevant receptacle/designated area. 7.6.5 Parking Lot for Collection Vehicles A shed with fencing should be provided for the carts, trolleys, covered vehicles etc. used for collecting or moving the waste material. Care has to be taken to provide separate sheds for the hazardous and non-hazardous waste so that there is no chance of cross contamination. Both the sheds should have a wash area provided with adequate water jets, drains, raised platform, protection walls to contain splash of water and proper drainage system. 7.7 HANDLING AND TRANSPORTATION This activity has three components: collection of different kinds of waste (from waste storage bags/containers) inside the hospital, transportati on and intermediate storage of segregated waste inside the premises and transportation of the waste outside the premises (to the treatment/disposal facility). 142

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7.7.1 Collection of Waste Inside the Hospital/Health Care Establishment The collection containers for bio-medical waste have to be sturdy, l eak proof, of adequate size and wheeled. Two wheeled bins of 120-330 litre capacity and four wheeled bins of 500-1000 litre capacity (IS 12402, Part I, 1988) may be used. The 4 wheeled containers have two fixed wheels and two castors and they are fitted with wheel locking devices to prevent unwanted rolling. There should be no sharp edges or corners, especially in metallic bins. Specifications of bins are mentioned in chapter 4 of this manual. For convenience as well as for avoiding any confusion, the colour code applicable for the bags / containers should also be used for the bins. Collection timings and duty chart should be put in a prominent place with copies given to the concerned waste collectors and supervisors. For general waste from the office, kitchen, garden etc., normal wheel-barrows may be used. 7.7.2 Transportation of Segregated Waste Inside the Premises All attempts should be made to provide separate service corridors for taking waste matter from the storage area to the collection room. Preferabl y these corridors should not cross the paths used by patients and visitors. The waste has to be taken to the common storage area first, from where it is to be taken to the treatment/disposal facility, either within or outside the premises as the case may be. As already mentioned under 7.6.4, the wheel-barrows containing general waste may be sent to a dumper container or further segregated as described under section 7.8.7 (later). 7.7.3 Collection and Transportation of Waste for Small Units Smaller units, such as, nursing homes, pathological laboratories etc. do not have many departments/divisions and the generation of waste ais small nd normally they do not have treatment facility for the bio-medical waste. In their case, intermediate storage area is not required. They should install a needle cutter and a small device for cutting plastic tubing, gloves etc. In case, highly infectious bio-medical waste is expected to be generated, they may consider to install a separate steam autoclave of suitable size exclusively for this purpose. Adequate precaution must be taken to ward off any occupational hazard or environmental problem. This particular autoclave should never be use d for sterilising medical supplies or surgical equipment. Such establishments require provision for segregated storage (according to the rules) which can be packed in sealed containers/sturdy bags and handed over to the agency carrying them to the common treatment/disposal facility.


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7.7.4 Transportation of Waste Outside In case of off-site treatment, the waste has to be transported to the treatment/disposal facility site in a safe manner. The vehicle, which ma y be a specially designed van, should have the following specifications : . It should be covered and secured against accidental opening of door, leakage/spillage etc. . The interior of the container should be lined with smooth finish of aluminium or stainless steel, without sharp edges/corners or dead spaces, which can be conveniently washed and disinfected. . There should be adequate arrangement for drainage and collection of any run off/leachate, which may accidentally come out o f the waste bags / containers. The floor hould have suitable gradient, flow trap and collection container. . The size of the van would depend on the waste to be carried per trip. . In case, the waste quantity per trip is small, covered container of 1-2 cu.m., mounted on 3 wheeled chassis and fitted with a tipping arrangement can be used. 7.8 WASTE TREATMENT AND DISPOSAL : THE RULES AND THE AVAILABLE OPTIONS Different methods have been developed for rendering bio-medical waste environmentally innocuous and aesthetically acceptable but all of them are not suitable for our condition. The 'Bio-Medical Waste (Management & Handling) Rules, 1998' has elaborately mentioned the recommended treatment and disposal options according to the 10 different categories of waste generated in health care establishments in Schedule I of the rules (Annexure 7.2). Standard s for the treatment technologies are given in Schedule V of the Rules, which must be complied with. A comparison of the advantages and limitations of the different technologies for treatment of bio-medical waste is given at Annexure A review of the above schedule would show that there is no single technology, which can take care of all categories of bio-medical waste. A judicious package has to be evolved for this purpose. For example, small and medium hospitals can opt for local (in house) disinfection, mutilation / shredding and dedicated autoclaving plus off-site incineration at a common treatment / disposal facility followed by disposal in sanitary and secured landfills. 7.8.1 Incineration This is a high temperature thermal process employing combustion of the waste 144

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under controlled condition for converting them into inert material and gases. Incinerators can be oil fired or electrically powered or a combination thereof. Broadly, three types of incinerators are used for hospital waste : multiple hearth type, rotary kiln and controlled air types. All the types can have prim ary and secondary combustion chambers to ensure optimal combustion. T hese are refractory lined. In the multiple hearth incinerator, solid phase combustion takes place in the primary chamber whereas the secondary chamber is for gas phase combustion. These are referred to as excess air incinerators because excess air is present in both the chambers. The rotary kiln is a cylindrical refractory lined shell that is mounted at a slight tilt to facilitate mixing and movement of the waste inside. It has provision of air circulation. The kiln acts as the primary solid phase ch amber, which is followed by the secondary chamber for the gaseous combustion. In the third type, the first chamber is operated at low air levels followed by an excess air chamber. Due to low oxygen levels in the primary chamber, there is better control of particulate matter in the flue gas. In a nutshetll, he primary chamber has pyrolytic conditions with a temperature range of about 800 (+/-) 50 deg. C. The secondary chamber operates under excess air conditions at about 1050 (+/ -)50 deg. C (Schedule V of the Rules). The volatiles are liberated in the first chamber whereas they are destroyed in the second one. Some models are fitted with Eductor mechanism , which maintains the system under negative pressure and helps control the flue gases more effectively. The chimney height should be minimum 30 meters above ground level. Installation of incinerators in congested area is not desirable. In the Bio medical Waste (Management and Handling) Rules, Incineration has been recommended for human anatomical waste, animal waste, cyto-toxic drugs, discarded medicines and soiled waste. 7.8.2 Autoclave Treatment This is a process of steam sterilisation under pressure. It is a low heat process in which steam is brought into direct contact with the waste material for duration sufficient to disinfect the material. These are also of three types : Gravity type, Pre-vacuum type and Retort type.In the first type (Gravity type), air is evacuated with the help of gravity alone. The system operates with temperature of 121 deg. C. and steam pressure of 15 psi. for 60-90 minutes. Vacuum pumps are used to evacuate air from the Prevacuum autoclave system so that the time cycle is reduced to 30-60 minutes. It operates at about 132 deg. C. Retort type autoclaves are designed to handle much larger volumes and HOSPITAL SUPPORTIVE SERVICES

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operate at much higher steam temperature and pressure. Autoclave treatment has been recommended for microbio logy and biotechnology waste, waste sharps, soiled and solid wastes (as mentioned in the table above). This technology renders certain categories (mentioned in the rules) of bio-medical waste innocuous and unrecognisable so that the treated residue can be landfilled. Sanjay Gandhi Memorial Hospital in Delhi has installed a Prevacuum Autoclave. 7.8.3 Hydroclave Treatment Hydroclave is an innovative equipment for steam sterilisation process (like autoclave). It is a double walled container, in which the steam is injected into the outer jacket to heat the inner chamber containing the waste. Moisture contained in the waste evaporates as steam and builds up the requisite steam pressure (3536 psi). Sturdy paddles slowly rotated by a strong shaft inside the chamber tumble the waste continuously against the hot wall thus mixing as well as fragmenting the same. In the absence of enough moisture, additional steam is injected. The system operates at 132 deg.C. and 36 psi steam pressure for sterilisation time of 20 minutes. The total time for a cycle is about 50 minutes, which includes start-up, heat-up, sterilisation, venting and depressurisation and dehydration. The treated material can further be shredded before disposal. The expected volume and weight reductions are upto 85% and 70% respectively. The hydroclave can treat the same waste as the autoclave plus the waste sharps. The sharps are also fragmented. This technology has certain benefits, such as, absence of harmful air emissions, absence of liquid discharges, nonrequirement of chemicals, reduced volume and weight of waste etc. Tata Memorial Hospital in Mumbai has installed the first hydroclave in India in September 1999. 7.8.4 Microwave Treatment This again is a wet thermal disinfection technology but unlike other thermal treatment systems, which heat the waste externally, microwave heats the targeted material from inside out, providing a high level of disinfection. The input material is first put through a shredder. The shredded material is pushed to a treatment chamber where it is moistened with high temperature steam. The material is then carried by a screw conveyor beneath a series (normally 4-6 nos.) of conventional microwave generators, which heat the material to 95-100 deg. C. and uniformly disinfect the material during a minimum residence time of 30 minutes and total cycle is of 50 minutes. A second shredder fragments the material further into unrecognisable particles before it is automatically discharged into a conventional / general waste container. This treated materi al 146

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can be landfilled provided adequate care is taken to complete the microwave treatment. In the modern versions, the process control is computerised for smooth and effective control. Microwave technology has certain benefits, such as, absence of harmful air emissions (when adequate provision of containment and filters is made), absence of liquid discharges, non requirement of chemicals, reduced volume of waste (due to shredding and moisture loss) and operator safety (due to automatic ho isting arrangement for the waste bins into the hopper so that manual contact with the waste bags is not necessary). However, the investment cost is high at present. According to the rules, category nos, 3 (microbiology and biotechnology waste), 4 (waste sharps), 6 (soiled waste) and 7 (solid waste) are permitted to be microwaved. 7.8.5 Chemical Disinfecting This treatment is recommended for waste sharps, solid and liquid wastes as well as chemical wastes. Chemical treatment involves use of a t least 1% hypochlorite solution with a minimum contact period of 30 minutes o r other equivalent chemical reagents such as phenolic com pounds, iodine, hexachlorophene, iodine-alcohol or formaldehyde-alcohol combination etc. Preshredding of the waste is desirable for better contact with the waste material. In the USA, chemical treatment facility is also available in mobilevans. In one version, the waste is shredded, passed through 10% hypochlorite solut ion (dixichlor) followed by a finer shredding and drying. The treated ma terial is landfilled. 7.8.6 Sanitary and Secured Landfilling Sanitary and secured landfilling is necessary under the following circumstances : . Deep burial of human anatomical waste when the facility of proper incineration is not available (for towns having less than 5 lakh population and rural areas, according to Schedule I of the MoEF rules - Secured landfill). A schematic of deep burial is s hown as per Annexure 7.5 . Animal waste (under similar conditions as mentioned above) - Secured landfill. . Disposal of autoclaved/hydroclaved/microwaved waste (unrecognisable) - Sanitary landfill. . Disposal of incineration ash - Sanitary landfill. . Disposal of bio-medical waste till such time when proper treatment and disposal facility is in place - Secured landfill. . Disposal of sharp s - Secured landfill. This can also be done within a hospital HOSPITAL SUPPORTIVE SERVICES

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premises as mentioned below. In case disposal facility for sharps is not readily available in a town, health care establishments, especially hospitals having suitable land, can cons truct a concrete lined pit of about 1m length, breadth and depth and cover the same with a heavy concrete slab having a 1 - 1.5 m high steel pipe of about 50 mm diameter. Disinfected sharps can be put through this pipe. When the pit is full, the pipe should be sawed off and the hole sealed with cement concrete. This site should not be water logged or near a borewell. 7.8.7 General Waste The waste material generated from the office, kitchen, garden , store, chemicals counter etc., which are non-hazardous and non-toxic, may be taken care of as follows : . Composting of green waste - to be carried to a municipal facility or a private facility, if available. If suitable land is available, a hospital may consider composting its green waste within the campus itself taking all precautions regarding health and hygiene and safety to patients. . Recycling of packaging material (caution - medical supplies such as unused or scantily used disposable items or those of uncertain history should never be allowed to be recycled). Certificate indicating origin and of non-contamination, issued by the concerned medical authorities of the health care establishment before these wastes are handed over to the municipality / private operator is essential from the point of safety. 7.9 COMMON TREATMENT/DISPOSAL FACILITY Common treatment facilities are necessary because it is not feasib le for smaller health care establishments to set up a complete treatment and disposal system due to lack of space and trained manpower, minimum scale of operation and scale of economy. Even large establishments located in congested or densely populated areas can not have such units due to environmental constraints . According to the rules, different kinds of treatment are required for different components of health care waste and the post-treatment residues have to be safely disposed. Hence, it is desirable that every town/city should have at least one common treatment facility, which may be used by all the units who can not have their own facility. It can be set up at the treatment / disposal and landfill site for the municipal garbage, with adequate precaution and control. 7.9.1 Establishment of the Facility The common treatment/disposal facility, as the name suggests, would consist 148

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of (i) the treatment unit(s) and (ii) a sanitary/secured landfill for the final disposal of the treated residues and incinerator ash. The treatment c hain, of necessity would consist of a properly designed incinerator (especially for human anatomical waste) and other systems such as autoclave/ hydroclave/ microwave unit etc. Chemical treatment units may also be added if felt necessary. The treatment part can also be a mobile facility, with the incinerator and the landfill located conveniently at one place. Usually these are large vans (as shown in the picture) housing small equipment for size reduction and microwave / chemical treatment. The van moves along a pre-planned route and is occasionally parked in certain zones, where it receives the bio-medical waste and treats the components which, according to the prevailing rules can be subjected to microwave treatment. Finally it reaches the static facility for incine ration of human anatomical waste and for secured landfilling of mutilated sharps and other final disposable items. The concerned medical establishments should establish such facilities by creating a common pool and platform. Proper planning followed by preparation of a feasibility report is necessary. The fund for capital investment may be raised by proportional contribution from participating institutions. The cost of operation & maintenance (O&M) may be met by monthly billing against advance deposit. Alternatively, private entrepreneurs may be encouraged to set up such facility on build, own, operate (BOO) basis (section 7.9.3). The State Health Authority or the Civic Authority may consider to establish at least one full-fledged facility with its own investment and operate the same through private operators on full cost recovery (capital as well as O&M) basis. Such a facility may act as a catalyst and a model for replication.


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CHAPTER - 8

FIRE SAFETY SERVICES DEPARTMENT GENERAL SAFETY The fundamental responsibility for maintenance of safety rests with the governing board. However, the responsibility of the administrator is only slightly less, both morally and legally. Under the administrator some major department head, such as the chief engineer, may be delegated a considerable amount of responsibility. In any case such a person must possess the ability to influence all other personnel if the total safety program is to succeed. While many aspects of a safety program are handled satisfactorily through a good preventive maintenance program, every hospital should have a formally organized safety committee, which is required to meet regularly. In addition to the administrator, the engineer, the housekeeper, and representative of the medical and nursing services, a number of the governing board the local fire marshal, and a safety engineer, if available, should be in attendance. FIRE SAFETY The fire protection program is an indispensable part of the general safety program of the hospital. Fire safety is so important to all hospital administrators, employees and designers that the leadership in the hospital field should make every effort to keep abreast of current developments in the fire safety field. Each of these person's actions, no matter how routine, may have an important bearing on the total fire safety environment of the hospital's occupants. Fires continue to occur in hospitals. Fortunately, most of the fires are small, are discovered early, and are extinguished promptly. However, no one can predict just when one of these major occurrences will get out of hand and cause a major disaster. The immediate effect of such a disaster is re-examination of the rules applying to fire prevention and fire protection. Frequently, because of the emotional reaction to the disaster, amendments to the rules overcompensate for previous deficiencies. Such extremes are neither desirable nor necessary. It would be much better if the basic principles of fire safety were constantly kept in mind during the design, construction, operation and maintenance of each hospital facility. Planning for fire safety can be divided into five steps: minimizing the chance of fire, early discovery, restricting fire spread, extinguishing the fire, and evacuating the building. 150

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MINIMIZING THE CHANCE OF FIRE The most effective contribution the building designer can make towards fire prevention is in the selection of proper and equipment. All materials used in building a hospital should be incombustible. Fabrics, trim and finishes, which because of esthetics or function cannot comply with this requirements, should be properly treated to reduce their combustibility. The fewer combustibles that can be used and the more combustibles that can be flame-proofed, the safer will be the patients in the hospital room or ward and the hospital personnel taking care of them. The proper selection and installation of equipment is very important in promoting high standards of maintenance and operation, thereby removing many chances of accidental fires. Sufficient space is required around and above all mechanical equipment and electrical services to permit safe operation and to encourage good maintenance. If equipment is placed in inaccessible locations, it will not receive adequate maintenance. Machinery that does not operate smoothly, hot bearings, parts that are broken, parts not properly aligned or loose pieces of metal can cause friction, heat and sparks that will lead to excessive wear of fire. It is good hospital design practice, therefore, to increase ceiling heights in kitchens, laundries, boiler rooms, mechanical equipment rooms, and similar spaces. Furl-fired equipment should be properly designed, adequate in size and correctly installed. Electrical devices, appliances and equipment should be of approved types and should be installed, operated and maintained in accordance with the manufactures' recommendations. Hospitals refrigerators are often used to store flammable liquids with low boiling points. These liquids can cause an explosive mixture that is ignited when the thermostat operates or the doors are opened and the electric switch for the interior light operates. Storing ether and similar chemicals in ordinary refrigerators cause numerous explosions. Such refrigerators can be made safe by the removal of all interior wires and switches. In purchasing refrigerators, only those, which are safe to use in explosive atmosphere, should be considered. Proper facilities for the handling and disposal of linen and trash will do much to minimize the chance of a hospital fire. Adequate space and an organized routine to prevent the untidy storage of laundry are important. In like manner the hospital employees should be trained in the proper disposal of hazardous waste materials. EARLY DISCOVERY Although elementary, it is important to realize that almost all large fires start from small ones. For this reason, the earlier the fire is discovered and the sooner extinguishing action is begun, the smaller the danger. In areas where someone from the hospital staff is on duty at all times, the fire is likely to be discovered HOSPITAL SUPPORTIVE SERVICES

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early. Prompt action in applying proper extinguishing techniques will result in minimum excitement and loss. Certain hospital areas, however, are not under constant staff supervision. Whereas other hospital areas may be considered of greater than normal fire risk because of their content or use. In such cases, installation of automatic fire detection and alarm systems is highly desirable. Such systems may be necessary in the large general storage rooms, various maintenance shops, trash collection rooms, and the corridors serving these areas. Several basic types of systems are available and can be classified as follows: smoke-detection alarm, heat-actuated alarm, automatic water sprinkler, and automatic chemical extinguishing. Several factors enter into the selection of the proper type of system for each application. For example, rooms containing intricate machinery or expensive supplies should be protected by a system, which will not damage the contents of a room. For conditions that are conducive to a raid spread of fire, a water sprinkler or chemical extinguishing system would be most appropriate since it discovers the fire, applies an extinguishing medium, and can be arranged to sound an alarm as well. All hospital buildings (except the very smallest ones) should be provided with an internal fire alarm system. Such a system gives immediate notice to the hospital staff and employees and all other building occupants of a fire on the premises. If the local fire authorities permit the system should be interconnected to transmit an alarm to the municipal fire department in order to eliminate any possible delay in calling them. Some alarm system have incorporated a pre-signal feature that sounds an initial alarm only in selected locations with provisions whereby authorized persons have subsequently sound a general alarm. This pre-signal feature is not recommended for hospital occupancies since it serves to delay the general alarm, and experience has shown that delayed alarms frequently result in loss of life and property. Some authorities are unduly concerned about the effect of harsh strident sounds of fire bells or gongs on certain types of patients. To minimize this possibility, the use of visual signal alarm panels is permitted in in-patient sleeping areas. In this case, enough visual signals should be distributed throughout the nursing unit to provide adequate warnings to the staff and should be located in corridors, nurses' stations, utility rooms, pantries and other workrooms. However, most fire authorities believe that an audible signal is preferable to a visual signal and would recommended that soft chimes or small bells be used. The paging or normal communication system is a useful adjunct at a time of fire emergency for issuing instructions and organizing the resources of the hospital to best meet the individual emergency at hand. It should not be used as an alerting system to notify key people in the hospital of the fire prior to the activation of the building alarm, since this is in effect delaying the alarm. 152

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RESTRICTING FIRE SPREAD The hospital fire emergency plan will usually direct the employee who discovers the fires first to remove any occupants from the room involved, close the door, and then sound the alarm. The purpose of closing the door is to try to confine the fire to its point of origin until the fire-fighting processes can be brought into play. Therefore, rooms should be considered as sealed units with no communicating openings to other parts of the building except for the necessary duct openings. Furred spaces behind wall finishes and other concealed spaces should be suitably fire-blocked to preclude the passage of smoke and gases from one room to another. Solid wood doors or their equivalent are recommended for hospitals because they have retarded the spread of many hospital fires. Doors should be equipped with door closers or latching devices. Roller latches may be used on patient room doors and would be expected to perform satisfactorily, if kept properly adjusted. Vision panels in corridor walls should be glazed with wire glass. A mechanical system that uses the corridor as a plenum for the supply or exhaust of ventilating air to individual rooms is not recommended for hospitals because this directly conflicts with good fire safety practice. This type of system requires the use of undercut doors and louvered panels or ventilating transoms in the corridor walls, which would make it impossible to confine the fire or smoke to an individual room. For a number of reasons it may not be possible to confine all fires to individual rooms until they can be controlled by organized fire-fighting services. It is, therefore, recommended that each floor be subdivided into a least two compartments by providing a fire-resistive partition horizontally from sidewall to sidewall and vertically from floor to floor above. Such partitions are called smoke barriers. In large buildings no more than 150 feet of corridor without such smoke barriers should be permitted. Where such smoke barriers cut across corridors, a pair of close-fitting solid wood or equally solid type doors should be installed. These doors should be equipped with door closers and held upon during normal operation of the hospital by devices, which will release the doors in the event of a fire emergency. The devices should be arranged to permit the closing or the doors manually, by activation of the building fire alarm, and by smoke-detection systems. In addition to the hazard to the occupants on the same floor as the fire, at times as great a danger exist from asphyxiation to the people on floors considerably removed from the floor on which the fire occurs. Many lives have been lost this way. To isolate each story in an effective manner, all stairways, elevator shafts, dumb-waiters, ventilating shafts, chutes and other vertical openings must be properly enclosed at each floor. Fire doors should be used on all openings into these enclosures. Door closers should be used on all doors to ensure that the door will HOSPITAL SUPPORTIVE SERVICES

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close after each use. The administrator should remove all wedges that are used to hold open any fire door and should initiate a policy to keep these doors closed. Fire doors are required to isolate areas of greater than normal hazard from the remainder of the structure. These doors are especially designed to resist the passage of fire through the openings in the walls or partitions in which they are installed. Doors should be labeled or otherwise marked to show that they meet the standard requirements for the various classifications of openings. Class B fire doors should be used for openings in vertical enclosures such as stairs and elevators and in rooms of high hazard occupancy, whereas class C doors would generally be found in low hazard occupancy rooms. Several types of fire doors are available. However, in hospitals only the swimming type should be used and they should be arranged to open in the direction of exit travel in such a manner as not to obstruct the corridor or the operation of other doors. Properly installed swinging doors are easier to operate under emergency conditions than any other type and permit rapid egress for persons who must be assisted in the evacuation process. Fire-fighting authorities say that the type of fire fighting attempted on a blaze can usually foretell the outcome of a fire. Many building fires, if discovered at an early stage, may be held in check, if not completely put out, by persons reasonably well trained in the handling of fire extinguishers. Certain types of fires, if not handled promptly or if not handled properly at their start, may quickly become a threat to the entire population of the building. For this reason, each hospital should be properly equipped with fire extinguishers and the hospital administration should follow through the requirements of its fire emergency plan and train as many employees as possible in the use of these extinguishers. It should be understood that a fire extinguisher is a first-aid appliance and is designed for a limited use pending the arrival of the organized fire services. Most fires can be classified as being primarily one of three general types. A fire in ordinary combustible materials (wool, paper, fabric) is called a Class A fire and one of the best ways for putting out such a fire is by quenching with water and thereby reducing the temperature of the burning material below its ignition point. Fires in flammable liquids and greases (oils, gasoline, and paint) are listed as Class B fires and care best handled by a blanketing technique which tends to keep oxygen from the fire and thereby suppresses combustion. Fires in the electrical equipment (motors, control, panels, and wiring) are Class C and are usually combinations of the previous types, but because of the hazard of electrical short circuits, it is important to use a nonconducting extinguishing agent. 154

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EVACUATION If a hospital fire can be confined to its point of origin, it can be brought under control before occupants are harmed. Fortunately, numerically, most hospital fires are in this category. If a fire should persist, it then may be necessary to remove patients from their usual locations to safer portions of the building. Since the time, extent or duration of an accidental fire cannot be predicted, plans should be made for sufficient and adequate exit facilities in every hospital. The usual rules for exits in hospital buildings are well-understood: 44 inch wide door openings, 8 foot corridors, exit stairways located at the end of each corridor to preclude dead ends where occupants may be trapped, stairways discharging directly to the outside at grade or into a safe corridor on the first which leads to the street, and proper lighting and signs for exit-ways. Not so well understood is a planning technique that may obviate the need for an extensive evacuation procedure or, if total evacuation is necessary, will afford more time with less risk to the patients. This is the principle of compartmentation. Compartmentation simple means the division of a floor area into two or more sub-areas by the use of transverse fire-resistive partitions and corridor doors. These corridor doors are kept open by suitable hold-open devices during all times except in a fire emergency and therefore do not interfere with the daytoday operation of the hospital. The value of compartmentation from a timesaving point of view is readily demonstrable. If a nursing floor, without compartmentation, containing 40 patients must be evacuated; the staff must see that each patient is assisted at least to the floor below. The time to accomplish this total floor evacuation would depend upon the number of staff available and the condition of the patient on the floor. If the 40 bed nursing unit is divided into two compartments, the primary evacuation would involve only 20 patients from the compartment in danger through the cutoff doors to the safer compartment on the same floor. The time saved in moving 20 patients horizontally compared with 40 patients vertically is readily apparent. Hospital designers may wish to compartmentalize their elevator circulation. This may make the elevators available for evacuation for a longer period of time in case of fire emergency and also would provide a sound barrier between the noisy elevator circulation and patient units. A hospital complex is a chain of many disciplines performing their functions under stressful circumstances. It would not be reasonable to expect such an environment to be free from the possibility of fire. Each link in this chain, therefore, is a potential fire risk.


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CHAPTER - 9

PHARMACY The goal of every department of the hospital is to furnish the patient with the best service at the most economical cost. The pharmacy is not an exception since it is one of the most extensively used therapeutic arms of the institutions. The volume of service is appreciable; in the average hospital, the pharmacy will fill thousands of prescriptions and dispense as many ward orders and requisitions in a single year. Purchase of drugs and the value of the annual inventory run into many thousands of rupees. This will vary, of course, with the extent of both inpatient and outpatient services. However, a fairly high percentage of the total annual expenditure of the hospital goes for pharmaceutical services. This emphasizes the need for very careful attention on the effect that pharmaceutical services have on the efficiency of both clinical and administrative services in every hospital. That a hospital pharmacy with a well qualified pharmacist in charge is a necessity has been accepted by the larger hospitals. Small hospitals have not taken this position at all times largely because of the fear of increasing their operating deficits. However, if the advantages are clearly understood by the medical staff, administration, and the board of trustees, that more efficient operations will result in better services or savings, the general advantages to all, including the patients and the community's pocketbook, should be well worth the effort. Hospitals which fail to employ a pharmacist with proper training, experience, and talent, are seriously lowering the efficiency of their services and operations. A well-organized pharmacy will function effectively in its own right, and also contribute to the whole hospital organization. Employment of a full-time pharmacist, even in a hospital of moderate size, far from being an exorbitant expense, will more than pay for itself through collateral savings. Many states have laws making it mandatory that prescriptions be compounded only by registered pharmacists. Pharmacy activities in hospitals are becoming more and more the object of much closer scrutiny from a legal viewpoint, particularly in relation to improving hospital licensure programs and the large number of new drugs constantly being developed, especially those used for investigational purposes. MINIMUM STANDARD FOR PHARMACIES IN HOSPITALS: ORGANIZATION: There shall be a properly organized pharmacy department under the direction 156

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of a professionally competent, legally qualified pharmacist whose training in hospital pharmacy conforms to the standards herein established by the Division of Hospital Pharmacy. POLICIES: The pharmacist in charge, with the approval and cooperation of the director of the hospital, shall initiate and develop rules and regulations pertaining to the administrative policies of the department. The pharmacist in charge, with the approval and cooperation of the Pharmacy and Therapeutics Committee, shall initiate and develop rules and regulations, subject to administrative approval, pertaining to the professional policies of the department. FACILITIES: Adequate pharmaceutical and administrative facilities shall be provided for the pharmacy department, including especially: (a) the necessary equipment for the compounding, dispensing and manufacturing of pharmaceuticals and parenteral preparations, (b) book keeping supplies and related materials and equipment necessary for the proper administration of the department, (c) an adequate library and filing equipment to make information concerning drugs readily available to both pharmacists and physicians, (d) and other proscribed drugs, (e) a refrigerator for the storage of thermo labile product, (f) adequate floor space all pharmacy operations and the storage of pharmaceuticals at a satisfactory location provided with proper lighting and ventilation. RESPONSIBILITIES: The pharmacist in charge shall be responsible for : (a) the preparation and sterilization of inject able medication when manufactured in the hospital, (b) the manufacture of pharmaceuticals, (c) the dispensing the drugs, chemicals and pharmaceutical preparations, (d) the filling and labeling of all containers issued to services from which medication is to be administered, (e) necessary inspection and others emergency drugs, (g) the dispensing of all narcotic drugs and alcohol and the maintenance for a perpetual inventory of them, (h) specifications both as to quality and source for purchase of all drugs, chemicals, antibiotics, biological, and pharmaceutical preparations used in the treatment of patterns, (I0 furnishing information concerning medications to physicians, interns and drugs, (j) establishment and maintenance, in corporation with the accounting department, of a satisfactory system of records and bookkeeping in accordance with the policies of the hospital for (1) charging patients for drugs and pharmaceutical supplies. (2) maintaining adequate control over the requisitioning and dispensing of all drugs and pharmaceutical supplies, (k) planning, organizing and directing pharmacy policies and procedures in HOSPITAL SUPPORTIVE SERVICES

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accordance with he established policies of the hospital, (l) maintenance of the facilities of the department, (m) cooperation in teaching courses to students in the school of nursing and he medical intern training program, (n) implementing the decision of the Pharmacy and Therapeutics Committee, (o) the preparation of periodic reports on the progress of the department for submission to the administrator of the hospital. PHARMACY AND THERAPEUTICS COMMITTEE: There shall be a Pharmacy and Therapeutics Committee, which shall hold at least two regular meetings annually and such additional meetings as may be required. The members of the committee shall be chosen from several divisions of the medical staff. The pharmacist-in-charge shall be a member of the committee and shall serve as its secretary. He shall keep a transcript of proceedings and shall forward a copy to the proper governing authority of the hospital. The purpose of the committee shall be (a) to develop a formulary of accepted drugs for use in the hospital, (b) to serve as an advisory group to the hospital pharmacist on matters pertaining to the choice of drugs to be stocked, (c) to evaluate clinical data concerning drugs requested for use in the hospital, (d) to add and to delete from the list of drugs accepted for use in the hospital, (e) to prevent unnecessary duplication in the stock of the same basic drug and its preparation and (f) to make recommendations concerning drugs to be stocked on the nursing units and other services. PURCHASE AND SUPPLIES: The pharmacist's principal function in purchasing is to establish standards and specifications for medication and equipment. He alone is responsible for sub standard or dangerous items reaching the patient. The pharmacist is familiar with the pharmaceutical and chemical manufacturers, their distribution system and discounts system and discounts. He is also familiar with firms which furnish other professional supplies. It is his duty to have in stock at all times an adequate supply of the proper quality. A sound purchasing and control system is essential. This can effect savings up to 20 per cent in purchasing. Good management indicates that the money invested in a pharmaceutical inventory be turned over about four times a year. For example, should the pharmacy inventory amount to Rs. 7,500, the total purchases for the year would be about Rs. 30,000. A purchase record card on each item stocked in the pharmacy is necessary. The purchase when recorded with the date, quantity and price, will reveal when recording the product the need for obtaining larger or smaller quantities. Quantity discounts may be taken advantage of, dependent on business conditions, and over-stocking is prevented. Control of prices to be charged is easily effected, cost changes are noted and the selling price adjusted 158

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at the time. To further efficiency, an inventory should be taken annually but it is appreciably simplified when a purchase record system is already installed. Purchase of drugs and pharmaceuticals should be on a bid basis where practicable. Records and Reports: The pharmacy must adopt a policy to record the movement of stock daily and do a physical check and evaluate the monthly cost of each item. Quarterly inventory checks should also be done so that up to date information is available regarding stock position and problems of pharmacy. Some records maintained by the pharmacy are compulsory by the state laws, particularly concerning receipts and issues of alcohol, narcotics, barbiturates and such other as may be stipulated by the government. Hospital formulary : The pharmacy and therapeutic committee is responsible for developing a suitable formulary for hospitals. This permits rational therapy and prevents unnecessary duplication, waste, and confusion. It is hence economical both to the hospital and patient. The guidelines pertaining to the establishment of a hospital formulary are: 1. The Medical Staff shall appoint a pharmacy and therapeutics committee composed of physicians and pharmacists and outline it's purposes, organisation, functions and scope. 2. It shall be sponsored by the medical staff based upon recommendations of the committee, the medical staff should adopt the principles of the hospital formulary system to the needs of the particular hospital. 3. The medical staff must adopt written policies and procedures governing the hospital formulary system as developed by the committee. These polices and procedures are subject to the normal process of administrative approval and shall afford guidance in the evaluation, selection, procurement, storage, distribution, use, safety procedures and other matters related to drugs in the hospital and shall e published in the formulary of the media and made available to all members of the medical staff. 4. To ensure maintenance of the responsibility and prerogatives of the physician in the exercise of his professional judgment, the hospital formulary system shall not contain any policies or procedures which, prior to the time of prescribing, provide for consent by the physician to the dispensing of a non proprietary drug or to the dispensing of a proprietary brand different from the brand that he prescribed. 5. The medical staff shall adopt the policy of, and formulate the procedure for, including drugs in the formulary by their non-proprietary names even though proprietary names are and will continue to be in common use in the hospital. 6. In the absence of written policies approved by the medical staff relative to HOSPITAL SUPPORTIVE SERVICES

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the operation of the hospital formulary system, and authorization from the prescribing physician, the pharmacist must dispense the brand prescribed, bearing in mind his professional prerogative to confer with the physician should the prescribed brand be unavailable. 7. The hospital shall make sure that it's nursing personnel are informed in writing about the existence of the formulary system in the hospital and the procedures governing its operation. 8. Provision should be made to apprise the medical staff of changes in the working of the hospital formulary system or in the content of the hospital formulary. 9. Provision shall be made for the appraisal and use by members of the medical staff. ü Of drugs not included in the formulary. ü Of investigational drugs. 10. In the formulation of policies and procedures, terms such as substitute and substitution should be avoided since these terms have been used to imply unauthorized dispensing of a brand different from that prescribed or the dispensing of an entirely different drug, neither of which takes place under a properly operated hospital formulary system. 11. The pharmacist with advice from the committee shall be responsible for specifications as to quality, quantity and source of supply of all drugs, chemical, biological and pharmaceutical preparations used in the diagnosis and treatment of patients and for assuring that quality is not compromised for economic considerations. 12. The labelling of a medication container with non-proprietary name of content is always proper. The use of a proprietary name other than describing the actually contents is improper if it is used in a manner that can be taken as descriptive of the contents, even though personnel familiar with the hospital formulary system may understand that is not descriptive. The following format is recommended for labeling: (Non proprietary Name) (Name of Manufacturer or Distributor) Note for information of staff : Prescription order for Dispensed as per formulary policies ; contents are same, basic dug as prescribed but maybe of another brand. PHARMACEUTICAL SERVICES IN SMALL HOSPITALS: Quality of patient care should be the same in all hospitals, regardless of size or type of services. However, many hospitals, particularly those with less than 100 beds, have not yet developed satisfactory solutions to the problem of good 160

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pharmaceutical services. In hospitals where pharmaceutical services do not appear to be of sufficient volume fully to utilize the time of a competent registered pharmacist, several alternatives are employed to maintain good services without undue cost. It has been traditional to assign to the pharmacist other duties, particularly those relating to general administration, such as purchasing. Most pharmacists, by experience, are well qualified in this regard. Recently there has been a movement to retain the pharmacist in professional medical fields. Examples of division of time between limited pharmacy duties and others include laboratory or x-ray functions, or supervision of central sterilizing and supply services. Another alternative which probably will gain in favor in coordinated hospital programs is the employment of a qualified pharmacist on a part-time basis by two or more small hospitals where travel time is not too great. Some small hospitals have approached the problem by securing the services, as needed part-time, of competent registered pharmacists from a local retail pharmacy. All of these, and other methods which may appear to be feasible locally, should be fully explored by the small hospital. Delegation of full responsibility for pharmacy services to the nurse or lay person is not detrimental to good patient care, but could easily have legal implications. PHYSICAL FACILITIES: LOCATION: Where feasible, the pharmacy should be located on the first floor of the hospital and readily accessible to the elevators to ensure adequate and efficient service to the various nursing stations and departments. If the hospital has an outpatient department, the pharmacy, or a branch thereof, should be located so as to be convenient to it. Space should be provided in the outpatient department, if it is nearby, for seating of patients who are waiting for medicine. FLOOR AREA: Necessary net area for efficient pharmacy services will vary, of course, with the program and services of the hospital, utilization and workload. Used as a point of departure however, one finds an indicated need for a minimum of 250 square feet for any sized hospitals. From that point, basic estimates range from 10 square feet per bed in the 100 bed hospital; six square feet per bed in the 200-bed institution; and an average of at least five square feet per bed in larger hospitals. Teaching hospitals require considerably large space. FINISHES AND LIGHTING: The floors of the pharmacy should be resilient, smooth, easily cleaned and acid resistant. Rubber or asphalt tile and heavy linoleum are considered satisfactory. The sterile solution and manufacturing rooms should have a floor which is smooth and waterproof, have a nonskid surface and be provided with a drain. HOSPITAL SUPPORTIVE SERVICES

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Walls should have a smooth surface with painted or equally washable finishes in light color. The finish of the cabinets and similar items should be light colored wood or white enameled. Good lighting and ventilation are imperative. The prescription case stock fixtures should be arranged to have maximum benefit of daylight without glare. Venetian blinds are favored. In addition to general illumination, fluorescent lamps should be placed immediately above the prescription counter where necessary to assume adequate light; ample electrical outlets should be provided for, in both the pharmacy and sterile solution room. Gas outlets are required on the worktable or counter for the Bunsen burners. EQUIPMENT: Equipment lists are generally prepared as guides which will require alteration in adapting to specific problems encountered in the design and services of any individual hospital. Since considerable variance from suggested floor plans may be necessary, it is advisable to consult the pharmacist on the floor plan, location and selection of equipment. Equipment includes a prescription case and drug stock cabinets with proper shelving and drawers for a large assortment of drugs. Sectional drawer cabinets with cupboard bases are manufactured specifically for pharmacies and to fit any area. This type has the advantage of appreciably reducing the area required for the drug stock. It is also readily adapted to future expansion as more storage space is needed. Worktables or counters are required for manufacturing solutions, batches of powders, ointments and for filtering; also for the loading of ward baskets and checking orders. The counter with drawers and cupboard base has the advantage of providing more storage space. The standard counter height is 36 inches, with minimum length of 74 inches desired. The finish of the work top may be acid resistant to match the prescription case or of heavy linoleum. Also necessary are an acid-proof sink with swivel faucet and with a drain board approximately 5 feet in over-all length; a cabinet below to provide space for heavy mortars and pestles, and a cabinet with adjustable shelves above the sink for glass utensils, large graduates, flasks, funnels and beakers. The advent of the antibiotics has increased the needs for refrigerator capacity. Space is required for a refrigerator of at least & cubic feet in the 50-bed hospital, 16 cubic feet in the 100-bed hospital and 32 cubic feet in the 200-bed hospital. This increase can be taken care of in the pharmacy stores of the central storeroom. A narcotic safe is necessary if individually locked drawers are not provided in the sectional prescription case. A desk and other office equipment should be provided, including a telephone for interdepartmental communication, a bulletin board and a file cabinet for records and manufacturers' current 162

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literature. A small card index file is also required for commodity records, purchases, stock and manufacturing data. Shelf space for the pharmaceutical library is also included in this area. A dispensing window is needed through which prescriptions are dispended to nurses and outpatients. A separate solution room for the preparation of parenteral solutions in larger hospitals should be equipped with a water still, workbench, cabinets, resistant glass storage tank, burettes, fitted glass filters, conductivity meters, bottle racks, adjustable metal shelves for storage of a large number of bottles, large acid proof double sink with drain-board and graduate racks and a rectangular pressure sterilizer. The solution sterilization may be done in the central sterilization and supply section, but preferably in the solution room. MANUFACTURING: Hospitals, tend to do less manufacturing. The kind and the amount of pharmaceutical manufacturing are dependent on several factors; size of the hospital, general policies, scope of its activities and space and equipment; this will be resolved by the responsible authority of the hospital. Equipment such as ointment mills, mixing machines, collapsible tube filters, powder mixers, granulators, tablet compressing machines and filter presses may be considered. Space must be assigned for the routine manufacturing of preparations which can be properly and profitably prepared e.g. stock solution, bulk powders, ointments, and for such facilities as tanks and mechanical mixers, filtering racks, a cradle cabinet for demijohns and adequate open adjustable shelving. The manufacturing room can be located in the basement directly below the pharmacy. A dumb-waiter should connect the two; also, direct access between the pharmacy and bulk stores should be provided. In the smaller hospital, where only one pharmacist is on duty, often without assistance, it is preferable that the manufacturing room be adjacent to the pharmacy. GENERAL STORAGE: From an operational standpoint, of course, the ideal area for bulk pharmacy stores would be adjacent to the pharmacy itself. However, this is not often feasible. The second most desirable area is directly beneath the pharmacy with dumb - waiter and spiral stairway connection. If it is necessary for bulk pharmacy stores to be kept in the general stores area, they should be within an enclosure to which only the pharmacy staff has access. This staff must have control of purchasing, storage and utilization of pharmacy supplies for efficiency and economy. Equipment required is open adjustable metal shelving for reserve stock, raw material, empty bottles and packaging containers. A separate locked fireproof room with a drum cradle is necessary for alcohol HOSPITAL SUPPORTIVE SERVICES

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CHAPTER - 10

PUBLIC RELATIONS Public relations for hospitals has its origins in the acts, attitudes and aptitudes of every employee, staff member and the governing board. Individually and collectively they mould the image and opinion of the hospital in the community. Good publicity, while an essential part of good public relations, is too often considered to be all that is necessary. Largely, good publicity is an end result, and no amount of newspaper space, radio or television time in themselves produce sustained community support without adequate understanding and sympathetic services on the part of the hospital and its personnel. The quality of Nursing care, the food service, the efficiency of the housekeeping service, the general attitude of doctors, the general attitude of the employees, all play a role in image formation. Public relations applied to the people of a community must utilize methods and channels of communication that the people understand. The large nervous system of man gives him unique powers or consciousness, memory, learning and synthesis of information by reasoning. People differ in these as in other powers. Four levels of intellectual activity are recognized. (1) simple facts; (2) simple concepts; (3) principles and their application to solution of problems; (4) broad appreciations. A good public relations program must be geared to all these levels. Never in history have people known more, and demanded to know even more of health, hospitals and medical care. One of the major drug firms has as its slogan "The priceless ingredient of every product is the honor and integrity of its maker". In hospital relations this same honesty must prevail. Patient Redressal: One finds in dealing with hospitals that they are always on the defensive. There is no doubt that one finds the odd patient who is never satisfied, or the relative who is never satisfied, or entitled to or disgruntled or frustrated doctor who failed to get an attachment to the hospital. These are all potential detractors of the hospital. All complaints must be dispassionately investigated and where necessary remedial action must be taken. Blindly denying any charge made against the hospital only goes to damage its reputation further, It is an important Public Relations function to represent the Hospital to its public in a 164

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correct perspective. The facilities available and their timings must be known and adhered to. It's no use saying that you have ambulance service when your ambulance service is only available on a restricted time schedule and is not available to bring patients to the hospital and so on. The Staff and Public Relations: Public relations, as related to this microorganism we call the hospital cannot be dignified with the name unless it stems from the dedication of every individual, at every level, who works in or for the hospital. There is no substitute for sympathetic patient care, nor is there a substitute for a job well done, on a continuing basis. Every action by every employee is an act of an ''operatingtrustee'' and an irremovable ingredient of public relations. It is the job of administration, of which public relations is a part, to be constantly cognizant of this fact and take steps to make the most of it. It is the people for whom the hospital exists; it is they who make or break its reputation, its very existence. This means, then, that people of the hospital, of the community, all of whom form the therapeutic community, are the focus of public relations. It means that the person skilled in public relations is a serious student of human relations. Every member of the hospital staff is a member of the public relations department of the hospital. Either as an individual or as a body they are responsible for projecting the image of the hospital. Hence there is great emphasis on good relations for maintenance of the image and prestige of the hospital. In Mumbai a start has been made by some hospitals and medical establishments which have recently advertised in local papers about the facilities that they offer. It is in this context that public relations assume importance in our country. It is the function of Public Relations to develop and promote understanding and appreciation of the hospital by the people it serves. One of the first tenets of good communication is that to be understood, one must understand, that no program in public relations can operate successfully unless it understands the total community and the forces that define and delineate the therapeutic community. It is the function of public relations to develop and be ever on the alert to promote understanding and appreciation of the hospital by the community. Public relations interprets to the public, to patients, relatives and to their friends, to the staff and employees, the objectives and ideals of service to which the hospital is dedicated, always operating with the confines of good taste and professional ethics.


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Materials for release: Public relations is responsible for clearance of all material intended for release and must not fail to consult any part of the organization concerned with such material. When all affected parties have approved the material for accuracy, public relations will put it in proper form and release or distribute it in the manner best calculated to benefit the hospital. Authority to release such information will have been granted exclusively to the public relations head, through the administrator, by the board of trustees. This also imposes on public relations the duty to seek out, originate and develop constructive publicity ventures in connection with all phases of the hospital's operation. It is the point of issue for all material and information, written or verbal, that involves the hospital, its patients or its staff and which may be released or distributed for public consumption. Larger hospitals require a full time director of public relations. In smaller ones the administrator retains the basic responsibilities largely for himself, but delegates functions to selected individuals as a part time duty. One person should be given the responsibility for carrying out the public relations program. The individual responsible for personnel should work closely with him. This involves a good program in personnel management with a continuing orientation and education program. In addition, it may well be advisable for the governing board to have an active public relations committee. Representatives of the press and radio should be requested to serve as technical advisors, and a positive action program carried on. As a part of its functions, this committee would formulate a code of ethics in conjunction with the local press for release of information concerning patients and hospital activities. Sensitive areas of the hospital: In the matter of Public Relations the hospital staff that can play an important role in the maintenance of a good image of the hospital are: 1. the telephone operator 2. the admitting office clerk 3. the information desk 4. the cashier 5. the emergency department staff. These people who are in close contact with patients or their relatives must be very tactful in their dealings with patients and also in the impression they create on them. It is a good policy for the Public Relations department or Officer to maintain friendly relations with other hospitals in the area.

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INFORMATION REGARDING PATIENTS Information concerning patients (except as required by law ), as well as pictures of patients, shall not be released without consent of the patient, his parent or legal guardian, from whom a signature should be required on the hospital's publicity consent form. The consent of the attending physician should also be obtained, although his name should not be released except in unusual circumstances, without his approval and that of the local medical society. With the exception of medical staff papers and addresses by medical staff members for professional audiences, all statements and questions about the hospital and its operations should be referred to public relations for reply, or to be acted upon in a manner approved by him if the statements may result in publication, quotation or general distribution. CODE OF PRESS RELATIONS Release of information should be governed by an approved code, an example of which is given below: I. Responsibility for providing information on a twenty-four-hour basis is to be arranged by the hospital. II. For emergency cases the following items of public information may be given without the patient's consent: 1. Name: (a) married or single, (b) age, (c) sex, (d) color, (e) occupation and name of the employer, (f) address and (g) general condition of the patient. 2. Nature of the accident, i.e., injury by automobile, explosion, fire, shooting; if there is a fracture it is not to be described in any way except to state the part involved and whether it is simple or compound. 3. In injuries of the head no opinion as to the severity may be given until the full condition is determined, and no prognosis is to be stated. 4. Internal injuries may be stated simply as such, and the location when determined. 5. Unconsciousness; if the patient is unconscious when brought to the hospital; a statement of that fact may be made. 6. Poisoning; causes of poisoning, if known, may be given but no comments concerning the motive, whether accidental or suicidal, and no statement on prognosis may be released. 7. Shooting; a statement may be made that there is a bullet wound, but not as to how it occurred, i.e. accidental, suicidal, homicidal, or in a brawl, and not the environment in which it happened. HOSPITAL SUPPORTIVE SERVICES

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8. Stabbing; the same general statements as mentioned under shooting. 9. Intoxication; no statement as to this condition may be released. 10. Burns; a statement may be made that the patient was burned, the part of the body involved, and the severity if known; also, as to how the accident occurred if the absolute facts are known; no statement on prognosis may be released. III. Attending Physician; the name of the attending physician of private patients may be released, but the press representative should be referred to the physician for information about the case, and the name of the physician shall not be used without the approval of the local medical society. IV. Pictures; photographing a patient in the hospital may be permitted if, in the opinion of the attending physician, the patient's condition will not be jeopardized, and the patient, his parents or guardian do not object. V. Interviews shall not be permitted if the patient, his parents or guardians object, and, in the opinion of the attending physician, his condition permits it. THE PATIENT'S BOOKLET In addition to the general aspects outlined in the foregoing, each member of the hospital family must take every opportunity to promote good public relations with the individual patient. THESE ARE ESSENTIAL Introduction or administrator's message: Basically, to further the personalization of service; to explain the booklet; to solicit suggestion; to extend a welcome and assure wholehearted effort by employees. Admission information: Admission hours; special time for major or minor surgery; proper notification if admission must be cancelled; which entrance to be used; presentation of insurance cards. Instructions to patients: Articles to be brought; any jewelry that may interfere with nursing care. Care of valuables: How, where, when and what should be deposited; hospital's responsibility. Radios: Whether patient can bring his own, rent from hospital or use built-in system; statement of hospital's right to restrict use when necessary. Special nurses: Procedure to employ and reimburse. Visiting hours: Allotted hours; statement of maximum visitors for each patient; procedure to obtain visitor's pass; which entrance to use. Message to visitors: Reasons why hour and maximum visitor limitations are set: solicit co-operation for brief and quiet visits; no visitors in surgery. Children: Conditions under which children may visit and the explanations of 168

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reasons for the age restrictions. Clergy: How and when to obtain their services. Operation permit: Who must sign for a minor or a patient unable to sign for himself/herself. Discharge: Time of the discharge, and penalty for leaving after discharge hour. Financial arrangements: When bills are payable (in advance, weekly, on discharge); no charge for last day; cashier's office hours; types of credit held available. Insurance: What is and is not paid for; procedure to follow when hospital insurance is carried; instructions for filling out insurance papers. Discounts: Explanation of any routine cash or terminal discounts. Sales tax: List of tax payments required by state law and items on which there is a tax. Blood donations: Blood bank; replacement procedures and charges; if donors are necessary, how are they to be paid. Cafeteria: Where, when open, available to whom. New stand and candy shop; where, when open, how patients can obtain items. Library: Description of service; name of auxiliary group that operates it. Barber shop: How patients may obtain barber and beauty shop service. Birth certificates: When newborn's name should be known; procedure for obtaining certificate. Smoking: Where prohibited or where allowed. House staff: Brief description of who serves patients (residents, interns, nurses' aides, laboratory technicians) ; staff relationship. Gratuities: Hospital policy on tipping and gifts. Criticisms and suggestions: A request for suggestions if not included in the administrator's message. THESE SHOULD BE INCLUDED: Rate schedule: A list of room accommodations; telling what is and what is not included in rate; If space permits, a listing of other common charges. Rate information should be listed on a separate sheet, which can be inserted to show changes. Length of stay : An explanation of the need for early discharge; an estimate of length of usual stay for maternity patients. Hospital costs: An explanation of how the hospital bill is spent and why costs have increased. Volunteers: Naming them and their achievements. Overnight visitors: Facilities available and under what conditions they must be HOSPITAL SUPPORTIVE SERVICES

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used. Food brought by visitors: Restrictions. Taxi service: How it may be procured. Notary public: How this assistance can be obtained by patients (especially if it is offered free ). Donations: Generous gifts in the past; hospital's need, and how gifts can be made. Flowers: When they should be sent; size restrictions; need for preservative. Telephones: When they are or can be installed; cost per call; how to send telegrams or long distance calls; restriction on using nurses desk telephone. Mail delivery : Procedure for delivery to rooms; what happens when received after discharge. Patient's condition reports: How the most recent report on a patient is given to friends telephoning about them; restrictions about releasing information on diagnosis. Role of volunteers in public relations: Volunteers coming in their individual capacities or in groups to help the hospital, are important for creating a good image of the hospital in the community. As regards patients, hospital volunteers can help: 1. in meeting the personal needs of patients. 2. patients to accept hospitalization. 3. in rehabilitation of patients. 4. to renew or retain contact with their community. 5. breakdown the sense of isolation a patient feels from normal living As regards the staff they can: 1. Supplement staff services in clinics, nursing, clerical duties, library, occupational therapy, reception, snack bar etc 2. increase staff knowledge on the community. 3. share with the staff their observations of patients needs. 4. gain recognition by the community. As regards the community volunteers can: 1. help to raise the status of the hospital. 2. bring the hospital closer to the community. 3. bring first hand information to the community 4. help to change community attitudes towards physically and mentally handicapped patients.

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CHAPTER - 11

FOOD SERVICES Food service is one of the most important activities in any hospital. As a therapeutic measure it contributes directly through scientifically prepared nutritious diets, aimed at specific disease conditions. It is a most potent psychological force in patient acceptance of hospital regime and its concomitant contribution to early recovery; it can be a major factor in employee satisfaction and morale; another, it can play a major role as a general public relations measure, bringing returns far beyond its costs. The question often arises as to whether a discussion of food services should be within the realms of management of clinical services. The truth is that it is an equal responsibility of each, a truly medico - administrative area. Since it impinges so heavily on the clinical care of patients, it is appropriate to discuss it under that general heading. Major operating functions of the dietary department include the direct responsibility for menu planning for general and special diets for patients and employees; for selection and purchase of food, in a close working relationship with the purchasing agent; for receipt and storage of food; for preparation and distribution food; for cleanliness and safety in the department, including dishwashing; for continuing training programs and supervision for personnel; and, in cooperation with the medical and nursing staff, the education of patients in appropriate dietary habits and control. In teaching hospital, research may be animportant function. The dietitian is recognized as the chief of a major department (unless a food manager serves in this capacity), responsible directly to the administrator. Preferably she should be a graduate of a recognized school of home economics and have served a period of practical training in a hospital approved for such a course. Because of the variety of her duties and their importance, she must have technical knowledge of nutrition as well as administrative ability and training to enable her to organize her staff and its work so as to produce the best possible results at the least cost. The ability to organize and manage is of particular importance since speed, coordination, human relations, and efficiency are essential. It would be highly desirable if all hospitals had the full - time services of a competent professional dietitian, but the limited number of such individuals makes this impossible. Since the need HOSPITAL SUPPORTIVE SERVICES

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exists in all hospitals, but is less satisfied in the smaller ones, serious consideration should be given to the cooperative use of the part - time or consultant dietitian. A number of state hospital agencies or regional hospital councils have dietitians on their staff that can be of much assistance. FOOD SERVICES: The method of distribution of prepared food of patients has long been controversial, and it is realized that remarks at this points will not settle the issue. Basically, the two methods are by centralization, in which the complete tray is set up in the main kitchen, and by decentralization in which trays are served in the nursing unit. Many modifications and combinations of the two methods have developed. In general, the building must be designed for a particular method for it to really successful. It becomes an expensive procedure usually, both in remodeling costs and personnel utilization, to implant a method into a building for which it was not designed. Factors which must be weighed against each other include hot and cold food services to patients, original costs of space and equipment, maintenance, cost of personnel in numbers and efficiency, control by dietitians, serving time, noise and other disturbances to patients, dishwashing and food waste disposal, and future expansion and flexibility of the system. A detailed study of the institution is required for building or for evaluation of existing procedures. Flow charts showing staffing, equipments, time elements, and other factors mentioned above should indicate answers to specific requirements. Advantage and disadvantages attend any system. It is felt that any one of several systems will work if the responsible personnel want to make it work; and that no system will work satisfactorily if the personnel do not wish it to do so. Food service in hospitals is somewhat different from that in the conventional restaurant because of the transportation problem of the food from the kitchen to the patient which requires additional handling and resultant hazard of contamination. Because of the increased opportunities of contamination and the possible lower resistance of the patients to food infection, increased emphasis on proper food handling in hospitals in necessary. Every effort must be made to achieve all of the above objectives with minimum effort and without confusion and waste. With automation, disposables, increase in availability of prepared, cooked, frozen foods, and improved equipment hospital dietary services may well be in for major modifications in the next decade. Many hospitals have found a central system of service offers economy, better sanitation, maintenance of facilities and equipment and efficient utilization and supervision of employees. In 172

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centralizing food service activities, the number of employees is reduced, and duplication of dietary facilities in patient care areas is eliminated or decreased. Direct labour hours and costs are lessened when tray serving and dishwashing activities are centralized. It must be remembered however, the success of either system will depend on facilities and equipment, equitable istribution of workload, organization of duties, and a good employee orientation. Methods which are being used effectively in hospitals for tray distribution are mechanical belt carrier systems, high - speed dumbwaiters, and service elevators. Horizontal and vertical mechanized belt systems are being used to transport trays automatically from the serving table to the belt in the vertical shaft and / or to mobile tray conveyors. Horizontal belt systems with variable speed mechanism are recommended for installations that serve more than 100 trays and have at least five workers to assemble the trays. When vertical belt system is used, a shelf - typedumbwaiter should be provided so that any special requests may be taken care of without interruption to the serving line. Dumbwaiter systems which operate automatically are also being used for transporting trays to patient - care floors. Dumbwaiters may be either floor - level or shelf - type. Floor - level dumbwaiters will provide speedy service for inFloor - level dumbwaiters will provide speedy service for installations planning to use enclosed, unheated carts (5 to 8 tray capacity) for service. Two dumbwaiters should be considered. Shelf dumbwaiters will require at least two or three shafts. Most shelf - type dumbwaiters can carry only six trays which must be unloaded and the dumbwaiter returned for additional trays. One shaft will slow up the operation. Hospitals planning to use elevator service for their food distribution system should plan to make available one elevator devoted exclusively to tray distribution during the meal service periods. If regular passenger elevators must be used, hospitals should avoid using open or semi - enclosed unheated carts. When mobile hot - cold or unheated tray conveyors are used, service elevators are usually required because of the weight and size of the equipment and the space needed to accommodate the food service worker assigned to handle the conveyor. There are many types of mobile tray conveyors. Some are designed with separate compartments for hot and cold food trays. These trays must be combined on the patient floors. Others conveyors have been designed to physically separate the hot and cold foods on the tray without having to interfere with the arrangement of foods on the tray. Such mobile units will require storage space on the patient floors during the serving period. If trays HOSPITAL SUPPORTIVE SERVICES

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must be combined in patient corridors, it is preferable to provide a separate area or enclave. Time schedules need to be established for both patients and employees to obviate, as much as possible, floor and elevator traffic confusion and delay, and to keep nursing units adequately covered for patient care. A common complaint of patients is the early hour of service. Such hours should correspond as closely to local habits as possible. If patient serving cannot be completed in 45 minutes, the entire system should be evaluated. The dietitian has overall responsibility for food services, and as a therapeutic measure, she has the last immediate duty of checking the tray for proper identification, accuracy, attractiveness, temperature of foods and palatability. Methods and contents of between - meal nourishment must be established in cooperation with the medical and nursing staffs. The problem of food brought to patients by visitors can be resolved in the same manner. Infant formulae and service is sometimes the responsibility of the dietary department, at others that of the nursing department. With added numbers of ambulatory patients - convalescent, extended care, psychiatric, self care - increasing use being made of patient dining room and cafeteria services. Milk purchase and service should adhere to sanitary regulations, procured from an approved source, pasteurized and served to employees and patients in individual sealed containers. Service to employees is usually recommended as cafeteria style, with cash payment on a per meal basis. This may not be practicable in the very small hospital. CONTRACT FOOD SERVICES: An increasing number of hospitals are contracting for food services with outside commercial sources. Results have been reported as ranging from excellent to most unsatisfactory. Like any system there are advantages and disadvantages. In 1962, the American Hospital Association and the American Dietetic Association approved guiding principles for contractual services, some of the highlights of which include: 1. Hospital dietetic services should be under the direction of a qualified manager, preferably a professionally trained dietitian. If the contract food manager is not a professionally trained dietitian, such competency should be available as full or part - time consultant. 2. As the head of a major department, reporting directly to the appropriate hospital administrative authority, functions, responsibilities, and relationships should be fully documented and clearly understood. 174

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As with any type of dietary organization, constant liaison with the medical staff should be maintained. The plan, program, organization, and relationships should be in writing and reviewed periodically. Responsibilities of the contractor cover all appropriate activities such as nutritional standards, individual patient contract, patient education, systematic employee training and adequate supervision, quality food procurement, sanitation and maintenance, appropriate records and reports.

MENUS: Preparation of menus is the immediate responsibility of the dietitian and must be undertaken in the light of clinical requirements, economy and practical management procedures. Dietitians usually prefer to prepare them on a two - to three week schedule, using basic outlines and making adjustments on daily orders as the market and special diets dictate. While menus will vary with requirements, food habits, nutritional adequacy, seasonal availabilityand funds, standardized recipes can still be established. The selective menu has gained much favour, although more adaptable in the larger hospital. A successful modification is accomplished through daily visits to patients by the dietitian. This is a most important psychological and public relations gesture to the patient and is of real value to the dietitian for economy purposes, improvement of services and forestalling complaints. The Master Menu Service, published monthly in Hospitals, is an excellent guide and time saver if properly adapted to local needs. Good tested quantity recipes are axiomatic before standardization can be accomplished. Guidance in the conversion and preparation of quantity recipes can be obtained from AD professionals. FOOD PURCHASING: Since the dietitian plans the menus, the selection standards, purchasing, and scheduling for delivery of food items must be her immediate responsibility unless there is a food manager. This is particularly important in relation to seasonal fresh vegetables and fruits. Although the use of commercial frozen foods has increased tremendously, some hospitals use slack periods of personnel activity for purpose of any canning or preparation of its own frozen foods that might be undertaken. Staple groceries and other supplies may be bought by the purchasing agent upon requisition by the dietitian. These can usually be obtained through bids, effecting economy through bulk and HOSPITAL SUPPORTIVE SERVICES

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standardization, based upon need, storage facilities, and delivery scheduled based upon proximity to source of supply. Procedures for effective cost control: 1. To maintain accurate inventory of all items of the department. 2. To maintain record of all purchase made, particularly of the quality and quantity of food. 3. All bills must be checked against the quotations. 4. The standard system of purchasing so that a written requisition is ready for purchase. 5. Where more than one kitchen or pantry for servicing is maintained, any transfer of equipment between two areas must be recorded in the ledger of the respective areas. 6. Specifications laid down or established for purchases. 7. Accurate records of the meals served per shift. 8. A record of fuel cost and requirements as well as supply of disposable items like dusters, brooms etc. 9. A personnel record and their salaries including cost of uniforms, provident fund, leave etc 10. Last but not the least a daily report to the administrator by the department should be instituted. SANITATION: It must be emphasized that practices, personnel, and physical facilities for food services offer some of the greatest sanitation problems and hazards with which a hospital is faced. In addition to training, periodic inspection of the entire dietary department must be maintained, to include floors, walls, ceilings, utensils, machinery and equipment, cabinets, sinks, plumbing and grease traps and employee rest rooms and washrooms. Safety programs should include instruction in extinguishing grease and other fires, proper use of equipment guards, reporting of accidents and methods of eliminating slippery floors. The engineer should participate in these activities. Intensive vermin control measures must be vigilantly maintained. The cooking unit should be located as conveniently as possible between the preparation unit and the point of distribution to permit straight line flow. Range, at least two ovens, steamer or steam kettle, and mixer, are basic equipment. Each preparation employee should be allowed four linear feet of worktable space. For storing prepared ready to serve hot foods, most units for this purpose use counter - top arrangements for modular - sized, interchangeable serving pans. In some installations the heated lead disc, or pellet system, is used, generally in conjunction with a dumbwaiter, the vertical belt tray carrier system, or the 176

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unheated mobile tray conveyer. An area accessible to the hot food preparation center must be equipped for pot and pan washing, sink with drain-board, table and shelving are required. For cold foods and salads the preparation area must have ready access at the point of service. Refrigeration space for the holding of frozen desserts and garnishes, the chilling of dishes and the short - time storage of salad ingredients at below 50 degrees F is essential. For special diets, the trend is simply towards setting aside an area in the main kitchen for the purpose, since such diets are usually modifications of the basic menu. The serving area requirements will be governed by the method of service: centralized or decentralized. With centralized service, table or counter space is required for setting up trays and floor space for the conveyers used in transporting the food to the patients. Where a dumbwaiter is used the serving unit or tray setup must be located adjacent to it. The service unit should provide convenient facilities, as mentioned above, for refrigerating salads ice creams, and juices, for brewing coffee, for preparing toast and for storing trays, china and silverware. If a decentralized tray service is used space must be allowed for a tray service unit in the kitchen or an area for assembling the food before sending it to decentralized serving kitchens. These serving kitchens, if used, must also be planned as a part of the dietary department even though they are remote from it. They should be convenient to the service elevator and as close as possible to the patient area it serves. If a dumbwaiter is used, it should be in the floor kitchen itself. DISHWASHING: The dishwashing room should be physically separated from the food production and serving activities and from the cafeteria serving line and dining area. Health authorities feel it advisable to divide the dishwashing room by a wall so that activities connected with handling clean and soiled ware may be completely separated. They believe that equal emphasis is needed on improved supervision and techniques as well. If complete separation is not feasible the layout of the room should discourage the same worker from handling both clean and soiled dishes. Wash water should be at least 140 degrees F, and rinse water at least 180 degree F. A lavatory with a foot, knee, or elbow control should be located so that workers may wash their hands, preferable in clear sight of supervisory personnel who will ensure that they handle clean dishes with clean hands. A central system of dishwashing should be employed when patients' trays are assembled in the serving section of the food production area, when the cafeteria is located close to and on the same floor as food production, and when horizontal and vertical transportation is convenient to the dishwashing area from these points. A decentralized dishwashing system may need to be HOSPITAL SUPPORTIVE SERVICES

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considered only when physical layout or a separate layout or a separate building makes the use of a central tray system impractical. In planning for a central dishwashing system, consideration must be given to the work flow involved in handling and washing tableware from patients and personnel. The flow should be planned according to the method of transporting trays from the patient care units and the cafeteria to the dishwashing room, the rate at which they appear on the soiled and clean dish tables, and their return to the tray and cafeteria serving lines. The method of dish flow from the cafeteria should be selected on the basis of minimizing noise, confusion, and unsightliness. Various installations have found that a mechanical belt arrangement will remove dishes quickly and efficiently. If the conveyer belt is located near the cafeteria exit the trays may be placed on the moving elt by diners as they leave the area. The belt may be arranged next to a wall or, in larger rooms, placed in several sections for the convenience of the diners. The commercial food waste disposer is necessary to maintain better sanitation in food service installations, especially in the room where tableware is washed. Many hospitals are finding it economical to provide disposal units at the origin of waste; for example, the preparation, post washing, and dishwashing areas. The unit should be installed in drain board or drain table rather than in the sink. For housekeeping functions it is necessary that a cleaning area be provided in or near the kitchen. An adequate garbage storage unit is essential to the sanitary and efficient modern kitchen. The area designed for this purpose must be located near the service entrance, so there is no need for the trucker to have access beyond that area. Refuse from the rest of the hospital has to be accommodated; hence, the garbage storage unit should be easily accessible to all departments or personnel likely to use it. It is better to have the unit located on a corridor away from the main kitchen than to have it accessible only by passagethrough the kitchen.Garbage storage at refrigerated temperatures until time of collection is asanitary measure and npleasantodours are thus eliminated.Provision must also be made for the washing of garbage cans. A cement floorspace with a 3 inch coping, drain, water and steam jets will be sufficient for everyday cleaning. Since food service employee must change into uniforms and store their other clothes while on duty, lockers and dressing space are required. Lavatories and toilets should be provided at the rate of 1 to every 15 lockers. These rooms should open off a corridor rather than directly off the kitchen or dining room. However, unless these rooms are in close proximity to the working areas of the food service department, it will mean that cooks and other essential workers must leave their work long enough to travel long distances to a toilet. 178

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CHAPTER 12

AUTOPSY SERVICES

Autopsy services play an important role in maintaining quality of medical care through medical audit. It controls the functions of the hospital. It helps clinicians for learning unusual cases. It helps for clinical research to improve the medical care. Location: Ground floor is the best location for a mortuary block and postmortem room. It should have suitable exit leading to an area protected from the view of patients and public. Size of the department depends upon whether it is teaching or non-teaching hospital. 1.

Mortuary block: It consists of Mortuary room with racks for dead bodies. Cold storage facility should be available with temperature below 4 C.

2.

Postmortem room: It should be equipped with two drainage boards and two large sinks.

The flooring in both these rooms should be stain proof and easily washable. Sufficient lighting must be available. Drains with abundant water supply should be provided. The doors and the windows should be strongly protected by bars and the should be fly proof. The necessary wire netting should be provided to protect dead bodies. 3.

4.

Medical officer's room: It should be provided with a table, two-three chairs for patients' relatives. A resting area for medical officer should be provided with a toilet, bathroom and basin. Record Room: Dead stock register of equipments and supplies Medico-legal register for medico-legal post mortem Incoming and outgoing dead body register giving the time and date of dead bodies admitted to the morgue, identification data about the patient.


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A register for consent in case of non-medico-legal post-mortem examination. 5.

preservation room: All viscera required to be stored must be preserved in a proper container in steel cupboards that are properly locked and sealed.

6.

A dressing room for bodies

7.

A room for morgue attendants with toilet and bathroom.

8.

A waiting room for relatives

9.

A prayer room for relatives

10. A room for police equipped with telephone 11. Laboratory to carry out essential test 12. Room for clerk/photographer/artist Organizational structure of autopsy service: Chief Pathologist: 1.

To establish policies and procedures

2.

Decision making and planning

3.

Liaison with other departments

4.

Carry out research under their guidance

5.

To attend court of law for evidence as and when required

6.

Teaching and training medical and paramedical students

7.

Carry out all managerial and administrative functions Asst Pathologist: assisting the section in-charge Laboratory technician: accept specimen, carry out tests, maintain records and equipments. Lab attendants: assist in laboratory work, assist in making dead body ready for post-mortem Sweeper: to keep post-mortem and other premises clean. Record assistant: To maintain records for post-mortem and make it available to concerned person and also to protect it from leaking. Clerk/Stenographer/artist/photographer: help in administrative job, artist to take photographs whenever required.

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Study Material on PGDHHM Correspondence Course POST GRADUATE DIPLOMA IN HOSPITAL AND HEALTCARE MANAGEMENT (PGDHHM

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