MBAHCSSemester 3

MH0052 – Hospital Organization, Operations and Planning (4 Credits)(Book ID: B1213)

Assignment Set- 1 (Marks 60)

Note: Each question carries 10 Marks. Answer all the questions.

Q.1 a. Explain zoning in the Operation Theatre complex. [5 Marks] b. List out the various functions in hospitals? [5 Marks]

Answer (a): Zoning concept should be incorporated while considering the functional criteria. The design should follow the function and not vice-versa. The OT complex may be grouped into the following zones from inside-out:1. Ultra clean zone: This area covers 1meter around the operating site.2. Sterile zone: This area covers the operating room/suite; scrub room; gowning area; sterile linen area.3. Clean zone: This includes drug stores; sterile store; staffroom; anesthetist room; reception; premedication room.4. Protective zone: These are the areas through which patients are wheeled into the OT; personnel movement; lifts; reception; waiting area; change room, all form part of this zone.5. Disposal zone: This is the outermost zone and comprises of the dirty corridor around the OT complex. Soiled linen and unsterile instruments are taken out of the operating room through the hatch, and then moved out of the OT complex through this corridor.

Answer(b)

Functions of Hospitals

The functions and the roles of the hospitals change with changes in the environment (both internal and external). The hospital may choose its functions based on its type, its role in the healthcare system and its relationship with other healthcare services and providers. The hospital decision makers should not only bear in mind the functions based on their own requirements, but also need to look into what people want from them. The primary function of hospital is to care for the sick or to treat patients; hence, every other function of the hospital will revolve around this central function. Besides treating the sick, hospitals also function as centers of preventive health, medical education and research. Figure 2.1 represents the most important functions of the hospitals.

1. Patient Care may be inpatient or outpatient ambulatory care, emergency care, acute care and rehabilitation care.

2. Preventive Care and Health Promotion: Hospitals these days do not function only to care for the sick, but also the one who are healthy. Preventive care enables the healthy people to track their health status and prevents them from falling sick. Eg: Preventive health checks in hospitals enables people to know their health status. Diseases in their early stages could be detected.

3. Teaching, Research and Patient care are interdependent concepts. The very existence of a hospital or a healthcare organization necessitates the existence of trained personnel. This is possible only when they

are able to learn and practice it in hospitals. For betterment of health, advancement in the field of medicine is required. New techniques are being incorporated time and again. This would be possible only when research exists. Therefore, each of these three hospital functions is interdependent.

4. Health System Support: The hospital should also consider its role as part of the overall country’s health system.

5. Society Functions: The hospital decision makers should consider the society’s needs while deciding on the functions of the hospital.

6. Employment: Hospitals act as major sources of employment. It employs various groups of people. It employs the highly skilled doctors and also no skill labourers like the Janitors or sanitary staff.

Q2. Classify hospitals. [10 Marks]

Answer: Hospitals can be classified in many ways:

1. According to their objectives: Teaching Hospital, Non-teaching Hospital, Charitable Hospital etc.

2. According to the type of patients treated: Children‘s Hospital, Women’s Hospital, Geriatric Hospital etc.

3. According to the ownership and control: Government Hospital, Private Hospital etc.

Central Govt.

- under Ministry of Health –RML, Safdarjung- Railway Hospital – for railway staff

- under Labour Ministry- ESI Hospitals

- under Ministry of Defense- Army Hospitals

- under Home Ministry – BSF, CRPF Hospitals

- Under Act of Legislation : Central Act – AIIMS

State Act: PGI, NIMS

Under State Govt. – (also known as Public Hospitals), run by State Govt., like LNJP Hospital, Osmania General Hospital, Gandhi Hospital etc.

Under Local Self Govt. – Municipal Corporation Hospitals, Cantonment Hospitals

NON-GOVERNMENT HOSPITALS

Profit Oriented Non-profit Oriented

Private Nursing Homes, Maternity Homes

Corporate Hospitals:

1. Private Sector: Apollo, Fortis, Global, Yeshoda etc.

2. Public Sector: some of the public hospitals when they are offering services to others on payment basis, some CGHS/Railway/ Army Hospitals

Hospitals registered under Registration Act 1860- Voluntary Hospitals, such hospitals may offer Free/subsidized services

Hospitals registered under Trust Act, 1882 – Charitable Hospitals. They offer free/subsidized services. No member of the Trust is entitled to any profit/remuneration.

Hospitals managed by Cooperative Societies: they are quite common in Maharashtra

According to the System of Medicine: Allopathic, Homeopathic, Ayurvedic, Naturopathic, Unani, Sidha etc.

According to the Bed Strength: Arbitrarily, into Large, Medium and Small depending on the no of beds available there. More than 300 beds= Large Hospital, between 100 to 300= Medium Hospital, less than 100 beds is a Small Hospital.

According to Clinical Basis: clinical classification. General Hospitals, Specialized Hospitals

According to Length of Stay of Patients: Short-term Hospitals, Long-term Hospitals

According to the Directory of Hospitals in India 1988 (G.O.I): A) General Hospital: where services offered are in the basic specialties. B) Rural Hospital: located in rural areas providing services in 4 basic specialties. C) Specialized Hospital: offering services in only one discipline- TB, ENT, Eye, Orthopaedic, Paediatric etc.

D)Teaching Hospital E) Isolation Hospital

Central Government/Govt. of India: All hospitals administered by the GOI viz., hospitals run by the railways, Military/Defense, Mining/P & T or public sector undertaking of the central govt.

State Govt.: All hospitals administered by the State/UT of State Govt. including police, jail and canal depts.

Local Bodies: administered by municipal corpn., municipality, Zilla Parishad, Panchayat

d) Private: All private hospitals owned by an individual or by a Private Organization.

e) Autonomous Body: All hospitals established under a special Act of Parliament/State Legislation and funded by the Central /State Govt./Undertakings like AIIMS, PGI, NIMS

f) Voluntary Organization: All hospitals operated by a Voluntary body/a Trust/ Charitable Society registered or recognized under Central/State Govt. Laws, including hospitals run by missionary bodies and Cooperatives.

Q3. Kunnath enterprises is a construction company would like to open a new hospital at Yelahanka, Bangalore. They have got a team who constitute the hospital planning

A. Who are the team of experts who constitute the hospital planning? [5 Marks] B. What are the steps followed in hospital planning? [5 Marks]

Answer(a):  The hospital planning team should ideally consist of the following members:

1. Hospital AdministratorThe Administrator is the chairman of the planning team. He is mainly involved in putting uphospital requirements to his team in terms of, facilities for the hospital, design consideration,orientation of interrelated departments and service facilities. He also oversees and coordinatesthe various activities involved in planning.2. Hospital EngineerThe engineer appointed to prepare the plan of the hospital should have previous experience inconstructing hospitals. He works in close coordination with the administrator and the architect.3. Hospital ArchitectThe hospital architect should have knowledge of the work flow involved in a hospital setup so asto suggest the design considerations of the hospital. The experience and expertise of the architectand the hospital engineer helps in planning a good hospital.4. Financial ExpertThe financial expert helps the administrator to study the feasibility of the project. He can adviceon the funds required for the project and the sources available for the same. The estimates given by the finance expert helps in drawing up a smooth plan.5. Health StatisticianThe health statistician also contributes to the study of the feasibility of the project. He helps theteam by providing vital information on the demographic picture of the region, disease relatedstatistics, socio-economic condition of the people, all of which helps the administrator indeciding the type of facilities required and charges to be levied.6. Representatives of government or local bodiesThe representatives of the government or local bodies help in the coordination of the project.They form a link between the community and the hospital7. Nursing Director/SuperintendentThe nursing director can give valuable inputs to the project team, especially in ward planning.8. Social scientistThe social scientist helps in identifying the felt needs and real need of the community. Hissuggestions during the planning process helps in fulfilling the communitys expectations of the project.9. Consultant representative from user departmentThe success of everything planned in the hospital depends on whether it is user friendly. It istherefore necessary for the planning team to take into consideration the suggestions of theconsultant representative from the user department. The design and functioning should be user friendly.

Answer (b): Step 1 :  Project Conceptualization :  This is the preliminary stage where one is trying to visualize his / her hospital in terms of its ownership, philosophy, bed-mix, facility-mix, etc.  This requires undertaking at the very least a basic but comprehensive research of the physical, geographic surroundings of the proposed area. Most important, this information can be obtained through the web, current and

archived newspaper mentions, municipality reports, and then undertaking a short survey or holding focus group discussions.  The basic idea is to understand the gaps in the medical market in that area and intending to fulfill them, unless of course, the owner is a Doctor entrepreneur, who knows exactly what he wants.

Step 2 : Feasibility Analysis :  When the project concept in understood, agreed on and locked-in, the next stage is to understand the viability of the proposed hospital.  This would mean undertaking a detailed working of at least the following :

 Project Cost:  Comprising of civil work, medical equipments, furniture and fixtures, professional fees, interest during construction, pre-operative expenses and contingency expense appropriations.

 Department wise assumptions of income, expenses, depreciation schedule, loan repayment schedule, etc.

 Profit & Loss, Balance Sheet,  Cash Flow Statements.

 Sensitivity Analysis:  This is the most important document generated for the project and helps the Promoter to undertake a “go or no go” decision. It also identifies the financial limitations of the proposed project and  frequently helps the Promoter to structure the means of financing the project.  It’s important to note here that all assumptions should be made with a realistic view.

Step 3 : Hospital Designs :  Hospitals are highly engineered buildings, so this step requires a meticulous attention to micro details.  For this reason alone, its vital that one hires a competent team of designers, which would include a  architect, a structural consultant, a electrical consultant, a plumbing consultant, a interior and designer consultant, a landscape consultant, etc.  The emphasis should be a building which does its job brilliantly, more functional than glamorous.  The focal point of this exercise should be to ensure that energy efficiency, natural light and ventilation and ease of maintenance get all the special attention they need. Always remember that the highly engineered buildings cost more and the per sq.ft. cost  would vary between Rs. 1,500  and  Rs. 3,000 per sq. ft.

Step 4 :  Project Management  :  The  notion that an architect is automatically a good Project Manager is a myth. Even from a layman’s angle, it should not be very difficult to understand that the architecture should effortlessly accommodate the complexities of engineering services and the installation of very sophisticated, very costly medical equipment — apart from the various financial  and speed of work related issues involved in project execution.  You can see why it is extremely important to have a separate project management entity to ensure that the final designs are executed as per what was envisaged.  All tendering activities, quality of construction, managing change of design midway, site safety and bill certification periodically are some of the vital aspects of project management.

Step 5 :  Commissioning the Hospital :  The last step of hospital project is to ready it for accepting patients and starting all operations.  This process should begin at least 6 to 9 months prior to inauguration as there are a plethora of activities  to be completed before the patient walks in, issues like developing personal policy, salary structure, standard operating procedure for all department selecting and customizing hospital information system, recruitment, trial runs of equipments, stationary, designs, etc.  It is generally easier to put up the hardware, but the success of the project will depend on how the software bit of commissioning the hospital is handled.

I hope this is a sufficient primer to this issue, and it throws light on how best to set up a Healthcare facility.

Q.4. Explain the various ward designs. Explain them with diagrams. [10 Marks]

Answer: Design and Layout

Size: The size of the wards depends on several factors. It can vary from as low as 10 beds to as high as 90 beds in a single ward. Some of the parameters influencing the design and layout of the wards are:

1. Severity of the patient condition The more the severity, smaller the ward. E.g.: ICU, CCU, T.B Sanatorium etc.

2. Category of the ward General wards has more number of beds than special room or deluxe wards.

Location: The location of the wards depends on the activities taking place, services rendered, movement of patients, relatives of patients, doctors, nurses, paramedical staff, visitors etc.

Example: It is desirable to have the surgical wards close to operation theater and post op; ante-natal wards close to labour theater; ICU close to the Accident & Emergency centre etc.

Ward Areas: the various areas that need to be included while designing the wards are:

Patient space: it includes: Multibed bays, patient rooms

Day space: serves as a space for reading, writing, watching TV, etc.

Patient relatives area

Visitors waiting area

Corridor space that would allow movement of man, machines and trolleys, stretchers, etc.

Ward Design

Nightingale Ward:

The nightingale ward is named after Florence Nightingale. This pattern came into existence after the Crimean war during the 19th century. Each ward has a total of 40 beds. Schematic picture of this plan is given below. This arrangement has the following advantages; 1) excellent cross-ventilation, 2) good lighting, 3) clear and unimpeded view of all patients.

Fig. 4.1: Nightingale Ward

The disadvantages are: 1) No privacy for the patients, 2) Lot of traffic (food cart, patient trolley, ward stock etc) moving through the patient care areas causing inconvenience and disturbance to patients admitted, 3) Nurses/ other staff fatigue factor, due to the distance to be covered for rendering services located in separate areas.

Variant Nightingale:

To overcome some of the disadvantages faced in the Nightingale pattern, a variant of the same was created. Even in this pattern there are 40 beds. The Variant Nightingale pattern is also called Cruciform Shape. The length of the ward is 26 meters. This concept gave rise to the evolution of having single bed room/double bed room wards. A sketch of this type of layout is illustrated below.

Fig. 4.2: Variant Nightingale Pattern

Advantages of this design is: 1) Privacy for patients 2) Reduction in noise levels 3) Reduced incidence of cross-infection 4) Attached toilets making it convenient for patient attenders/visitors 5) Flexibility in usage of wards among different departments. This pattern was not free of defects as it had a few

disadvantages; 1) Reduced view from the nursing station 2) Patients found it difficult to communicate to nurses and doctors 3) Cost of construction, maintenance, overheads etc was more with high capital costs 4) Maintenance also was difficult as this pattern increased the floor area.

Rigs Design:

The Rigs pattern of ward was first designed in 1910 and implemented in Denmark. The length was reduced and width was increased as compared to the Nightingale pattern. A schematic representation of this layout is given below.

Fig. 4.3: Rigs Design

Some of the special features incorporated in this design are as follows:

1. There was a major shift in the earlier concept of spacing of beds.

2. Privacy in general wards was enhanced due to wall partition of 5 ft height.

3. The distance walked by the nurses for rendering service was reduced

4. Patient beds are arranged parallel to the main corridor, in order to reduce traffic disturbances in the ward

Some of the other patterns worth mentioning are:

Nuffields ward:

A lot of research was done on hospital design during 1950s. Nuffields study (1949-1955) deserves special mention. Based on the findings, an experimental ward was constructed. The design is represented below.

Fig. 4.4: Nuffields Ward

Race track design/deep plan:

This concept arose during 1950s in the United States. Also called double corridor system, this design has 36 beds with two nursing stations.

Fig. 4.5: Rack Track Design Harness type ward:

Also known as the crossed type, this design is known to have different types of rooms with single, double, four and even eight beds.

Fig. 4.6: Harness type Ward

Other ward types:

Courtyard ward:

This type of wards makes provisions for natural light and ventilation. This also helps in saving costs and hence contributes towards the hospitals economy.

Q5. Write short notes on:

i. ICU [5 Marks]

ii. Nuclear medicine [5 Marks]

Answer (i) : An Intensive Care Unit (ICU), Critical Care Unit (CCU), Intensive Therapy Unit or Intensive Treatment Unit (ITU) is a highly specialized department of a hospital that provides intensive-care medicine.

Intensive Care Units cater to patients with the most serious injuries and illnesses, most of which are life-threatening and need constant, close monitoring and support from equipment and medication in order to maintain normal bodily functions. They have higher levels of staffing and specialist monitoring and treatment equipment, alongside doctors and critical care nurses who are specially trained in caring for the most severely ill patients.

Hospitals may have ICU's that cater to a specific medical speciality or patient, such as those listed below:

Neonatal Intensive Care Unit  (NICU)

Pediatric Intensive Care Unit  (PICU)

Psychiatric Intensive Care Unit  (PICU)

Coronary Care Unit  (CCU) - Also known as Cardiac Intensive Care Unit (CICU)

Post Anesthesia Care Unit  (PACU) - Also known as the Post-Operative Recovery Unit, or Recovery Room, the PACU provides immediate post-op observation and stabilisation of patients following surgical operations and anesthesia. Patient's are usually held in such facilities for a limited amount of time, and must meet a set physiological criteria before transfer back to a ward with a qualified nurse escort takes place. Due to high patient flow in Recovery Units, and owing to the bed management cycle, if a patient breaches a time frame and is too unstable to be transferred back to a ward, they are normally transferred to a High Dependency Unit (HDU) or Post-Operative Critical Care Unit (POCCU) for closer observation.

High Dependency Unit (HDU) - Many hospitals have a transitional High Dependency (HDU) facility for patients who require close observation, treatment and nursing care that cannot be provided on a general ward, but whose care is not at a critical enough level to warrant an ICU bed. These units are also called step-down, progressive and intermediate care units and are utilised until a patient's conditions stabilises enough to qualify them for discharge to a general ward.

Answer (ii): Nuclear medicine is a medical specialty involving the application of radioactive substances in the diagnosis and treatment of disease.

In nuclear medicine procedures, radionuclides are combined with other elements to form chemical compounds, or else combined with existingpharmaceutical compounds, to form radiopharmaceuticals. These radiopharmaceuticals, once administered to the patient, can localize to specific organs or cellular receptors. This property of radiopharmaceuticals allows nuclear medicine the ability to image the extent of a disease-process in the body, based on the cellular function and physiology, rather than relying on physical changes in the tissue anatomy. In some diseases nuclear medicine studies can identify medical problems at an earlier stage than other diagnostic tests. Nuclear medicine, in a sense, is "radiology done inside out" or "endo-radiology" because it records radiation emitting from within the body rather than radiation that is generated by external sources like X-rays.

Treatment of diseased tissue, based on metabolism or uptake or binding of a particular ligand, may also be accomplished, similar to other areas of pharmacology. However, the treatment effects of radiopharmaceuticals rely on the tissue-destructive power of short-range ionizing radiation.

In the future nuclear medicine may provide added impetus to the field known as molecular medicine. As understanding of biological processes in the cells of living organism expands, specific probes can be developed to allow visualization, characterization, and quantification of biologic processes at the cellular and subcellular levels.[1] Nuclear medicine is a possible specialty for adapting to the new discipline of molecular medicine, because of its emphasis on function and its utilization of imaging agents that are specific for a particular disease process.

Q6.Write short notes on [10 Marks] b. ABC analysis

c. Economic Order Quantity

Answer: (b): ABC-Analysis:Economics of materials control is a matter of self-preservation in todays competitive environment. Since material control is a matter of rupee control, stringent control must be placed on higher value items.

Paretos law:

According to this law, The significant items in a given group normally constitute a small portion of the total items in the group and the majority of the items in the total will, in aggregate be of minor significance.

Principle

A small number of items represent a large percentage of the cost value. Conversely, large percentage of the items represents only a small portion of the cost value. The procedure adopted to determine varying levels of control is called ABC-analysis.

Procedure

The list of all items in the store & the current annual consumption of each item (in Rupees) are taken down from the records available in the Stores / Purchase dept. The items in the list are then re-arranged in the descending order of annual consumption cost (highest to lowest)

An analysis of this list will show that:

The first 10% of the items account for approx.70-75% of the annual consumption cost. These are categorized as A items.

The next 20% of the items account for approx. 20-30% of the annual consumption cost. These are categorized as B items

The remaining 70% of the items account for only 10-15% of the annual consumption cost. These are categorized as C items

Control

Low value items require low investment cost even to increase the level of safety stock. Hence large quantities can be purchased & because of higher stock the physical inventory can be lengthened. Conversely high value items require higher investment cost. Safety stock should be as low as possible and economical purchases should be made, close controls of these items should be ensured. Without ABC-analysis the ordering policy may be to order all items once in 3 months, in which case the stock position may become chaotic.

Summary of ABC-analysis:

Other Classifications

VED Analysis (Vital, Essential, Desirable)

HML Analysis (High cost, Medium cost, Low cost)

FSN Analysis (Fast, Slow, Nonmoving)

SDE Analysis (Scarce in market, Difficult to procure, Easy to procure)

Answer (c): Economic Order Quantity (EOQ)

Definition

It is that quantity at which, the cost of ordering the requirements of an item and the inventory carrying costs are nearly equal i.e. when the sum of the two costs is the lowest. In other words, it seeks to strike a balance between purchase costs and the cost of holding inventory.

Advantages of EOQ

1. Helps in finding appropriate levels of holding inventories.

2. Facilitates the function of ordering sequence and the quantities so as to minimize the total material costs.

In order to understand EOQ method two important costs must be considered and analyzed.

Ordering Cost

In most cases, ordering cost is hidden under overheads. Ordering costs include many variables and are not easily measurable.

They include salaries / wages of the involved personnel

Postal / Telephone / Telex and similar bills

Advertisements

Stationeries

Entertaining Vendors / Suppliers

Travel by Stores Personnel (staff)

In general the ordering cost per order may vary between Rs.15 to Rs.40, which is quite acceptable.

Inventory Carrying Cost

It is obvious that holding excess inventories will result in an increase in the cost of storage, space, maintenance, electricity, insurance and other holding charges along with money tied up in holding it. However there are tangible and intangible costs and problems in carrying too little inventory.

Some inventory carrying costs are as follows.

Cost of storage / Insurance

Salary / Wages of stores personnel

Stationary forms / Paper work

- Loss of interest on money deadlocked in inventory

- Deterioration and Obsolescence

- Losses due to pilferage

Inventory carrying cost is expressed as a percentage of the average investment in inventory. The total inventory carrying cost may range from 1% - 5% of the total inventory cost of a health organization.

EOQ Formula

TC = RP + (RC / Q) + (QH / 2)

Where,

Factors Influencing Order Quantities

Lead time

It is the period that elapses between placing an order and receiving the supplies in stores.

Administrative lead time: Time required for preparing purchase requisitions, obtaining quotations, initiating purchase order etc. It also includes checking and inspection of materials on arrival, recording and sending the material to the appropriate stores.

Delivery lead time: It is the time taken by the supplier in getting the materials ready, transport of materials from his warehouse and actual delivery to the user organization.

Minimum Stock Holding

The guiding principle is that high value items should have a very low stock (since orders are closely followed up). Low value items can have high quantum of minimum stock. Medium value items fall in between. Shelf life affects the minimum stock holding of an item to a great extent.

Safe Buffer Stock

This is the quantity of stock that is set aside as insurance against variation of demand and procurement period for unforeseen reasons and to avoid stock out.

Reordering Systems

Reordering Point: The reordering level is equal to the minimum stock plus requirement during lead time.

It is given by the formula B = RL / 12, where B = Reordering point;

R = Annual demand (units); L = Lead Time (months)

Cyclic System: In this system the physical position is reviewed at fixed intervals. Orders are placed depending on the stock in hand and rate of consumption, i.e. ordering interval is fixed but the quantity ordered varies each time. Ideal for A value items and high value B items.

Two-Bin System: In this case sufficient stock to meet consumption before placing of the next order is held in one bin and the other bin contains stock sufficient to meet probable consumption during the period of replenishment. Here, the order quantity is fixed but the frequency of the order varies. Fixed order quantity is suitable for C items and low value items.

MBAHCSSemester 3

MH0052 – Hospital Organization, Operations and Planning (4 Credits)(Book ID: B1213)

Assignment Set- 2 (Marks 60)

Note: Each question carries 10 Marks. Answer all the questions. Q1. Explain in detail about Hospital pharmacy. [10 Marks]

Answer: Hospital pharmacies can usually be found within the premises of a hospital. Hospital pharmacies usually stock a larger range of medications, including more specialized and investigational medications (medicines that are being studied, but have not yet been approved), than would be feasible in the community setting. Hospital pharmacies typically provide medications for the hospitalized patients only, and are not retail establishments. They typically do not provide prescription service to the public. Some hospitals do have retail pharmacies within them (see illustration), which sell over-the-counter as well as prescription medications to the public, but these are not the actual hospital pharmacy. Pharmacies within hospitals differ considerably from community pharmacies. Some pharmacists in hospital pharmacies may have more complex clinical medication management issues whereas pharmacists in community pharmacies often have more complex business and customer relations issues.

Because of the complexity of medications including specific indications, effectiveness of treatment regimens, safety of medications (i.e., drug interactions) and patient compliance issues (in the hospital and at home) many pharmacists practicing in hospitals gain more education and training after pharmacy school through a pharmacy practice residency and sometimes followed by another residency in a specific area. Those pharmacists are often referred to as clinical pharmacists and they often specialize in various disciplines of pharmacy. For example, there are pharmacists who specialize in hematology/oncology, HIV/AIDS, infectious disease, critical care, emergency medicine, toxicology, nuclear pharmacy, pain management, psychiatry, anti-coagulation clinics, herbal medicine, neurology/epilepsy management, pediatrics, neonatal pharmacists and more.Hospital pharmacies can often be found within the premises of the hospital. Hospital pharmacies usually stock a larger range of medications, including more specialized medications, than would be feasible in the community setting. Most hospital medications are unit-dose, or a single dose of medicine. Hospital pharmacists and trained pharmacy technicians compound sterile products for patients including total parenteral nutrition (TPN), and other medications given intravenously. This is a complex process that requires adequate training of personnel, quality assurance of products, and adequate facilities. Several hospital pharmacies have decided to outsource high risk preparations and some other compounding functions to companies who specialize in compounding. The high cost of medications and drug-related technology, combined with the potential impact of medications and pharmacy services on patient-care outcomes and patient safety, make it imperative that hospital pharmacies perform at the highest level possible.

Q2. Mr Manoj Kumar has been recruited as material manager in Kethams health care located in HAL, Bangalore. He has found that there is a huge wastage of drugs and money in the hospital. He wants to stop this wastage. He called for a meeting and discussed the same with his colleagues and sub ordinates, they took some decision for solving the issue. As per the discussions they found out that the staffs need some training in managing drugs and there are some common causes for these problems [10 Marks] a. What are the common causes of wasting drugs and money? b. Do you think is it necessary to educate or train the staff and patients in the use of drugs? c. What are the steps for educating the staff and patients in managing drugs?

Answer(a):  Common causes of wasting drugs and money

1. A non-optimal use of drugs results in waste. We find cases where a number of drugs are administered on one patient when he/she requires an optimal dose. This results in waste and in addition to the side-effects, we also find non-availability of drugs for the needy patients.

2. Some of the doctors develop a craze for using expensive drugs when we find low-cost drugs equally effective. This draws our attention on brand loyalty resulting in waste and an increase in Medicare costs.

3. ‘Just to try it’ or ‘Trial and Error’ Method has been found common. A large number of drugs though not necessary for the patients are used by the doctors. This in addition to an increase in the cost of treatment also generates side-effects. It is really amazing that some of the doctors just to get commission from the dispensaries adopt such a practice which results in the waste of drugs, vis-à-vis over medication.

4. Disproportionate dose also results in a waste. We also find cases where the doctors administer a larger dose of drugs when even smaller dose would have been equally effective.

5. Providing drugs to those patients who don’t use them and throw it away. Or, the patients not serious about the treatment avoid using the drugs regularly, resulting in waste of drugs.

6. Over supply also results in waste. We also find cases where just to get commission, the over supply of drugs is practiced and we have no option but to throw them because of the expiry date.

7. Inadequate provisions for preserving the expensive and sensitive drugs also result in waste. This is due to the fact that proper refrigeration or preservation facilities are not available. Vaccines in a majority of the cases are no longer effective and we throw them.

8. Mismanagement of drugs is also found to be due to improper steps such as exposing drugs to sunlight or heat.

9. A non-optimal supply by the stores also results in waste. Giving out too many drugs from stores to Departments at one time results in wastage, theft and misuse.

The aforesaid reasons generate huge financial losses and in addition also increase the cost of treatment. Hence there is need for a scientific management of drugs so that cases of waste are checked and financial losses to the hospitals are regulated. It is the prime responsibility of a material/stores/hospital manager to take due care of drugs so that the increasing cases of waste are checked.

Answer(b): We have studied that one of the main causes of wastage of drugs in hospitals is negligence, ignorance of the employees connected with purchase, storing and usage of drugs in hospitals. Particularly the latter category is often involved in wastage. For example, often nurses or other attendants do not care about the minimum use of drugs. Hence educating staff in hospitals becomes important function in material or drug management. It becomes a part of the internal control measure of hospitals.

This can be done in the following ways:

1. Put one or more copies of a simple book on pharmacology in the library.

2. Make notes on the common drugs used, explaining their uses and side effects. Give copies of these notes to all staff.

3. Set out the correct doses of common drugs on wall boards in the hospital.

4. Hold staff meetings to discuss causes of wastage.

5. Inform all staff about cost of various drugs.

6. Make presentations; hold lectures by specialists explaining about the various drugs .

7. Optimizing the use of ‘life saving drugs’. Some steps that can be taken in this regard are:

a) The materials and stores manager should be advised to keep stock of life saving drugs.

b) A list of vital or life saving drugs should be prepared

c) These drugs should placed on a separate shelf.

d) This shelf should be checked frequently by a responsible employee of the hospital.

e) These drugs should be put in A category while doing ABC Analysis

f) Ordering these should be done when stock level reaches 50% (half of the drugs are issued)

Answer (c ):

1. Narrating the Facts: At the very outset, it is the responsibility of doctors attending on the patients to explain to their attendants. Write on the prescription the required dose of medicines to be used by them. Let them know about the side-effects of excess dose and over-medication. It is essential because in a number of cases we find patients and attendants believing in the principle of taking excess dose of medicines.

2. Explaining Facts in Catalogue: In the hospital libraries, we find catalogues detailing the list of medicines. It is quite important that a hospital manager with the consultation of doctors explain the dose and duration to be followed by the patients. The facts should be mentioned in the catalogue and all the doctors should be made available the literature regarding the same so that they remember the details and explain the same to the patients while writing the prescriptions.

3. Displaying Signposts: For educating the patients and attendants, it is also pertinent that some of the selected medicines often prescribed by the doctors should be mentioned in the signposts detailing the dose and duration besides the side-effects. At different important places of the hospitals where patients and attendants assemble in a large number, the display of signposts would be instrumental in informing and informing them. Since the hospital managers are supposed to know about creativity in messages and slogans, the task of sensitizing the patients and attendants in a right fashion would be found easier.

4. Information Packaging: In addition, the pharmaceutical industry also bears the responsibility of informing and sensing the patients and attendants with the help of detailed information regarding the dose, duration and the side effects. If the patients and attendants come to know about the details, there would be less scope for taking the excess dose.

Pre packaging drugs for outpatients also helps in avoiding misuse. Pre packaging means that a full course of treatment with instructions is put in a small envelope or paper before the out patient session. This has several benefits.

a) The patient is correctly told about the course of treatment

b) It saves the time of the doctor as he need not explain in detail

c) It saves the patient’s as he need not wait in a queue

d) There is no abuse or misuse of drugs.

5. Social advertising to be promoted: Besides this, the media, pharmaceutical industry, health department, social organization, and leading hospitals bear the responsibility of promoting social advertising. This would let the patients and attendants know about the side-effects and over-medication due to the excess dose of medicines. This is necessary since the masses are illiterate and they don’t know about the harmful effects of taking excess dose and over-medication.

6. Explaining the use of Drugs: It is pertinent that we explain to the patients the right way of using the medicines. Each drug has a particular effect in a particular condition and therefore a drug taken by an individual will not help another. It should be made clear to them that the optimal dose of medicines plays an important role. If it is too little, the effects are very slow and if it is too high, the reactions and side-effects can’t be avoided. The dose for children is different. It should be clarified that regularity or continuity in treatment plays an effective role because it helps in maintaining the required dose of medicines in the body. We find treatment as a course and the patients need to complete the full course. If the course remains incomplete, the possibilities of relapse resulting in an even more dangerous condition can’t be ruled out. The place for drugs should be out of the reach of small children who may use it and the effects may be very dangerous.

7. Explaining the Importance of Life-saving Drugs: While sensing the patients, it is also significant that we explain to them the importance of life-saving drugs. In a few cases, we find the condition of patients so acute that immediate use of drugs is essential since a delay in the use of drugs may result in irreparable loss.

In the true-sense, drug management is a major problem requiring due attention of almost all the segments. The staff, doctors, the patients, the media, the social organizations, the Red Cross societies need to understand the importance of use of drugs or medicines to get the positive effects and remove the side-effects.

Q3. Write short notes on a. Hospital Engineering services [5 Marks] b. Laundry services [5 Marks

Answer(a): Basic engineering services in hospital can be divided into:

ACTIVE SERVICES1. Technical Services : Like Radiologist, X Ray technician, MRI, C.T. Scan ?"2. Infrastructual: Gases, Compressors3. Hospital Systems Engineering; Materials / Work Flows/ Operation Theater/ ICU/ CCU / Instrumentation/ Systems & control /Automation4.Infrastructual Operational Services : Refrigeration, Laundary, Fumigation, Waste handling & Mangaemnent, supplies, Lift, Signage systems - informative and protective, CSSD, Mortuary, Sytems & IT, Water Heating systems, Steam generators, Diesel generators as auxiliay power

Maintenance: Building Maintenance. Maintenance of Bio-medical equipments, DG, Transformers, UPS, Medical Gas, Water treatment plants, Effluent treatment plants,Misc Support Services: PA systems, Telephone, Fire prevention and fire detection systems,Infrastructural : Buildings, VehiclesWaste Handling, Incinerations Etc.SUPPLIESWater, Electricity ( including Recyclining)Uninterrupted power to Critical operations etc.Contingency Plans

Answer(b): In any residential establishment, a lot of dirty linen accumulates in the various units and departments. It is essential to ensure a continuous supply of linen, which is well laundered, so that operations can be carried out smoothly and efficiently.Linen is an expensive item, so how it will be laundered requires serious consideration. People involved in handling linen should have some knowledge of the process. Moreover, the Housekeeper and Linenkeeper should have a good rapport with the Laundry Manager. Although it is essential that good quality linen be purchased, the life of the linen depends on the care of linen in use and the treatment it gets at the laundry. A good laundry facility ensures the following:

- careful handling of linen articles while laundering.

- correct processing and use of a suitable laundry agent.

- while materials are kept white, excessive bleach is not used.

- proper counting and records maintained to avoid shortages of linen.

- speedy operations to meet with operational requirements.

- sound policies regarding damages or loss.

A commercial or off-premises laundry refers to laundering activities performed outside the establishment i.e. given on a contract basis to specialists in the field. In a rare circumstance, the laundry is contracted and on-premises. An on-site or onpremises laundry, however, refers to laundering activities carried on within the establishment by staff employed by the hotel.

ADVANTAGES AND DISADVANTAGES OF AN ON-PREMISES LAUNDRY

Advantages

• Time taken for laundering is reduced because transportation is eliminated.

• Linen is readily available especially in the case of emergency requirements.

• Control over the wash process and the laundry agents used making the wear and

tear on linen comparatively much lesser.

• Pilferage is reduced.

• The ‘par’ stock required is reduced.

• Revenue is earned from guest laundry.

Disadvantages

• Cost of equipment and its maintenance is fairly high.

• Related expenses like printing of forms, employee taxes, water taxes, energy costs

and insurance are high.

• More staff who are technically qualified and adequate space is required.

• Must be justified by an adequate amount of linen.

Q4. Explain Hospital committee in detail. [10 marks]

. Answer: The committee convened by the JPPC assumed four roles: advisory, communication, advocacy and facilitation. The committee was established to give advice regarding how the performance easurement process should develop and to allow communication between hospitals and MOHLTC on performance measurement. Committee members individually and collectively played a role in advocating for performance measurement among their peers. The terms of reference and membership for the committee are shown in Appendix A. The objectives of the committee are:

• To define indicators that enable hospitals to compare performance with each other on a global and functional centre basis.

• To develop a web-based reporting system that enables hospitals to set efficiency targets and compare with each other.

• To develop a web-based hospital profile and inform hospitals on which hospitals would be good comparators.

• To develop a plan for education and support of the field with respect to this work. These four objectives are discussed separately in this report.

Methodology

To achieve the mandate established, the committee monitored and reviewed emerging research on hospital performance measurement in Ontario and in other jurisdictions. A substantial review of the literature was completed for articles related to performance measurement in hospitals. Articles were selected that met the following criteria: 1) articles that described measures of hospital program outcomes or processes; or 2) articles that provided a conceptual review of performance measurement issues specific to acute care hospitals. From the literature, some of the challenges to the implementation of performance measurement systems include: conceptual and organizational barriers, definition of indicators and data quality. For more details on these challenges see Appendix B. Fortunately, performance measurement is

neither a new task nor an isolated one. The literature highlighted that the critical success factors for performance measurement include the following:

! User Friendly: It is important that any tools or processes developed both seem to be, and actually are, easy to implement.

(1) This is necessary to overcome the

perception that performance measurement is not possible

(2) as well asdeal with the fact that industry does not have a wealth of resources to devote to performance measurement activities. Involving people in the design of a performance system will result in a process that is not only easier to use, but also perceived to be easy to use.

(3)• Relevant to the solution of existing problems:

Performance measurement must not be an activity unto itself. It must be useful in dealing with existing problems in order to generate the necessary enthusiasm, confidence and skill to apply it to new challenges such as limited financial resources.

(4) ! Provide skills:

The tools developed and disseminated must include components of training, support and coordination of existing hospital staff. ! Appeal to middle management:

Performance measurement will be most successful when those involved in generating and capturing the data see value for themselves in the measurement process. Managers need to believe that efficiency and quality are not competing goals.

(5) Consequently, it is critical that the initial tools and processes focus on the needs of senior and middle-level management staff, clinicians and the MOHLTC staff. ! Focus on a speific goal:

Part of the reluctance to move forward with performance measurement is the sense that the process is already underway. Another source of reluctance is related to the sense that performance measurement is the role and responsibility of other external groups. Performance measurement tools need to have specific tangible goals to allow organizations to realistically assess their need for participation.

! Produce measurable gains:

Fundamental to the concept of performance measurement is the idea that best practice costs less. nfortunately, the process of measurement itself may require investments of time and resources. It is therefore critical that initial performance measurement tools focus on areas where it will be both possible and likely to show gains in efficiency and/or quality. After reviewing the hospital performance measurement activities in Ontario, the committee recognized that there are several initiatives, for example the Hospital Report, CIHI/Hay Group Benchmarking Comparison of Canadian Hospitals, with variations in definitions of some indicators. To assist the committee in understanding these variations, a report was written for the committee explaining the variations. This report is in Appendix C. After the review of the literature and performance measurement activities in Ontario and other jurisdictions, the committee recognized that: there is a strong need for a standardized definition of indicators across the

hospital system; hospitals need be focused on only key indicators; and the indicators should be produced with the most recent data available. With this background, the committee focused on the tasks to achieve the objectives of their mandate. The methodology used to achieve the objectives of the committee and results/outcomes are discussed in the following sections

Q5. Explain planning, staffing and workflow on CSSD [10 Marks]

Answer: The purpose of the Central Sterile Supply Department is to make reliably sterilized articles available at the required time and place for any agreed purpose in the Hospital as economically as possible, having regard to the need to conserve the time of users. The objectives of the department are:

To provide sterilized material from a central department where sterilizing practice is conducted under conditions, which are controlled, thereby contributing to a reduction in the incidence of hospital infection.

To take some of the work of the Nursing staff so that they can devote more time to their patients.

To avoid duplication of costly equipment’s, which may be infrequently used.

To maintain record of effectiveness of cleaning, disinfection and sterilization process.

To monitor and enforce controls necessary to prevent cross infection according to infection control policy.

To maintain an inventory of supplies and equipment.

To stay updated regarding developments in the field in the interest of efficiency, economy, accuracy and provision of better patient care.

To provide a safe environment for the patients and staff.

2.General Cleaning of the Department :

To prepare a clean environment for preparing items for sterilization, to maintain the cleanliness in CSSD & to reduce and minimize source of infection.The general working area of the CSSD is mopped everyday including the following area within the CSSD environment.

a. Packing area

Wipe working table, shelves and trolleys with the recommended disinfectant. Wipe the machines with damp cloth.

b. Sterile packs Storing

Wipe the shelves and walls with recommended disinfectant weekly. Mop the floor twice daily and ensure that the mop that is used is only meant for the sterile

store.

c. Decontamination area and sluice room

Wipe the trolleys with recommended disinfectant daily. Wipe the machines with a damp cloth daily. Mop twice and as and when required with the recommended disinfectant. The floors are cleaned thoroughly and polished whenever required.

3. Generation of Items to Sterilize

The items to be sterilized at the Central Sterile Supply Department are washed (with detergent or chemical as applicable), sorted and packed at the respective point of generation (Wards, ICUs, Emergency Department, OTs, OPDs etc ).The Housekeeping staff is responsible for transporting the prepared packs from the point of generation to the Central Sterile Supply Department.

OT linen are send directly to the laundry for cleaning. The laundry washed linen are received , packed and forwarded to the CSSD for sterilization.

a. Process:The CSSD technician receives the unsterile packs, inspects them to check the status of the item (torn, punctured, cracked etc) and places them at the unsterile packs storing platform. Entry is made in CSSD receipts register including date, time, type of instruments in the pack, its source, procedure used for, and case infected or not, name and signature of person handing over, and name and signature of person receiving it.

The autoclave indicator is pasted in the packs by the CSSD technician and the packs are taken to the main sterilizing area where the sterilizing units are placed .The CSSD technician places the unsterile packs under appropriate temperature and pressure specifications in the sterilizing units. The temperature, pressure specifications and accordingly the temperature period are as follows

Temperature Pressure Sterilizing Period

Normal Sterilization: 121*C 15 lb 30 minutes

Rapid Sterilization : 140*C 20 lb 20 minutes

At the end of the sterilization period the packs are removed from the sterilizing units, the autoclave indicators are checked to confirm adequate sterilization of the packs, incase the sterilization is not adequate the process is repeated. Packs which are adequately sterilized are stored in the sterile packs storing area. The following procedure is followed for storing the sterile packs:

Packs are pushed directly to the sterile store to maintain sterility

1. Sterility of the pack is checked as follows :

i. Packs are not torn.ii. No attempts at opening the pack have been made.

iii. Packs are not wet or dirty.iv. The chemical indicator tape color changesv. If any of the above is detected, the instruments are cleaned, dried and re-packed

again.

2. The sterile packs are kept over trolleys to allow them to get cool prior to their arrangement in the shelves. Sterile packs are always handled wearing gloves.

3. Inventory of sterile packs are checked everyday to ensure that they are stored without being distributed to the respective user department.

4. Once the temperature of the sterile packs fall they are stored in appropriate racks in the sterile packs storing area.

Thereafter the sterile packs are issued to the user departments and an entry of the same is entered in the packs issue register.

b. Return of Unutilized Packs:

Incase the packs which are sterilized in the CSSD remains un utilized in the respective user departments for a period of 72 hours , the same are returned to the CSSD department for re-sterilization.

c. Maintenance and Calibration of Equipment

Maintenance of the equipments are done as per the annual maintenance contract (AMC) entered into with the vendor of the respective CSSD equipments. All details in these regard are maintained by the Biomedical Equipments Engineering and Maintenance Department of the hospital.

All equipments used in the department are appropriately calibrated at periodic intervals to ascertain whether they are performing at the expected level and a record of the same is documented in the department as well as with the concerned clerk in the administrative Department of the hospital

Q6. Write in note on functioning of reverse osmosis (RO) plant.[10 Marks]

Answer: Reverse osmosis (RO) is a membrane-technology filtration method that removes many types of large molecules and ions from solutions by applying pressure to the solution when it is on one side of a selective membrane. The result is that the solute is retained on the pressurized side of the membrane and the pure solvent is allowed to pass to the other side. To be "selective," this membrane should not allow large molecules or ions through the pores (holes), but should allow smaller components of the solution (such as the solvent) to pass freely.

In the normal osmosis process, the solvent naturally moves from an area of low solute concentration (High Water Potential), through a membrane, to an area of high solute concentration (Low Water Potential). The movement of a pure solvent to equalize solute concentrations on each side of a membrane generates osmotic pressure. Applying an external pressure to reverse the natural flow of pure solvent, thus, is reverse osmosis. The process is similar to other membrane technology applications. However, there are key differences between reverse osmosis and filtration. The predominant removal mechanism in membrane filtration is straining, or size exclusion, so the process can theoretically achieve perfect

exclusion of particles regardless of operational parameters such as influent pressure and concentration. Reverse osmosis, however, involves a diffusive mechanism so that separation efficiency is dependent on solute concentration, pressure, and water flux rate.[1] Reverse osmosis is most commonly known for its use in drinking water purification from seawater, removing the salt and other substances from the water molecules. A reverse osmosis plant is a manufacturing plant where the process of reverse osmosis takes place. An average modern reverse osmosis plant needs six kilowatt-hours of electricity to desalinate one cubic metre of water.[1] The process also results in an amount of salty briny waste. The challenge for these plants is to find ways to reduce energy consumption, use sustainable energy sources, improve the process of desalination and to innovate in the area of waste management to deal with the waste.