organization of hospital

8/13/2019 Organization of Hospital

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a. A governing board made up of persons who have demonstrated concerns forcommunity and leadership ability.

b. Policies that assure availability of services to all people.c. Participation of the hospital in community programmes to provide preventive

care.Economic viability: this is achieved by adopting measures like:-

a. A corporate organization that accepts responsibility for sound financialmanagement in keeping with desirable quality of care.

b. A planned programme of expansion based solely on demonstrated communityneed.

c. An annual budget plan that will permit the hospital to keep pace with times.Orderly planning: orderly planning should be achieved by the hospital by following:-

a. Acceptance by the hospital administrator of primary responsibility for short andlong-range planning with support and assistance from competent financial,

organizational and functional advisors. b. Preparation of a functional programme that describes the short range objectivesand facilities, equipments and staffing necessary to achieve them.

Sound architectural plan: it is achieved by the following:-a. Selection of a site large enough to provide for future expansion and accessibility

of population. b. Recognition of the need of uncluttered traffic patterns within for movement of

staff, patients and visitors and efficient transportation of supplies.Medical technology and planning: development in medical technology is taking place sorapidly that now the use of sophisticated technology determines the professional status.

Classif ication of hospitals:

Hospitals in general are classified into two categories depending upon the agencies whichfinance them:

1. Government or public hospitals: they are managed by government services, either centralor state or public, municipal or departmental bodies that are financed from the overall

budget for public services.2. Non-government hospitals: they are managed by individuals, charitable organizations,

religious groups, industrial undertakings etc.

On the basis of ownership patterns, non-governmental hospitals are classified as: Private (personal) Partnership Private (family) trust Public charitable trust Cooperative society Private limited company


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Public limited company

H ospital pl anni ng process:

i. Conceptualization of hospital: here the imagination or idea of the originator takes into a practical shape, and compares his dreams with the existing hospitals of country or outside

world, tries to fit dreams into any such project.

ii. Support groups: once the idea is developed, the entrepreneur, discuss project, and thenfinds support groups to join hands and complete the project.

iii. Temporary organization and securing funds: a group should be formalized called as ahospital trust, which must be registered under the societys act or companies act. Theoriginator is the chairman and others are members who are assigned different tasks.A detailed work out as to how much capital will be required for establishing the hospital.

iv. Geographical, environmental and miscellaneous factors:Meteorological information: temperature, rainfall, humidityGeographical information: existing road and rail communications, susceptibility toquakes/floods, building height restrictions due to proximity of airports.Miscellaneous availability: trained manpower, water, sewage disposal.

v. Hospital design: Bed planning: it should be realized that the hospitals are not only utilized by the

population in the vicinity but also will constitute the indirect population in the largercatchment area. About 85% bed occupancy is considered optimum.

Hospital size: as a very large hospital of 1000 beds or more becomes extremely unwidelyto operate, and a small hospital of 50 or less are not profitable. From functional efficiency

point of view, it is advisable to plan two separate hospitals of 400 beds, each with a scopeof future expansion, rather than a single one of 800 beds.

Land requirements: in rural and semi-urban areas, plentiful land may be available permitting the hospital to grow horizontally, whereas in urban areas there will always begreat premium on land and only avenue will be a vertical growth.

No. of beds Land in acres Storey of building

50 beds 10 acres Single storey

100 beds 15-20 acres -do-

200 beds 20-25 acres Double storey


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500 beds 55-70 acres 3-5 storey

700 beds 80-90 acres 4-6 storey

1000 beds 90-100 acres 6-9 storeys

Public utilities: the national building code of ISI suggests 455 liters of water perconsumer per day (LPCD) for hospitals up to 100 beds and 340 LPCD for hospitals of100 beds and over.Additional availability of water in case, staff quarters and nurses hostel are a part ofhospital campus. The hospital sewage disposal is connected to the public sewage disposalsystem, otherwise it needs to build and operate its own sewage disposal plant.It is preferable that power supply should be available on a multi-grid instead of uni-grid

system in general use, to ensure a continuous supply of electricity to hospital at all times.Electricity requirement is 1 KW per bed per day 2.

Approval of plan by the local authorities: once the detailed plan has been formulated,the local bodies are consulted and persuaded for approval of plans.

vi. Circulation routes: the utility and success of hospital plans depend on the circulationroutes on hospital site and within building. there are two types of circulation in thehospital :-Internal circulation: the circulation space involves corridors, stairways and lifts.Corridors with less than 8 ft. Width are not desirable in hospitals and protective corner

beading is a necessity in hospital corridors.External circulation: only one entrance to the hospital for vehicular traffic from the mainroad is desirable. the entrance and exit points should be wide enough to take two lanes oftraffic, one entry for clarity of all visiting traffic and one exit for security fromadministrative viewpoint.

vii. Distances, compactness, parking and landscaping: distances must be minimized for allmovements of patients, medical, nursing and other staff, for supplies aiming at minimumof time and motion.

Functional efficiency depends on the compactness of the hospital which is achieved byconstructing multistoried as they are convenient due to compactness as compared tohorizontal development of hospital which demands more land involving extra costs andinstallation of services, roads, water supply, sewage etc.One car parking space per 2 beds is desirable in metropolitan towns, lesser in smallerurban areas while much less in semi-urban and rural areas. Separate parking for 3-


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wheelers and scooters, employees and staff parking areas separate from public parkingshould be considered.

viii. Zonal distribution and inter-relationship of departments: the departments which come inclose contact with the public (e.g. outpatient department, emergency and casualty) should

be isolated from the main in patient areas and allotted areas closer to the main entrance.The supportive services like X-ray and laboratory services need to be located near theOPDs. From the main entrance should be main inpatient zone consisting of ICU, wards,OT and delivery suit. The other supportive and clinico-administrative department in thehospital consists of hospital stores, kitchen and dietary department, pharmacy etc. thesedepartments should be preferably grouped around a service core area.

ix. Gross space requirements: gross total area (building gross)-780-1005 sq ft, add walls, partitions: 95-125 sq ft. a building gross square footage figure includes everything a

buildings perimeter viz. stairs, corridors, wall thickness and mechanical areas. On average, space will be required for a reception and enquiry counter in the mainwaiting area near the OPD entrance. The bed distribution is calculated as:

Bed:population= A x S x 100

365 x PO

Where, A= number of in-patient admissions per thousand population per year

S= average length of stay (ALS)

PO= percentage occupancy

Bed distribution among various specialties will vary from hospital to hospital andconforms to following range:

Medical: 30-40%

Surgical: 25-30%

Obstetrical: 15-18%

Pediatric: 10-12%

Miscellaneous: 10-15% (including eye and ENT)

x. Climatic consideration in design: in very hot climate buildings need to be cooled insummer by artificial means. Some natural cooling can be achieved by buildingorientation and design. The building should be open, and oriented in such a way that evena slight breeze can pass through the building to cool its insides. Another way is to keepthick walls and small windows where the thick walls absorb the heat during day anddissipates during night, and small windows minimize the amount of radiated heatentering the building.


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Administrative control nurses station Cash counters Medical record room

DIAGNOSTIC AND SUPPORTIVE ZONE: the various functional units in this area are: Clinical laboratory Imaging section

AMBULATORY ZONE: This is a zone where the patients come in direct contact withthe doctors and paramedical staff for consultancies, advice and treatment. it includes unitslike:

Clinics for various medical disciplines Pharmacy Treatment room Minor OT

STAFF ZONE: this zone is used exclusively by the staff members only. It includes dutyrooms, stores, housekeeping and conference room.

Functional management:

OPD timings: it is recommended that OPD shall work 6 days in a week with facilities ofmorning and evening clinics. The morning timings is usually from 8am-12 pm, whereasthe evening hours shall be from 3pm to 5 pm, and specialty clinics from 2 pm to 4pm.overcrowding and waiting time of the patients and relatives must be minimized.

Records: a unit record system combining both in-patients record and continuous out patient record is recommended.

Public relations: public complaints can be minimized and defused through publicrelations, the entire staff of OPD including public relations persons should act as agents.

Facilities in OPD: The waiting lines should have enough furniture so that patients dont have to

stand in queues but can sit comfortably. The general procedure and rules should be painted on boards or walls for the

public. The registration area should be easily recognized and reachable. Health education messages can be promoted through TV-VCR system, closed

circuit TV and also to reduce the boredom of the waiting patients and theirrelatives in OPD.

Staffing of OPD: It includes the medical staff (consultant, professor, senior lecturers,medical officers, residents, junior and senior should be available), nursing staff (usuallyone nurse/OPD/clinic), paramedical staff (for injection room, dressing room, registrationand MRD), receptionists and medico social worker.

Planning and organization of Wards:


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A ward is the most important part of hospital where the sick persons are kept for supervisedtreatment. It is also a nodal point for research in medicine and nursing field, training andteaching of medical, nursing and paramedical personnel.

Types of wards:

a. General wards: in these wards, patients with non-specific ailments, requiring no lifesaving care are admitted. The nurse patient ratio of 1:5 in big wards, and catering to the

patient s routine investigat ion, treatment and care needs. b. Specific wards: these include patients admitted for specific care due ti illness or social

reasons. It includes: Emergency ward Intensive care unit Intensive coronary care unit Nursery

Special septic nursery Burns ward Post operative ward Post natal ward

c. Units with specialist nursing, treatment and equipment: wards like burn ward, transplantward functions at national or regional centers where particular service skills areconcentrated.

Ward planning:

Physical facilities: it includes:

Size of ward: size of the ward depends on- types of patient (an area of 100-120 sqft/bed is required and smaller rooms of 2-4 beds are preferable), requirement ofward staff (a small ward will have same requirement throughout the day, helped

by a head nurse and a clerk for administrative and clerical responsibilities) Patient housing area: this is an area where patients are kept for treatment.

The area per bed within the ward is 80 sq ft/bed but in acute ward it is 100sq ft/bed

Space left between two rows of bed is 5 ft.distance between two beds is31/2 to 4 ft.

Clearance between wall and side of bed is 2ft. Length of bed is 66, width of the bed is 3.

Size of rooms:

Single bed room should have a size of 125 sq ft/bed 2 bed room 160 sq ft/bed 4 bed room 320 sq ft/bed 6 bed room 400 sq ft/bed


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ICU 120-150 sq ft/bed Obstetrics and orthopedics 120 sq ft/bed

support service area: this section of ward includes: Nursing station/duty room: it should be located at such a place that the

time taken by a nurse for moving from one place to another is limited.Centralize location is desirable.

Treatment room: the room is meant for examination of patients and should be equipped with examination table, spotlight, dressing material, handwashing facility etc.

Clean work room: it is a working room for staff nurses in nursing unit,contains work benches for preparation of trays, care of materials,equipments and supplies etc.

Pantry: it is a place where the dishes are cleaned, washed and stored.

Unit store: it is meant for storing the supplies and linens. Sanitary area: it includes baths and toilets, dirty utility room, store for

sweepers etc. Auxillary areas: this section includes duty room for doctors, clinical side

room, seminar room, attendant room, locker room for staff. Ward design: the primary objective of a ward design is to facilitate the nurse to hear and

see everything in the ward and to enable the patients to easily call the nurse when needhelp.

I. open ward: in an open hall, beds are placed in rows facing each other and nursingstation in the center of the hall.

II. Rigg s ward: in this design, 3 -4 beds are placed parallel to the windows in open bays separated from each other by low partition.

III. Unilateral rigg s ward: side beds are placed in each bay separated from nursesstation with its standby services by a common corridor.

IV. Bilateral ward: it has been accepted as most suitable and workable conditions, twounilateral riggs wards are on either side of a central nursing station.

V. T-shaped ward: bed bays are placed in front of the nursing station and critical patients bays are in front of nursing station. Isolation bays are at both sides andancillary and other service areas are behind the nursing station.

Open ward


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Open ward

Rigg,s ward

Riggs unilateral ward

Riggs bilateral ward

Ward management: it is the optimal utilization of the ward resources to produce maximumoutput, namely care and comfort of patients. It includes:

Strategic management: responsibility of giving a strategic direction to a ward lieswithin the nursing unit set up in each ward. Strategy formulation for ward has to


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be done in the context and parameters defined by the strategy, direction, resourcesand constraints of hospital.

Operational management: whereas strategic management gives an anchor anddirection, operational management works towards the strategy. The responsibilityof operational management of a ward rests with the ward head nurse/ nursing unitwith the help of other ward personnel like ward clerk. It includes objectives of

providing comfort and good care to the patients and long term objective ofimprovement and establishment of systems in functioning of the ward.

Centr al Ster il e Supply D epartment (CSSD):

Definition of CSSD: A CSSD is a department that furnishes all supplies required for the nursingunits and departments of a hospital- theatres, wards, out-patient and casualty departments withcomplete, sterile equipment ready and available for immediate treatment of patients.

These supplies include sterile linens, sterile kits, operating room packs, needles, syringes and

other medical surgical supplies. In addition, the personnel in this department clean, inspect,repair, assemble, wrap and sterilize special treatment trays for various nursing units.

Planning and organizational consideration of CSSD:

Planning of CSSD: the CSSD should be planned in all hospitals above 100 beds. Theatre sterilesupply unit (TSSU) is to meet emergent and large requirement of OT and is established insideOT complex. In large hospitals like 500 beds and above, TSSU is established in addition to theCSSD in service area.

Bed size of the hospital Location of CSSD

Up to 100 beds In operation theatre

100-500 beds CSSD centrally located in service area

Above 500 beds CSSD in service area and a separate unit forOT to be called theatre sterile supply unit (TSSU).

The following areas are to be provided in CSSD:i. Equipment storage room

ii. Receiving counter and clean up roomiii. Needles and syringes processing roomiv. Gloves assembling room with rubber goods processing roomv. Clean work area including sterilizers

vi. Sterile storage area and issue counter


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vii. gauze and dressing assembly area

Percentage distribution of the space is as follows:

Clean area including sterilization- 40% Sterile storage area-15% Equipment storage-14% Fluids, needles and syringes- 14% Receiving and clean up area-12% Glove processing area-5 to 7% Additional 25% space located for future expansion

Layout:

Location should be where the most rapid means of transportation of supplies andequipment is possible.

There should be avoidance of back tracking of sterile goods. There should be a continuous flow of equipment from the receiving counter to thedispensing counter.

The contamination of sterile goods should be avoided. Sterilizing area should be the last area before the sterile storage and dispensing counter. The receipt and issue counters are separated by a corridor to avoid contamination.

Separation of sterilized items by a partition or corridor

Area requirements:It is recommended that the area of 1.64 sq.m/bed for a CSSD would be appropriate up to 400

bedded hospitals, and for more than 400 beds an area of 1 sq.m/bed would be sufficient.The manual of IGNOU has recommended following functional area for a 100 bedded hospitals:

Facilities In sq.meter

entrance 10.50

lockers 7.00

Counter of receipt of

used itemsDecontamination and

cleaning areaProcessing

Packin of items

SterilizationSterilized items storeDistribution point


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Staff change room 7.00

Dirty receipt and disassembly 7.00

Washing, disinfection and decontamination 17.50

assembly 10.50

Linen processing 10.50

sterilization 14.00

Sterile storage 21.00

distribution 10.50

Trolley wash 7.00

Trolley bay 10.50

Bulk store 17.50

Duty room 3.50

toilet 3.50

Total per 100 bed hospital 164.50

Staffing pattern:One CSSD worker per 30 beds plus one supervisor is recommended. In 200-300 beds hospital,you need 10-15 persons. Staff for 1000 bedded hospitals is:

Supervisor 1(senior most and trained technician)Asst. Supervisor- one of the senior technicianTechnicians 6 (promoted attendants)Sweepers- 15Clerk- 1

Equipments and materials required:

Hot and cold running water Cleaning brushes and jet water gadgets Ultrasonic washers Hot air oven for drying instruments and sterilization Globe processing unit Instrument sharpener like needle sharpening machines Stem sterilizers and boiler for steam Autoclaves of various sizes including gas autoclave Testing equipment Chemicals to clean materials


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Wall fixtures like sinks, taps Trolleys for supply of sterilized items and separate trolleys for collection of used items

are needed

Methods of sterilization:

Sterilization is a process of freeing an article from all living organisms including bacteria,fungus, using dry or wet heat, chemicals or irradiation.

a. Steam sterilization: autoclaving is the commonest method b. Hot air sterilization: Vaseline and oils cannot be sterilized with steam. these items are

exposed to hot air to 160-180 0c for 40 minutes.c. Gas sterilization with ethylene oxided. Sub atmospheric pressure sterilization with formalin: it is meant to disinfect instruments

like endoscopes. the temperature required is 90 0c for 10-30 minutes.e. Chemical sterilization with activated glutaraldehyde

f. Gamma irradiation sterilization: it is used for disposable goods but is a costly method.g. Formaldehyde steam sterilization

Inventory management:

i. Stock: to ensure the availability of sterilized items to the hospital units, five times theaverage daily requirements. The replacement and procurement of condemned itemsshould be laid out so that situation of stock out can be avoided.

ii. Issue of materials: the principle of first in - first out ensures proper rotation of suppliesin CSSD and prevents any item from being kept for longer time so that its sterilizationdate expires.

iii. Distribution of sterile items: the method that can be used for distribution of sterile itemsare:

Grocery system: in case CSSD is open 24 hrs, wards and departments can sendrequisition to CSSD and stock is supplied accordingly.

CSSD is open for limited hours: Clean for dirty exchange system: one clean item is provided for each item

in the ward used. Milk round system: it includes daily topping up of each ward/ department

stock level to a pre determined level decided by users. Basket system: a basket with daily requirement of ward is changed

everyday irrespective sterile items used or not, and the items of the whole basket is sterilized every day.

In case the items are to be stocked in wards, the date of sterilization is written oneach item so that the unused items are returned to CSSD for re-sterilization after72 hrs.


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iv. Quality control methods: Routine temperature/pressure and holding time testing of each autoclave. Steam clox is also very handy and reliable. Changes color from brown to green Heat/time, moisture sensitive tapes may be used in same way as that of steam

clox Random samplings of sterilized items are also tested in laboratory Culture of wall/floor and scrapings.

L aundr y services:

Functions of laundry:

Control of cross infection: it reduces the chances of cross infection. Patient satisfaction: the patient likes to have clean linen which is changed and washed

frequently and has a psychological effect on patient.

Public relation: the image of hospital also depends on clean look of linen as it instillsconfidence in patients and relatives.

Types of laundry:

a. In-plant or in-house laundry: in this system, the hospital has its own linen and laundryand all activities of the hospital laundry services are done in hospital premises. A hospitalwith more than 100 beds can run this type of laundry services.

b. Rental system: this system is used in advanced western countries. The owner of the linenis also the supplier of linens to the hospitals and is also responsible for the replacement aswell as the laundering of patients and staff linen.

c. Contract system: in India, all hospitals have their own linen, majority of the hospitals getthe laundering done by contract dhobis. In some cases, a subsidized contract type is

prevalent and in some cases, the hospitals provide water and washing area within thehospital premises.

d. Co-operative system: it is most beneficial to the smaller hospitals than the large hospitalsas they share the service of highly qualified laundry services.

Planning and organization of laundry services:

Location: if possible, the laundry should be in the same building as the hospital, and should haveseparate entrance and exit areas. It is recommended to have a mechanized laundry in the

basement, with proper drainage arrangements.

Space requirements:

The requirement for any laundry services has been worked out to be approx. 10-15 sq.ft./bed.

No.of beds Space


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200-300 beds 3750 sq.ft.

300-500 beds 5670 sq.ft.

500-600 beds 6460 sq.ft.

>650 beds 8210 sq.ft.

Floor area/space requirement:

According to Dr. Mc Gibony, the area for a laundry for a teaching hospital in India should be atleast 5800 sq.ft.

Physical layout:

1. Straight through flow: the planning of the building and installation of equipment in astraight flow from the dirty end to the clean end.

2. U-flow: where the dirty and clean ends are in the same direction.3. Gravity flow: this takes advantage of the underground, with dirty end at the top and clean

end at the bottom.

Laundry is divided into two distinct areas:

Dirty area: it comprises of Reception of solid linen Sorting of soiled linen into suitable quantities for processing

Clean area: it comprises of drying finishing discharge a barrier wall between the clean and dirty area is desirable

Schematic design of functional areas:

Reception of dirtylinen and storage

Decontamination and sluice

roomBoiler room

Toilet Washer

Laundry Staff room Store of

detergentStore of spare

linen


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Ancillaries:

Laundry managers office StoresTailoring bay

Workers rest room ToiletBoiler room

Material and decor:

The route of soiled linen from the using points to the laundry and the flow of clean linenfrom laundry to the using points should be planned as to minimize the possibility ofcontamination of clean linen.

The laundry should be grouped into specific separate areas. Laundry managers office should be located as centrally as possible to properly supervise

the entire laundry operations. The walls should have large vision panels to allow full view of each area. A toilet, locker and shower facilities should be provided in the soiled linen receiving,

sorting and washer loading room and clean linen processing room. Supply storage room should be adjacent and connected to the soiled linen receiving,

sorting and washer loading room. Sufficient space should be provided for the storage of one weeks supply of detergents,

bleaches and others. The floor for the laundry should have smooth, slip resistant and water proof surface, the

walls should have a smooth washable surface free from all corners, edges or projectionswhich create maintenance problems. Utility services like piping, electrical wiring should be designed and sized with

appropriate consideration for future expansion. The steam supply system should be designed to deliver steam to the equipment in right

quantity at a desired temperature.

Linen mending Hydro extractor

Issue area Storage of

clean linen

Pressing and

launderinDrier


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Hot water should be available at 180 0F by the pipeline to the laundry at the requiredtemperature from the boiler room.

The power supply to the laundry is usually 220 or 440 volts in three phases , four wirealternative system and must be accessible

Lighting should be free of glare and shadows. Fire extinguishers should be located in the laundry near the clean linen and the processing

areas. There is a need for flow of drains in the sorting and washing areas. Ventilation system must be able to provide a comfortable environment for the workers. Sewing and mending room should be located near to the clean linen and pack preparation

room.

Laundry management:

The management of laundry contributes to morale of the staff and patients with fresh laundered

linen:a. Sequence of operation:

Collection of laundry by laundry staffs in trolley with clean and dirty linenseparately and is sorted out as soiled, infected and foul linen to avoid nosocomialinfection.Disinfection is done using disinfectants for infected linens.Sluicing and washing: sluicing is done for foul linen in sluice machine and then thelinen along with those that are disinfected are put in washer for cleaning.Hydro-extractor: it is then put in extractor for removing extra water.

Drier tumbler: the linens are put for drying.Pressing: the linens are pressedMending: the torn linen is sent for repair or condemnation and replacement.Repaired linen is again washed in washer and washing cycle after that is to becompleted.Distribution to ward is done by laundry staff after it is ready for use.

b. Linen distribution system: Topping up: in this, the ward is given certain number of stock of linen based on

24 hours requirement and shortfall of linen due to use is topped up by the laundrystaff everyday and used ones are collected.

Clean for dirty exchange: the issue of clean linen to exc hange number of piecesof dirty linen.

Exchange trolley system: this is expensive and not used in India. In this, totaltrolley is supplied which has 24 hours requirement and next day fresh trolley issupplied with same number of pieces and old trolley is taken back to laundryirrespective as how many pieces have been used and linen is brought and washed.


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c. Quality control of laundry services: the quality assurance of laundry should be developedsince laundry is important from where infection can be transmitted to other patients,which should be seen by the hospital infection control committee.

d. Policies and procedures: Collection and distribution system of linens with periodicity to each ward and

department. Detailed instruction about handling infected and foul linen. Charter of duty of each person handling laundry and training schedule of staffs. Sluicing and disinfection procedures. Operation of laundry machines. Maintenance and service contracts of machines. Provision of detergents Procedure for condemnation of linen and procurement of new linen Fire safety drills and fire extinguishing measures

Record of distribution, collection, inventory of detergents and linen procured/condemned. Security arrangements for laundry. Regular physical verification of linen and fixing responsibility of any type of loss.

Ki tchen services:

A hospital dietary service includes most importantly a production unit that converts raw materialinto palatable food. The preparation and distribution of food from store to spoon has manychallenges for the administration such as proper preparation, cost accounting, pilferage andwastage.

Functions of dietary services:

The dietary services cater for the following:

therapeutic dietin-patient cateringdiet counselingeducation and training

Staff requirements:

Category of employees Beds

100 200 300 500 750


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Chief dietician - - - - 1

Senior Dietician - - - - 1

Dietician - - - 1 1

Asst. dietician 1 2 3 5 7

Steward - - 1 1 1

Storekeeper(ration) - - - 1 1

Storekeeper(general) - - - 1 1

Clerk/typist - - - 1 1

Head cook 1 1 1 2 2

Therapeutic cooks - - 2 2 3

Cooks 4 6 8 10 16

Asst. cook 6 14 20 28 32

Cleaners, waiters 4 4 6 8 10

Store attendants - 1 1 2 2

Sweepers 1 1 2 2 3

Fig. 1 shows staff requirement

Location and space requirement:

Location: the dietary department should be located on the ground floor near wards where thediets need to be taken and also accessible to road as supplies are to be carried to storage area.

Space requirement:

Hospital kitchen is divided into number of divisions which have a particular activity. The broadareas are supplies receiving area, storage area, cooking area, pots and pan wash, garbagedisposal, LPG stove and refrigeration facilities, housekeeping, dietician, steward offices andcirculation area.

Following space requirements are recommended for different size of hospitals:

200 beds or less: 20 sq ft per bed


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Office store

keeper

200-400 beds: 16 sq ft per bed or 18 sq ft per bed 500 beds and above: 15 sq ft per bed

Functional areas in department:

a. Recipient area: this is the place where all provisions are off loaded. these are checked forright quality and quantity, hence area should have unloading points, ramps, trolleys andweighing scales.

b. Storage area: this area where the provisions are categorized and stored in separate areas.the areas should have enough shelves and bins:

Dry provisions like flour, dal, sugar, oil etc. Fresh provisions like vegetables, milk, butter, meat etc.

They are further divided based on temperature requirements:

items to be stored at room temperature like onion, potato etc Items require cool temperature (8-10 0c is maintained) for which walk-in cooler

can be provided to store milk, eggs, butter etc. Deep fridge where temperature is below 0 0c fish and meat should be stored.

c. Day store: it is an area where provisions for one days cooking issued to the cooks arestored.

d. Preparation area: it is an area where provisions are cleaned, washed, soaked; meat ischopped, cut and sliced etc. the items like kneader, weighing scale, slicer etc has to be

provided.e. Cooking area: it should have pressure cooker, cooking range oven etc.f. Service area: the food is put in service pots in trolleys and if it is a centralized distribution

system, it is put in service trays, with specifying the name of patients.g. Washing area: this is meant for washing cooking and service pots, hence should haveliberal hot and cold water.

h. Disposal area: the area where all garbage and left over food is collected for disposal.

Fig 2. - The figure explains the layout of kitchen

Walk-in cold

storeDry store Fresh storeRecipient area of

provisioning


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Distribution of diet:

a. Centralized service: the food is set in individual tray centrally at dietary departmentincluding therapeutic diet of patients and are transferred to wards in trolleys and served to

the patients. b. Decentralized service: the food is sent to wards and served as per the need of the patient.

Dietary store management:

Storage of food items: for dry storage, the temperature should be 70 0c, with adequateventilation has to be insured. The storing shelves, bins should be placed 10 above thefloor.

Purchase of food products: the items can be purchased from open market or throughcalling tenders. The items to be purchased should have AG MARK OR IDI. For this, aninternal purchase committee may be constituted by the hospital administration.

Equipment planning: equipment purchase depends on the objectives and basic functionsof the department, workload and availability of the personnel, and quality standards.Modern gadgets like mixer grinders, pressure cookers, dish washers etc. Should be a partof hospital kitchen.

Financial control: The first thing to be done for an effective financial control is to control the labor

costs. Menu planning should be done in such a way that it reduces the inventory,

selection of items common to many areas of patient care, reduced handling,

wastage, use of automation or more equipment requiring less operational staff aresome measures that can be put to practice for an effective financial control.

L aborator y services:

The basic function of laboratory services is:

Preparation areaDry store

Cooking area Trolley+ pot wash

area

Distribution area and service

Wards

Dietician

Supervisor

Staff room

Staff toilet


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To assist doctors in arriving at or confirm a diagnosis and to assist in the treatment andfollow-up of patients.

The laboratory not only generates prompt and reliable reports, and also functions as storehouse of reports for future references.

It also assists in teaching programmes for doctors, nurses and laboratory technologists. It carries out urgent tests at any part of day or night.

Functional divisions:

The hospital laboratory work generally falls under the following five divisions:

a. Hematology b. Microbiologyc. Clinical chemistry/ biochemistryd. Histopathologye. Urine and stool analysis

Functional planning:

It covers the following activities:

Determining approximate section wise workload. Determining the services to be provided. Determining the area and space requirement to accommodate equipment, furniture and

personnel in technical, administrative and auxiliary functions. Dividing the areas into functional units i.e. Hematology, biochemistry, microbiology etc. Determining the number of work stations in each functional units. Determining the major equipments and appliances in each unit. Determining the functional location of each section in relation to one another, from the

point of view of flow of work and technical work considerations. Identifying the electrical and plumbing requirements for each area/ work station. Considering utilities i.e. lighting, ventilation, isolation of equipments or work stations. Working out the most suitable laboratory space unit, which is a standard module for work

areas.

Organization:

Location: it is preferable to have hospital laboratory planned on the ground floor and solocated that it is accessible to the wards. In large hospitals, the entry of outpatients to thelaboratory can be obviated by opening a sample collection counter in the outpatientservice area itself.

Outpatient sample collection: it should be located in the outpatient department itself. Thedesign of this area should include waiting room for patients, venepuncture area andspecimen toilets separately for male and female patients, along with provision ofcontainers with appropriate preservatives and keeping record of each patient.


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Area/space: in a small hospital, the laboratory facility consists of a room in which all theroutine urinalysis, hematology and clinical chemistry investigations are carried out. Asthe hospital size increases, the requirement of technical and administrative services alsoincreases with the necessity for departmentalization of the laboratory. The requirement ofspace for the laboratory consists of :-

Primary space: this space is utilized by technical staff for the primary task ofcarrying professional work.

Secondary space: it is utilized for all supportive activities. Administrative space, i.e. Offers for the pathologists and others, staff toilets etc. Circulation space: it is the space required for uncluttered movement of personnel

and materials within the department between various technical work stations,rooms, stores and other auxiliary and administrative areas.

Laboratory space unit (LSU): it is a module of space and all calculations fortechnical work areas and some auxiliary area are based on LSU. For allocation of

primary space, one of the most suitable sizes of a LSU is one measuring 10 x 20giving a LSU module of 200 sq. ft. a rectangular module is functionally moreefficient because in the same overall space, it can accommodate longer runs of

benching due to its longer perimeter. Layout: structural flexibility should be achieved by use of movable or adjustable benching systems in association with an installation of service mains that has beendesigned to permit the repositioning of outlets.

Administrative and auxiliary areas: the administrative area (the area is the centralcollection point for receiving specimens and is the reception and interaction area for

patients and hospital staffs) is separated from the technical work area so that the non-laboratory personnel need not enter the technical areas.

Reception and sample collection: this is the area should be well ventilated and lighted,should have a chair where the patient can sit in comfort and where his arm can bestretched for the phlebotomy, a bed where the patient can lie down for pediatriccollection or aspiration cytology.

Bar-coding system for samples: this system is used to trace the samples. The sample isreceived and then bar coded, and then sent to processing area. This protects patientidentity.

Specimen toilet: it is provided for the collection of urine and stool specimens.

Pathologist office: it is so placed that the pathologist can have an easy access to thetechnical areas particularly histopathology unit.

Glass washing and sterilizing unit: small labs collect blood in bottles that are washed andreused. This is partitioned into washing and sterilizing area, containing sterilizer, pipettewasher and sinks.

Report issue: the reports should be issued in printed format. The hospital lab software can be made as per the requirement of the hospitals.


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Utility services: it includes water, gas and compressed air systems. Piping systems should be easily accessible for maintenance and repairs with minimum disruption of work. Forsafety purpose and to facilitate repairs, each individual piping system should be identified

by color, coding or labeling. Internal design and fitments:

a. Work benches: the height of the work bench on which the technicians sit whileworking (revolving stools) vary from 75-90 cm depending upon the height of theworkers.

b. Lighting: natural light should be used to the fullest. Each work bench should be provided with adequate electric points especially fluorescent fixtures that giveuniform illumination and minimize heat.

c. Storage: each laboratory bench length should have storage space for reagents,chemicals, glass wares and other items, provided in the form of under benchdrawers, cupboards etc.

d.

Partitions: it may be required between some laboratory spaces.e. Air conditioning: whole or at least histopathology section of the laboratoryshould be air conditioned due to accumulation of formalin vapors or else a

powerful exhaust system should be installed.f. Working surface/ flooring: the surface of work benches should be resistant to

heat, chemicals, stain proof and easy to clean. Floor should be easy to clean, andnot slippery. Flexible vinyl flooring is preferred for laboratory floor coverings.

Staffing: the hospital laboratory services should be under the control and direction ofa doctor with qualifications in pathology or a PG degree in the new discipline oflaboratory medicine.

Number of personnel: staff requirement of laboratory technicians can be worked outempirically on the basis of generally accepted norm which is about 30 tests per day

per technician.

Equipment:

Some of the core instruments that are needed are:

Colorimeters/ spectrophotometers: they were used in old days, are nowreplaced by new auto-analyzers these days.

Auto analyzers: it is used maximum in biochemistry works. Cell counter: it gives a more complete blood picture. The principle of the

instrument is to pass the cells through a thin capillary. Centrifuge Refrigerators Pressure sterilizers Pipette washers Analytical balance


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Semi auto analyzer ELISA reader Blood gas analyzer PCR instrument Flow cytometer

Policies and procedures:

Laboratory samples: samples to be examined falls in two categories: Samples collected by nursing staffs in nursing units Samples obtained by lab. Personnel.

All requests for lab. Examinations must be in writing.Sample receiving: in the reception area, all samples of blood, urine, body fluids etcshould be received at the reception counter. Sufficient racks and hand washing facilityshould be provided in this area.Request forms: all request forms should be uniform in size and contain only pertinentinformation.Time for accepting specimens: a time schedule for accepting certain types of specimenwill facilitate the operations of the laboratory.Containers: all specimens sent should be in proper containers. Instructions on the time oftaking specimens, minimum volume required, type of container etc. Should be posted atthe nurse s station in wards.Identification of specimen: the lab. Personnel should be responsible for proper dispositionof all specimens and requests within the lab. to identify the specimen received, thespecimen and request form should be numbered with same number and is also entered in

the request register.Reports and records: lab. Personnel should give reports only to authorized ward/ OPD

personnel and never directly to patients. A daily record register should be kept of allexaminations performed in the lab. In order to maintain a monthly and yearly account ofthe work done.Blood bank services: it should be controlled by the officer in charge and the technicalsupervisor, to ensure that all are aware of the establishment of written procedures foridentification of blood samples, storage facility etc.Outpatient samples: it is necessity in large hospitals where the volume of workload fromoutpatient department is considerable.HIV: necessary safety precaution should be clearly understood by all concerned whiledrawing blood samples from suspected HIV and hepatitis patients.Liaison with clinicians: differences between the patients lab. reports as compared to theirclinical status arises which should be discussed in the medical audit committee.Motivation and cross-training: the in charge should discuss professional, technical andadministrative matters concerning the laboratory during periodical meetings with staff.


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The lab. Policy must lie down that all staff is cross-trained to work in all the differentsections of the laboratory.Waste disposal: histopathology and microbiology laboratory waste be considered ashazardous waste and should be disposed accordingly.Optimal utilization of laboratory services: to better utilize the laboratory services, aconstant emphasis is needed on ordering only the appropriate tests required for diagnosisor prognosis based on clinical judgment and filling the required form s completely.Quality control: as a part of quality control function, standard operating procedureshould be laid down by the in charge pathologist for each function and each functionaryin the laboratory.

Emergency services:An emergency department must be developed as a mini hospital within a hospital i.e.Independent and self sufficient in day to day working.

Planning and organizational considerations:1. Location: there are two essential location requirements: It must be on ground floor and easily accessible to both ambulatory and ambulance

patients, and there should be minimal separation between it and radiology department. Secondly, the emergency department should have ready access to the acute patient care

areas, eg. Operation theatre, ICU, blood bank etc.

Emergency department must be designed; usually 1000 sq.ft is required for daily patient load of100 patients.

2. Stretcher, trolley, wheelchair store: a store for stretcher, trolley and wheelchairs should

be located adjacent to the entrance.3. Ambulance attendants, police, mass media room: an equipped room of about 10 m 2 near

the entrance hall with attached toilet serves the needs of above personnel.4. Work area: it should be spacious with enough room for personnel and patients.5. Waiting area for emergency department patients: the main function of this is to be the

passageway to patient examination and treatment area.6. Waiting area for relatives: patient relatives should not be allowed in the work areas of

emergency department. Waiting room with recreational facilities may be provided.7. Visitor s toilet: it should be provide near the main waiting space. 8. Nurse s station and administrative office: this should be next to the entrance and manned

on 24 hr. basis. It should be provided with multiple telephones, bulletin board with dutyroster of doctors on call and directive pertaining to the emergency department should bedisplayed. Nurses work room should be well stocked with drugs, IV fluids.

9. Examination and treatment area: this area should always be in readiness to receive patients at all times, and should consist of a large room and number of separate smallerrooms for examination and treatment. It should be well illuminated space with oxygen


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supply, resuscitation equipment, suction, portable X-ray, electrocardiographs, andBoyles apparatus.

10. Equipment: Stretchers On-the wall oxygen unit On-the wall suction unit BP apparatus, otoscope, stethoscope, opthalmoscope etc. Spot lights Utility table Airways and resuscitation bags

11. Resuscitation room: the patient is to be stabilized in this room before shifting to treatmentor recovery room, or to ICU or nursing unit. It should be well equipped with resuscitationequipment, ECG machine and X-ray viewing screening with facility for performingminor operative procedures.

12. Operation room: a self sufficient operation room to serve patients who need minorsurgery and no admission or who are critically ill etc. in emergency department.

13. Fracture room: a separate fracture room equipped similar to OT and additional facilitiesfor reduction of closed fractures under local anesthesia can be planned with hospitalswith turnover of emergency patients in excess of 15,000 per annum.

14. Plaster room: it is needed for treatment of fractures and application plasters.15. Care of burns: a separate room with 20 m 2 area should be reserved for immediate care of

burn patients. An observation ward of about 6-8 beds for patients to be kept underobservation overnight or 24 hrs.

16. Isolation room: for obstetric patients, pediatric patients.17. Other rooms: these should be planned based on the local needs:

Room for dead bodies Pantry-7 m 2 Storage space Utility and soiled linen room-7 m 2 Cleaners room-house keepers room 4m 2 Change room duty rooms 9m 2 Conference room and reference library 8m 2

Staffing pattern:

Full time emergency physicians, especially trained in emergency medicine A well staffed emergency department needs 8 nurse shifts of 8 hours each per 100

daily patients visits. Additional staff nurses is required if there is observationward attached.

For registration and records, usually 3 clerks work in day and afternoon shift,and one during night.

Security should be available round the clock


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Public relations and social worker should be available to take care of the anxiousand disturbed patients and their relatives.

Medico-legal aspects of emergency department:

a. Negligence: it is the breach of duty owed by a doctor to his patients to exercisereasonable care/skills resulting in some bodily, mental or financial disability.

b. Duty to treat all: according to the recent supreme court decision, no doctor can refusegiving first aid treatment to accident victims or any other patients.

c. Problem areas in emergency department:Consent to treatment: a written consent must be obtained from the patient to treathim, with the patients knowledge regarding procedures. Medical records: medical records and proper record keeping are high priority inany hospital. Proper documentation of pati ents case histo ry with informedconsent is necessary.Reporting to authorities: all medico-legal cases e.g. Assault and battery, childabuse, accidents etc. Should be reported to proper authorities e.g. Police. Thecases of AIDS and venereal diseases should be reported to health authorities.

JOURNAL ABSTRACT:

A well managed outpatient services ensures not only a good relation, but also enhances the patient flow to the hospital. It also results in cost reduction and helps the hospital to becomemore economical. It also ensures patien t satisfaction and satisfaction of the patients relatives. And it is also effective in reducing the load of in-patients services in the hospitals. It reaches outto the community through curative, preventive and promotive activities, and helps in

rehabilitation of the patients.-The nightingale times

BIBLIOGRAPHY:

i. A.G Chandorkar. Hospital administration and planning. 2 nd edition. Paras medical publisher. New Delhi. 2009. pg no. 67-72,153-166,167-179,181-195.

ii. B.M.Sakharkar. principles of hospital administration and planning. 2 nd edition. jaypee brothers medical publishers ltd. 2009. pg.no-195-207.

iii. D C Joshi, Mamta Joshi. Hopsital administration. Jaypee brothers medical publishers pvtltd. New Delhi. 1 st edition. 2009. pg. no. 186-208.

iv. The nightingale times. volume II. pg. 32

organization of hospital

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