Muhammad Irfanullah SiddiquiMuhammad Irfanullah Siddiqui

Hospital Administration and Management

36

ObjectivesAt the end of chapter students should be able to:

Defi ne hospital administration Describe the history of hospital development Enumerate the factors responsible for development of hospital Classify hospitals using different criteria. Describe the functions of hospital Enumerate the factors affecting distribution of beds in hospital Describe indices related to hospital and population. Apply different indices to solve hospital issues. Defi ne hospital utilization. Enumerate factors affecting hospital utilization Describe the type of specialties available at various tiers of hospital. Defi ne administration Describe role profi le of administrator Defi ne management Enumerate principals and functions of management Describe the elements of personal management Describe steps of personal management Design and monitor budget Defi ne and concept of scalar principals Describe importance of nosocomial infection

Hospital Administration2

Introduction Hospitals which utilize most of the health budget play a

very important role in the country’s health system1. Hospital Administration can not be done on intuition. A hospital ad-ministrator must be well aware of the scientifi c methods to run and evaluate the hospital functions and services in an objective fashion.

All the doctors should be having a good understanding of hospital organization and management for better care of their patients. Moreover they should also have enough knowledge for management of human, material and fi nancial resources in a cost effective way with optimum time approach.

Hospitals are among the most complex organizations in modern society. The modern hospital itself is a universe, with a variety of objectives, and a scalar division of labor to achieve those objectives2.

DefinitionOlder concept of hospital for the provision of curative care

is not valid any more. A hospital’s role is not only in the pro-vision of curative care, but an equally important role is, the provision of preventive & promotive health care.

A W.H.O. expert committee on organization of health care defi ned Hospitals as follows;

“The hospital is an integral part of a social and medical organization, the function of which is to provide for the popu-lation, complete health care, both curative and preventive, and, whose out patient services reach out to the family and its home environment; the hospital is also centre for the training of health workers and for social research”3.

“ Hospital without beds” is the latest concept about hospi-tals. Preventive and promotive efforts should be so effective that, the people should have optimum health with a minimum need for curative consultation, and even less for hospital admission.

Criticism Against HospitalThe public health physicians critically analyze the role of

hospitals in patient care. They argue;

Hospital exists in isolation and is benefi cial to only one component of community.

It absorbs most of the (50% to 80 %) of health budget4. It is not people oriented. Its procedure and style are infl exible. It overlooks the cultural aspect of illness, treating the disease without treating the patient i.e., directed to pathological agent approach, rather than origin approach. It is intrinsically resis-tant to change. Fascinating for politician to spend money as it is more tangible than expenditure on primary health care. Comprehensive Health Care will remain dream as it eats away most of the health budget.

WHO, UNICEF and NGOs worked together to change the role of hospital working in isolation, to involve primary health care. It started providing basic as well as referral services. It integrated preventive and curative health care, through primary health care centers.

History Of Hospital DevelopmentThe word hospital is an Italian word derived from hospitality

meaning to be guest.

It is represented by staff & serpent. Staff represents patient while the serpent represents caring off (Figure 10-1).

Hospitals were not always taken in high esteem. The initial hospitals were in alms houses in America, away from the city and were used to keep the people of infectious diseases.

Figure 10-1Generic Insignia for hospital

Hospital Administration 3Only people without family and homes were housed in

them, any one, of means, was cared for in home by their families.

In the United States, the fi rst modern hospital was the Pennsylvania Hospital, founded in Philadelphia in 1751. Slowly throughout 1800s other large facilities were built, such as Massachusetts General Hospital. It was not until middle of 1900, however, that modern hospital became common1.

Mayo Hospital Lahore is the oldest hospital in Pakistan5.

Factors Responsible For Development Of Hospitals

The following factors played important role in the develop-ment of hospitals.

Advances in Medical Sciences Development of Technological Sophistication and Spe-

cialization Development of Professional Nursing Advances in Medical Education Contribution by Industrialist Support by Health Insurance Role of Government

The fi rst infl uence on the growth of the modern hospital was the ability to perform surgical procedures successfully. This was the result of two important scientifi c advances. The fi rst was the discovery, in 1850s, of anesthesia. Before anesthesia, the very best surgeon was the speediest one; complicated procedures could not be performed because of the pain associated with them. The advent of anesthesia ushered in the golden age of surgery in the late 1800s.

The second major advance was the discovery of asepsis. Patients undergoing surgery frequently developed postop-erative infections. With the advent of asepsis the danger of postoperative infection was reduced substantially.

These advances allowed surgery to become a major force in the care of patients. Over 40% of total hospital beds are surgical beds to understand the impact of these discoveries. The more recent advances in outpatient surgical procedures probably represent another turning point in the infl uence of surgery on the system.

The19th century, saw the emergence of the biological revo-lution. The discovery of the new sciences of microbiology ushered in a new understanding of disease. The notion of the etiologic agent as the cause of disease required fundamental rethinking of diagnosis and treatment. New technology to as-sist in the diagnosis and treatment of patients developed rap-idly during that period. The discovery of the electrocardiograph and the x-ray, illustrate the expanding role of technology.

The early laboratories and machines of this technological

revolution were primitive by today’s standards and were physically very large. It made sense to provide a central place, the hospital, where all physicians could have access to this new technology. To this day, the hospital continues to serve a major role as the repository of technology for the community, although presently much is being done to move this technology into non-institutional locations.

A third major development occurred in the nursing profes-sion. Inmates provided what nursing care was available in the early alms-houses. In the mid-1800s, during the Crimean War, Florence Nightingale demonstrated the advantages of professional nursing services on reduction of both mortality and morbidity. She later introduced nurse training programs in Britain and for hospitals in United States. The availability of well-trained nursing personnel made hospitals much safer and more pleasant places.

The training of physicians also has changed dramatically, and this has been an important factor in the development of hospitals. Before 1900, medical education in the United States was seriously defi cient. Most physicians were trained in proprietary apprenticeships, with many lectures and little exposure to patients.

The development of professional licensure was important in the reformation of American Medical Education. Licensing was based on an examination and graduation from an ap-proved school. A second contributing factor was the Flexner Report. Flexner reported that the existing medical schools were grossly inadequate.

One school, however, stood out. This school, Johns Hop-kins University, served as an example for others. The positive features of this school were:

Students were required to have a college degree before they were admitted.

The medical curriculum was 4 years in duration, with 2 years dedicated to basic sciences and 2 years to work with full-time clinical instructors.

The medical school was an integral part of a comprehen-sive university.

Faculty of the school was actively engaged in medical research. Hospitals increasingly became the training site for both medical students and residents, training for a medical or surgical specialty.

Another development that was critical to the modern hos-pital was the increasing health insurance coverage held by the population. Health insurance was relatively unknown until the 1930s. During the 1940s, there was a rapid increase in the proportion of people who were covered.

Classification of HospitalsHospital can be classifi ed in any of the following way;

A. According to type of services providedB ccording to size or number of beds

Hospital Administration4C. According to ownershipD. According to duration of stay

A. According to type of services provided6

General hospitalThese are the type of hospitals where different specialist

services are provided to both adult and children under the same roof including Medical, Surgery, Pediatrics Gynae & Obs., Cardiology, Dermatology, Orthopedic and Ophthalmol-ogy etc.

Special hospitalsThese hospitals deal with specifi c category of diseases

e.g. Eye hospital, hospital of cardiac disease, ENT hospital, orthopedic hospital, kidney centre; or specifi c group of people e.g. children hospital, maternity home; or specifi c disease e.g. T.B Centre, Leprosy Centre.

B. According to size or number of beds7

Regional/Teaching hospital These hospitals have more than 500 beds. They are at-

tached to medical colleges and have all types of specialties and subspecialties e.g. radiotherapy, neurosurgery. Example of this type of hospital is Jinnah Postgraduate Medical Centre, Karachi & Mayo Hospital Lahore.

District HospitalsProvide about fi fteen specialties including Medical, Surgery,

Gynae & Obs. , ENT, Eye, anesthesia and dermatology and have a range of beds from 100-600, example include Civil Hospital, Thatta, Jacobabad, Attock etc.

Rural HospitalIt has capacity of 20 – 100 beds. It provides medical, surgi-

cal & obstetrical care only, e.g. Rural Health Centre Gharoo, Rural Health Centre, Murad Memon Goth, Malir.

C. According to ownership

Public HospitalThese hospitals are owned and managed by government

and/or autonomous bodies e.g. Civil Hospital, Sargodha, Pakistan Institute of Medical Sciences, National Institute of Child Health etc.

Private HospitalOwned by private people or entrepreneur, can be further

classifi ed into.

a) Commercialb) Non-profi t

D. According to duration of stayLong duration hospital; Stay more than 30 days as in lep-rosy centre, orthopedic hospital etc.

Short duration hospital; Stay less than 30 days as in acute diseases hospital. e.g. Eye hospital.

Functions of HospitalsFollowing are the main functions of a hospital. It should be

kept in mind that all functions will not be carried out by every hospital at all times.

a) Preventive & Promotive CareThis is the type of care which should be the main functions

of hospitals, for economic gain to the community in terms of health benefi t. It includes immunization against preventable diseases, screening programs for detection of common health problems & health education for personal hygiene, nutrition and management of chronic diseases.

b) Domiciliary ServiceThis is another important service provided by hospitals. It

means “Treating the patient at home”. This helps not only in decreasing the work load at hospital services, but, conser-vation of resources which are already scarce. The hospital administrator should create liaison with the private clinic existing in catchment area.

c) TrainingHospitals are the most suitable places for, both, medical &

paramedical personnel. Theoretical lectures supplemented by practical demonstration on patient will add to skill of the trainee both at undergraduate and postgraduate level.

d) ResearchResearch is an integral part of hospital services. It is by this

means that most of the advances in the medical sciences have been achieved. A good training regarding research principals followed by the application of the same in the real life situation helps in new discoveries.

e) Health EducationHealth education means providing information to the people

to change their behavior in the positive direction. This is the most neglected service, though most important one. This is the most effective way of preventing disease and promoting health in the community when a patient and his attendants seek care, they are very receptive to the information about the problem. Useful information can be provided through well baby clinic, asthma clinic, diabetes centre and vaccination canter, etc.

Hospital Administration 5

f) Curative CareThis is the service for which the hospitals are known to the

community since very long. It includes both outpatient and inpatient care.

Outpatient: The focus of attention in hospital has gradually shifted from the inpatient to the outdoor, i.e. the OPD’s. The diagnostic procedures which previously required hospitaliza-tion have become outpatient facilities and can be performed there. This is also one of the major means of keeping the patients out of the hospital. As outpatients are the fi rst point of contact between the patients and the hospital, it should be well organized, well staffed and well equipped. Facilities like laboratory, X-ray and pharmacy should be located near, to avoid patient discomfort.

Filter Clinics are mandatory for outpatients departments; now these are clinics where bulk of patients are seen and those requiring special consultation are referred to the con-sultants’ clinics.

Inpatient services: Previously the role of hospital was con-fi ned to inpatient department only. All the inpatient depart-ments should be in one block with free communication with the supplies. The nursing station should be rightly placed and suffi cient numbers of nurses should be available for the present number of beds. The general nurse to patient ratio is 1:10. The desirable number of patients per ward is 10-20, with one nursing unit. The ward could be divided into 2 rooms with capacity of 10 beds each, or rooms with single, double or four bed capacity. In all cases, adequate fl oor space per patient is needed to prevent cross infection. There should be adequate toilet facilities.

g) Accident & Emergency ServicesThis is an important component of hospital services. Hos-

pitals should be well equipped and staff should be properly trained to meet the emergencies.

h) Disaster ManagementThis is another component of health services. Though di-

sasters are rare events, every hospital should have a disaster management protocol, for the various types of disasters, and staff should always be prepared through regular mock exer-cises to deal with such situations. Types of disasters depend on the catchment region of the hospital, for example, a hos-pital in Baluchistan could prepare a earthquake management protocol, whereas an hospital in the Punjab plains would lay more emphasis on management of fl ood affected morbidity, and in NWFP, for a sudden infl ux of refugees.

i) Geriatric ServicesCensus in 1998 shows a signifi cant increase in the geriatric

population. Currently more that 1.5 million people are found in 75 years + group and more will be added during the next decade. Special arrangements should also be there to deal

with problems of old age people.

j) PhysiotherapyThis is an important service and suffi cient trained man

power should be there to deal with patients with chronic diseases such as CVA(cerebrovascular accidents).

k) Ambulance ServicesAn effective ambulance service is a part and parcel of

hospital services to deal with emergency problem and hence provision of timely care.

l) Laboratory ServicesAn effi cient laboratory’s with all necessary reagent and

effective blood transfusion service, is a prerequisite of good functioning hospital.

m) Social Medical ServicesThis is another neglected service. An effective social medi-

cal service will help in preventing the disease, promoting the health in the community and thus preventing the load on hospital services.

n) Medical Record KeepingIt is also a very important component of health services.

No effective planning can be done if the record keeping is poor. This is one of the reasons why health conditions of the communities have not improved.

o) OthersThe support services provided by hospitals include;

House Keeping Kitchen Medical Store Laundry Library Security

Factors Affecting Distribution of BedsA hospital administrator has always to face the problem of

scarcity of beds as complained by various heads of depart-ment. He should be well aware of the technique of justifi ca-tion of distribution of beds for the various departments of hospitals. Some of the factors effecting the distribution of beds are as under and they should always be considered before allocation of beds.

Type of Hospital. Availability of Resources

Hospital Administration6 Prevalence / incidence of diseases Accident and injury Male / Female ratio Level of Expertise Intensive Care Problems Community Program (Pressure) Premises / wards / theatre / kitchen Financial Resources Statistical Figure

Average Length of Stay Turn over period % Bed occupancy Throughput

Hospital Utilization And StatisticsThe term “hospital utilization” denotes the manner in which

the community uses its hospital resources8.

Since the modern concepts of hospital include curative, preventive, promotive, educational, domiciliary, in patient and ambulatory services, indices should be developed to evaluate all these components. The best known indices are only for the in patient care so we will discuss only the indices for in patient care.

Some of the common indices used by hospital administrator to evaluate the in - patient care.

A. Indices related to hospitalsBasically there are three indices related to inpatient care

in hospitals. These are:

Bed Capacity (BC) which is defi ned as the average number of beds during a specifi ed period, Average Bed Availability (ABA) which is the average number of beds available for patients to be admitted, and, Average Bed Occupancy (ABO), which is the proportion of beds which are fi lled during a specifi ed period. The indices given below are derived from these basic values:

Bed occupancy rate (BOR) Average length of stay (ALOS) Turn over period (TOP) Throughput (THROP)

1. Bed Occupancy Rate (BOR)It is calculated by dividing ABO and ABA

Example:In a hospital ABO is 600 and ABA is 800 calculate BOR.

BOR ABAABO 100

800600 100 75%= = =# #

2. Average Length of Stay (ALOS)It is calculated by summing the bed days occupied by

patients for a particular month and then dividing this fi gure by separation.

Separation may be defi ned as bed available due to the following reasons:

Deaths Discharges Transfers

Example:In a particular unit average bed days’ occupancy (ABO) by

patients of a particular month was 900 while separation was 60. Work out ALOS.

ALOS SeparationABO

60900 15= = =

3. Turn over period (TOP)It is the statistical test which provides you the information

about the difference between the BED DAYS AVAILABLE and BED DAYS OCCUPIED during a month with respect to separation.

It is calculated as following:

TOP (S)ABA ABO= -

Example:In a hospital ABA=600, ABO is 400, while separation is 35,

calculate the TOP:

TOP 35600 400 5.7 Days= - =

4. Throughput (THROP)It is calculated by dividing Separation with ABA/DAY

Example:In a hospital separation was 50 during a month and avail-

able no. of beds is 30/day. Calculate throughput.

ThroughputABA DAY

S3050 1.66= = =

B. Indices related to Population at Risk

a) Admission rateAlso known as hospital frequentation rate “(Fh)”, is usually

compared as no. of hospital admission (‘A’) per thousand population (P) per year however rate per person or per 100 persons may also be used.

Hospital Administration 7

hF PA 1000= #

b) Hospitalization rate per person (Hc)This index represents the volume of hospitalization in terms of number of hospitalization days per person per year.

It is calculated by dividing the total number of hospitalization days in a year “H” by the mean population in that year “P”.

H PH=C

c) Bed Occupancy RatioBed occupancy ratio (Bc) is the average daily number of persons hospitalized per unit of population. It is obtained by dividing the average daily number of beds occupied “N” by the mean population “P” in the same year.

B PN 1000= #

C

Factors Influencing Hospital UtilizationWhile evaluating the hospital services, a hospital adminis-

trator must consider the various factors effecting the hospital utilization.

The manner in which a certain community utilizes the hospital bed and the extent of such utilization are infl uenced by many factors that depend on the social, economic, edu-cational, and cultural characteristics of the people and on the attitudes and special habits of the medical profession. With regard to the latter, it may be presumed that the doctor orders or advise admission to a hospital primarily for medical reasons; however, this is not always the case. Very often the people themselves infl uence the decision for or against hos-pital admission. Thus, in less developed communities, fear of the hospital or unwillingness to separate from the family may be strong arguments against hospital admission, whereas in more sophisticated communities the hospital “habit” may be such that a person may bring pressure to bear on the attend-ing physician for admission to the hospital, even though there may not be objective reasons for this course of action. The main factors which affect hospital utilization are as under;

Availability of Hospital beds Methods of payment of hospital services Age of the population Services coverage & bed distribution Availability of extramural medical services Hospital bottle necks Medical custom and social patterns Supply of physician Research and training

Existence of proprietary hospital Housing Morbidity Internal organization

Specialties in a HospitalA frequently asked question is, what specialties should be

available at Teaching Hospital (Regional Hospital), District Hospital (DHO), Tehsil Hospital (THO), and Rural Health Centre (RHC).

Following is the distribution of specialties.

At Teaching HospitalsAll specialties including subspecialties should be available.

At District Headquarter Hospital (DHQ)At least following specialists should be available.

Physician One Surgeon “ Gynecologist “ Pediatrician “ Ophthalmologist “ E.N.T. Specialist “ Dermatologist “ Pathologist “ Radiologist “ Anesthetist Two Chest Physician One Cardiologist “ Orthopedic Surgeon “ Urologist “ Psychiatrist “

At Tehsil Headquarter Hospital (THQ)At least 10 specialties should be available which are also

available to DHQ excluding Chest Physician, Cardiology, Orthopedic, Urology and Psychiatry.

At Rural Health Center (RHC)Medicine, Surgery, Gynecology and Obstetrics and prefer-

ably pediatric facilities should be available.

AdministrationAdministration includes the following activities termed as

POSD CORB (Guillick).

Hospital Administration8Planning, organizing, staffi ng, directing, coordinating,

reporting and budgeting.

The term “hospital administration” covers a large number of activities which may roughly be classifi ed into three cat-egories.

Preparation of hospital legislation, planning of the hospital system as a whole, determination of international policy, regulation for the operation of hospitals, establishment of architectural control and standards.

Application of hospital legislation and of social assis-tance provision by the authorities responsible for the management of hospital services whether they be local or regional, public or private.

Daily running of the hospital by the administrative staff concerned with personnel, fi nance accounts and techni-cal services.

Role Profile of Administrator Ability to see ahead and plan accordingly: planning for

the future while managing the present. Ability to produce and accept new and creative ideas,

being an agent of change. Willingness to take risks to get the new ideas accepted

and implemented. Ability to co-ordinate, bringing about harmony, collabora-

tion, organizing, allocating resources and controlling. Ability to analyze, synthesize and integrate diverse infor-

mation. Sense of equity, fairness and social justice, in all dealings

within and outside the hospital. Knowledge, skills and experience. Ability to delegate, making effective use of own time and

that of others. Good personal motivation and ability to motivate the

people working in the hospital. Ability to review and evaluate, making adjustments as

necessary.

Role of AdministratorsThe Administrator reports to the Governing Body (or other

higher authority such as Director of Health Services, Secre-tary to Government, etc).

Persons Reporting Directly to Administrator Medical Superintendent Nursing Superintendent Associate Assistant Administrators Coordinator, Community Health Programs Principal, School of Nursing, where there is a school of

Nursing.

ManagementManagement is an old process and has existed ever since

man has been organized into communities. It is sometimes thought to be a process of 20th Century but this is not so. Where and whenever people have worked together in-groups to grow crops, to buy and sell, to wage wars, to build a temple, there was management.

The most comprehensive way to defi ne management is:

Management is a key process. The function of management is to enable our patient/doctor/nurse team to do their job as easily, effi ciently, economically, effectively and as humanly as possible so that they can develop and maintain a caring environment within the Hospital. OR

It is the process of organizing, using and controlling human activities and other resources towards special end9; OR

Management is a process whereby resources in term of people, fi nances, equipment and facilities are mobilized, ide-ally in an effi cient and effective manner to serve the purposes of an institution.

Resources are; Men Money Materials Machinery Methods

Principles of ManagementThe major principles are:

Unity of Command Span of Control Homogenous Assignment Delegation of Authority

Functions of ManagementThe main functions of management include the following:

Planning Organizing Staffi ng Leading Controlling

PlanningPlanning involves selecting the mission, goals, objectives

and actions required. It is defi ned as setting objectives, deter-mining resources and selecting courses and requires decision making i.e. choosing future courses of action from among alternatives. It can be defi ned as “deciding what is to be done and how it is to be done”. Planning must aim at the fulfi llment

Hospital Administration 9of the hospital’s role in terms of the appropriateness, quality, quantity and cost of the health care provided.

OrganizingThis includes the identifi cation and classifi cation of the

required activities. The activities are then grouped together and each group of activities is assigned to a manager, through the process of delegation both horizontally, among the dif-ferent managers on the same level, and vertically from the superiors to subordinates.

This is that part of Management that involves establishing an international roles for the people.

StaffingThis involves fi lling and keeping fi lled the positions in the

organizational structure.

Leading/DirectingThis is infl uencing people, so that they will contribute to the

organization and group goals in an effective manner.

ControllingThis is the measuring and correcting the activities of the

subordinates in order to ensure that the events conform to the plans.

All the above activities need to be backed up by the process of coordination by the manager/administrator at all levels.

Elements of ManagementThe following are elements of management.

A. Personal ManagementB. Financial managementC. Material ManagementD. Time Management

A. Personal ManagementThe function of caring for staff in the organization is known

as “Personnel management”. In the hospital services with very few specialists, the effective management of staff lies on the shoulders of departmental heads.

Steps of Personal Management Human Resources Planning Recruitment and Selection

Human Resource PlanningThis is information decision making process designed to

ensure that enough competent people and appropriate skills are available to perform jobs where and when needed.

Recruitment and SelectionThe aim of recruitment is to ensure that the organization’s

demand for manpower is met by attracting potential employ-ees in a cost-effective and timely manner.

Steps in Recruitment

Job AnalysisIt has two components;

Job specifi cationIt is a summary of the knowledge, skills and personal char-

acteristics required of the job holder to carry out the job to an acceptable standard of performance.

Job descriptionThe job description describes information about the job

concerned viz title of job, overall purpose of the job, principle responsibilities, location of job, grade/salary level of job etc.

The purpose of job description is to defi ne exactly for a worker, fellow worker and supervisor:-

How much is his authority? What is his responsibility? What the worker is expected to do? What standards he is expected to reach? To whom he is responsible? Whose work he supervises?

Job description helps each worker to know clearly and with-out doubt what his duties are and what he is expected to do. Such job descriptions should be interpreted fl exibly, as per guidelines.

Attracting the ApplicationBy advertisementThe aim of job advertisement is to attract suffi cient numbers of the right kind of candidates. It should include details about the position of the job, employing organization, candidate requirements-essential/desirable, the salary indicator etc.

Evaluating ApplicantsIt is a process of scrutiny of the applicant for their qualifi cation and experience for the required post.

SelectionThe aim of selection is to identify applicants most likely to fulfi ll the requirements of the organization. The initial selec-tion of candidates on the basis of their application form is called short-listing.

Placement and DevelopmentAfter selection of personnel a very important task for the management is assigning proper duties and responsibilities according to the skills and qualifi cation of the person.

Hospital Administration10

B. Financial ManagementFinancial management is one of the very important tasks of management and deals with how to spend money and get maximum benefi t for the organization.

Budget“Budget is formal fi nancial statements of policies, plans

and goals that are designed to assure that actions are taken within boundaries laid down by top management”.10

OR

“It is numerical statements of program showing the pro-posed or estimated schedule of expenditure in coming years keeping in view the estimated income of next year”.

Budget may be;

DevelopmentalThis part of budget used for a new process of expenditure

usually for a limited period usually prepared according to annual developmental program and called Annual Develop-mental Budget.

Non Developmental (Recurrent)This is that part of budget which an organization needs for

its non-developmental activities. e.g.,

Salaries Travelling Other daily expenditure e.g., bills

Monitoring of BudgetMonitoring means keeping an eye on expenditure of budget

to see if expenses are according to the schedule or not, and to avoid inappropriate use of funds.

Tools for Monitoring Monthly statements Excess statements Accounting Auditing

AuditingThis is an analysis of proposed or past expenditure with

respect not only to their legality but also to their desirability. This is of 2 types.

Pre AuditAudit taking place prior to payment.

Post AuditAudit done after payment has been made.

Audit ObjectionIf the auditors are not satisfi ed with any transactions, they

discuss it with the managers and if manager fails to satisfy them, an audit objection is submitted to Public Accounts Committee.

C. Material ManagementIt is the planning, purchasing and maintaining of different

items used in the hospitals. The job of a hospital administra-tor is to ensure;

“The supply of right thing at the right place, at the right time and at right cost”11.

It involves:-

Correct planning Sticking to time needs Correct purchasing procedures Standardization Stock control tools Documentation for audit

D. Time ManagementTime is one of the most important resources. Time is like

central nervous system i.e. it cannot be regenerated once destroyed or wasted.

Hospital administrator should be able to control and use-fully consume the time of his subordinates for the welfare of the patients.

This can be done by making correct duty rosters for the organizations and see to it that everything is done according to schedule.

The management of time is an issue, which is fundamental to job performance.

The Scalar PrincipleThis implies delegation of authority to the various staff

members in responsible positions. The principle is applicable not only in hospital administration but also in other areas of Health Sector. The power to execute the functions may be in the context of fi nancial requirements, but also in connection with leave sanctions, disciplinary action and job performance as well as complaints.

If an Administrator or a Director has to be approached by a lower sanctioning offi cer, he should follow a series of steps, as for example: If the Resident MO has to approach the Direc-tor, he is required to go through the scale, while the reverse, Director to Summon the residents he is also required to fol-low the channel down the scale. However this depends on the nature of event. In an emergency, the resident may have to establish contact with the director without going through the ladder. Likewise the director may, depending upon the circumstances, call for a lower ranking staff member directly

Hospital Administration 11without following the channel. This principle equally holds good in fi nancial sanctions and other areas.

Nosocomial InfectionNosocomial infections, i.e. infections acquired by patients

in the hospital have become more of a problem in human medicine, because of increase in drug-resistant microbial strains as well as increases in the use of invasive procedures for patient support and monitoring. Nosocomial infections are also expected to become a more serious problem in veterinary medicine for similar reasons.

The exact prevalence of the nosocomial infections is not known, but there are reasons to believe that this is a sig-nifi cant public health problem, particularly in the developing countries where sanitary conditions fall short of the required standards.

Studies carried out in hospitals of the US showed, urinary tract infections, surgical wound infections, lower respiratory and blood stream infections in varying degrees.

The mode of infection is either through direct contact or through fomites. Vehicular transmission through food, water and vectors has also been noted. The hospital administration has the responsibility of hand washing provision for the hos-pital staff of all categories and the patients and maintenance of sanitary standards at all levels, as preventive measures.

AcknowledgmentPart of this chapter has been taken from the previous

chapter 4th ed. written by A Sattar Tabani, Aamir Waseem Khan, Sabiha Khurshid Ahmed, Aamir Omair. For this we are thankful to authors.

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preventive medicine- 13th ed. Connecticut Appleton & Lange 1992 page 1066-8

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3. WHO technical report series No 261, 19634. Park K Park’s text book of preventive and social medicine 20th ed.

Jabalpur, Banarsidas Bhanot. 2009 5. http://en.wikipedia.org/wiki/Mayo_Hospital6. Davies RL, Macaulay HC.(ed) Hospital planning and administration.

Geneva. WHO. 1966.7. WHO Technical report series 1957 122, 178. Smith BA. Hospital costs and utilization. In: Davies RL, Macaulay

HC.(ed) Hospital planning and administration. Geneva. WHO. 1966.9. Rhea JC, Ott JS, Shafritz JM. The dictionary of health care management.

New York. Facts On File. 198810. Doty P , Liu K , Wiener J . . An over of long - term care

H e a l t h C a r e F i n a n c i n g R e v i e w. 1 9 8 5 ; 6 ( 3 ) : 6 9 - 7 8 . abs.sagepub.com/cgi/content/refs/30/2/143

11. Sand R, Parnell RW. Ed. The Advance to Social Medicine; Eng. trans. by Rita Bradshaw. New York-London: Staples Press, 1952. 655 pp. http://www.sciencemag.org/cgi/content/citation/117/3027/19-a

IndexA

Accident & Emergency Services 5Administration 7

Persons Reporting Directly to Administrator 8Role Profi le of Administrator 8

Ambulance Services 5Auditing 10Average Bed Availability 6Average Bed Occupancy 6Average length of stay 6Average Length of Stay (ALOS) 6

B

Bed Capacity 6Average Bed Availability 6Average Bed Occupancy 6

Bed occupancy rate 6Bed Occupancy Rate (BOR) 6Budget 10

Monitoring of Budget 10Tools for Monitoring 10

Hospital Administration12C

CRITICISM AGAINST HOSPITAL 2Curative Care 5

D

Disaster Management 5District Hospitals 4Domiciliary Service 4

F

Factors Affecting Distribution of Beds 5Factors Responsible for Development Of Hospitals 3Factors Responsible For Development Of Hospitals

Advances in Medical Education 3Advances in Medical Sciences 3Contribution by Industrialist 3Development of Professional Nursing 3Development of Technological Sophistication and Specializa-

tion 3Role of Government 3Support by Health Insurance 3

Financial Management 10Budget 10

G

General hospital 4Geriatric Services 5

H

Health Education 4History Of Hospital Development 2Hospital Administration 2

Defi nition 2Hospital Administration and Management 1Hospitals 2

Administration 7Classifi cation of Hospitals 3Factors Infl uencing Hospital Utilization 7Functions of Hospitals 4Hospital Utilization and Statistics 6Management 8oldest hospital 3Specialties in a Hospital 7

Hospital without beds 2

I

Indices related to hospitals 6Indices related to Population at Risk 6

Admission rate 6Bed Occupancy Ratio 7Hospitalization rate per person 7

L

Laboratory Services 5

M

Management 8Controlling 9Elements of Management 9Financial Management 10Function of Management 8Human Resource Planning 9Job description 9Job specifi cation 9Leading/Directing 9Material Management 10Organizing 9Personal Management 9Planning 8Principles of Management 8Recruitment and Selection 9Staffi ng 9Time Management 10

Medical Record Keeping 5

N

Nosocomial Infection 11

P

Physiotherapy 5Preventive & Promotive Care 4Private Hospital 4Public Hospital 4

R

Regional/Teaching hospital 4Research 4Rural Hospital 4

S

Scalar Principle 10Social Medical Services 5Special hospitals 4Specialties in a Hospital

At Teaching Hospitals 7At Tehsil Headquarter Hospital 7

T

Throughput 6Throughput (THROP) 6Training 4Turn over period 6Turn over period (TOP) 6