Introduction

Hospital is an institution or the organization for the treatment, care, and cures of the sick and wounded, for the study of disease, and for the training of physicians (teaching hospitals), nurses, and allied health care personnel. supervisors and managers of hospitals must not only have vocational, technical knowledge about hospitals and treatment, but also should have knowledge about contemporary management and its functions and principles. The work module of any job is based on two pillars, namely technical work and management work.

Hospital management in a nutshell hospitals or any healthcare facility passes through the following stages or in other words they need the management of below sections for the smooth running of their organizations, but it is often felt that the hospitals are very complex in its nature and needs a lot of care and understanding. Operations (actions) Finance (money and resources), Personnel(human relations) Information(needed information for wise decisions) Time (your own and that of others) Pathology services

Each of these five elements mentioned, must be managed by any person, who has its own set of principles and guidelines to follow. For instance, when it comes to managing people, the teachings of Industrial Psychology become pertinent. For operations, the teachings of Operations Management as a subject become important. So, in analyzing these five elements, it also becomes evident that the teachings of Financial Management, Information Management and Time Management, are also important for the other three elements. In a nutshell, for a hospital manager it is compulsory to have the sound knowledge of Operations Management, Financial Management, Information Management, Human Resources Management, Time Management and Communication. For the lower level jobs at hospitals and healthcare facilities, the principles of Supervision can become a starting point for teaching or studying the principles of management. A person in one of the lowest level jobs found at employers must also plan, organize and

control work, even if it is just to clean an office or do some washing in one of the departments of the hospital. Top Management members of the hospitals such as Chief Executive Officer, Financial Manager etc, must be able to plan, organize, control and lead the wards and departments with a focus on understanding and influencing the environment, setting the strategy and gaining commitment, planning, implementing and monitoring strategies and evaluating and improving performance. The Top Management must therefore have high capabilities with regard to human relations inwards and outwards, strategic planning, team building, leadership, and negotiation and performance management. Middle Management members must be able to plan, organize, control and lead departments and sections with a focus on assistance upwards for application of scientific methods and assistance downwards for application of scientific methods. They must have the same capabilities as Senior Managers as well as Supervisory Managers and also be good at interviewing techniques, goal achievement, conflict handling tactics and project management. Supervisory Management members must also be able to plan, organize, control and lead sections, units and individuals with a focus on operations, finance, people, information and time. Lack of Management skills in employer or employees at every hierarchy level of the hospital or healthcare facility can be detrimental. Lack of Management skills can lead to poor performance. lack of improvement, low profit, decisions making, disheartening of employees, lower productivity, and jeopardize your organization. Therefore; it is obligatory that hospital managers should have the updated and contemporary knowledge of Management. Concept of Productivity in the context of hospital: The concept of Productivity in the context of a hospital is equally important. So we must know that every organization whether it is Profitable or non profitable, governmental or non governmental needs and uses different resources, which is classified in many groups -Manpower/Labour/Task Force -Material/ Raw Material -Money/Cash/Budget -Machinery/Equipment -Space -Health Management Information System (HMIS) - Human Resource Management

Manpower: As it is a clear fact and I mean it is obvious to all of us that hospital totally and almost always on human resources/Man Power, the numbers of human resources usually higher than in other organizations. So in a result the quality of the services in hospital totally depends on the quality of their human resources and man power. So for that the management is very crucial in this stage. Actually the staff or personnel productivity (output) is quite low in many hospitals. It is a big problem that the staff is not assigning in a specific hours of work but not with whole hearted commitment. So they show insufficient commitment to their tasks, to the care for the patients, and towards creativity in finding solutions to institutional problems. Regarding the capacity building and training of the staff and personnel hospitals infrequently sponsor staff and personnel to external training program. But in large hospitals the training can take place in house with the help of professionals organizations, so these trainings should be conducted periodically so that the employees and staff make aware from the new changes in technology and techniques. It is so vital for the hospitals to train their staff qualitatively and quantitatively. The trainings by up gradation of staff and personnel skills can help in the improvement of staff productivity.

The effective and appropriate usage and utilization of the above mentioned factors or resources shows and determines the organizations effectiveness. For example if it is a profitable organization, its benefits and advantages are increased, while in case of other organizations, its costs are reduced and diminished, therefore the reliance on private sectors and donors or government grants and aids or itself the fee for its services are diminished. The effective and valuable usage/utilization/consumption of the resources or assets is important and significant for every organization or association, whether it is public or private.. Actually, Health care organizations or hospitals need to give more and more concentration and attentiveness to good and better management and execution because of the shortage of resources. Usually the health related organizations are short of resources, bearing in mind the demands for services placed on them. It is useful at this phase to comprise how management and productivity concepts as well as techniques are related to the health field. There is mistaken idea that modern management and productivity concepts and techniques are concerns to profit- making institutions and manufacturing organizations only. Productivity or Output, in simplest terms, is the relationship or bond between the resources, used and results produced. In shorter terms the productivity is the ratio or difference between Input and output.

The effective usage of inputs will ultimately increase or affect the output or productivity. So for the improvement and enhancement of the productivity it is so important to have qualified and well trained and skilled staff, by this way they utilize and use the resources and raw material in a good manner. This is the responsibility of the organization to conduct seminars, workshops and trainings for their employees. Personnel management is productive exploitation of manpower resources. This is also termed as Manpower Management. Manpower Management is choosing the proper type of people as and when required. It also takes into account the upgrading in existing people. Manpower Management starts with manpower planning. Every manager in an organization is a personnel man, dealing with people

Advantages of manpower planning:

Manpower planning ensures optimum use of available human resources. 1. It is useful both for medical organization and for others. 2. It generates facilities to educate people in the organization. 3. It brings about fast economic developments. 4. It boosts the geographical mobility of labour . 5. It provides smooth working even after expansion of the organization. 6. It opens possibility for workers for future promotions, thus providing incentive. 7. It creates healthy atmosphere of encouragement and motivation in the organization. 8. Training becomes effective. 9. It provides help for career development of the employees

Recruitment and selection:Recruitment and selection is the important stage in HRM, actually the selection processes, if use it inappropriately, may have the potential to discriminate against certain groups. Equally subjective judgments based on stereotypes, appearance, can disadvantage the applicant. The entire selection process must therefore be based on criteria related to the requirements of the job, the necessary competencies to perform the job and the potential for development such as intelligence, qualification, aptitude. The panel therefore needs to be clear on the necessary competencies for the job and how to identify them.

Interviewers need training, because every administrator or a medical doctor can not be a good interviewer. As we know in many private institutions the recruitment is done by referral basis, while in governmental institutions the routine advertisements of the posts, screening of documents, and then interviewing. So these all need an overhaul, and to introduce scientific methods for the selection and recruitment in order to avoid nepotism and referral system.

Job and Organization design:As it is clear from the definition of Job design, that job design is the specification of the contents, method and relationships of the jobs to satisfy technological and organizational requirements as well as the personal needs of the job holder. So the evidence that we have from social sciences and behavioural sciences such as sociology, psychology, they have been incorporated and applied in the management of organizations, so these all have a focus on the analysis of the jobs, roles and regulations, design and development of the organizations. Like other organizations and institutions, hospital and health facilities also have the same structure and roles; sometimes they are not able to achieve their targeted goals and objectives. So hospitals need clear job description and image, proper declaration of personnel policies and procedures, organizational charts and so on as much the other organizations have.

Employee Communication:Effective communication have much more effect on the human and organizational health, because if we have a proper channel and code of communication, so it is not easy that we have face any problems, the problems and obstacle is preventing by the virtue of effective communication, effective communication is the blood of any organization When there is a strike or the spread of infectious disease so in that time the effective communication can play a significant role to control all the matters. So newsletters, pamphlets, leaflets, slide presentations, and cassettes are so essential for employee communication. Material: It is clear fact that the good material management can be use to diminish operating costs for the time it is somehow been neglected in hospitals and other facilities, so it is most important to take inconsideration the vitality of the material management in order to achieve the goals and objectives of the hospital. As it is indicated in previous surveys that 40 to 50 percent of the annual budget of the hospital are spending on material used. Hospitals must adapt the ways and methods to streamline and make more efficient their procurement, consumption and utilization control, inventory and records control, storage and dissemination and service organization.

The following factors have a big role in the effectiveness of materials. -The items which are needed urgently should be provided. -Use the money in such a way that the cost of storage is reduced to a minimum. -Handle the items and equipments with the least loss in storage and management. In order to achieve the above mentioned objectives when need to have a good and stabilized policy decisions. However we have to put the short term polices for the time being to run our work. MONEY: In most hospitals and health facilities the financial and costing system are usually weak. The particular income or surpluses and the expenses of various departments are not separately analyzed or the different costs fixed. As a result the related medical and other staff has no idea and concept of the financial management and its implications of the resources at their disposal, or the relationship between costs and the fees for various resources. It is obvious that financial management becomes very critical to the productivity of hospitals. Public hospitals in general need a financial advisor who can advise the management on its spending policies; this will help cost reduction which is so vital. Many of the health related institutions suffer from the unfavorable and unpleasant ratio of administrative and actual healthcare expenditure. The financial management is so compulsory for the hospital and healthcare organization; because the hospitals are growing day by day and they are becoming capital intensive which requires a lot of investments by mean of equipment Purchasement and operating expenses. The hospital and other health facilities which are privately running or it is government based they need a tight and well managed financial department, financial Management is also one of the most important branch of the hospital as other branches like operation, administration, logistic and so on. We have many hospital in our society which are running and financed by Government, some are running by voluntary organizations and some are running and financed by influential and charitable members, so all of these need a financial management section, because if there will be no financial management so how we can analyze our revenues.

Steps in Financial Management:

Some of the best techniques in Financing

Budgeting:
-The process of translating planning and programming decisions into specific projected financial plans for relatively short periods of time. Budgets are short-range segments of action programs adopted that set out planned accomplishments and estimate the resources to be applied for the budget periods in order to attain those accomplishments. Budgeting is the back bone of the financial management, actually the budget is the financial forecast for the upcoming year, and it can be made quarterly or on monthly bases. In general it estimates the income and expenditure and also the in flow and out-flow of funds, so every department should have there own report on their activities and also the expenditure and should report to finance section.

Cost accounting and Cost Control:

Cost accounting is actually the process of tracking, recording and analyzing costs associated with the products or activities of an organization, where cost is defined as 'required time or resources'. Costs are measured in units of currency by convention. Cost accounting could also be defined as a kind of management accounting that translates the Supply Chain (the physical movement of products) into financial value to support decision making to improve costs and cash flows. While Cost analysis (also called economic evaluation, cost allocation, efficiency assessment, cost-benefit analysis, or cost-effectiveness analysis by different authors) is currently a somewhat controversial set of methods in program evaluation. One reason for the controversy is that these terms cover a wide range of methods, but are often used interchangeably. In general cost control has to be exercised if it is possible, while in some cases the income is enhanced by charging clients (Patients) more, it is the ethical obligation of the hospital to exercise cost control, so the patient does not have to charge or pay than standard values. It is essential that control must be exercised at all level and departments of the hospital.

Prices/Fees/Charges
It is important that an appropriate amount of fee for various services be charged. Actually the charges influence the number of patients receiving services and the income of the hospital or other health facilities. The fees should be based on:-- Cost and Competitors fees.

Funds:1-Sources of Funds o Public or Governmental hospitals are financed by government fund and grants, which is financed by income tax and custom duties. o Trust or charity hospitals or health facilities depends on the benevolent and charitable people of the society or community, they mainly deliver free of charge services. o Privately owned hospitals or health facilities are proprietary in nature or partnership types which are mostly managed by medical professionals. o Corporate hospitals and health facilities invite the civil people to invest and share. Whether it Private, corporate, or governmental hospitals or health facilities they are facing the same problem of limited/restricted financial resources. 2-Fund Raising. a- Fees Charged:-It is necessary that independence should be given to the governmental hospitals or health facilities and they should be confident to enhance the financial resources, it is not fair that all services should be rendered free. Special Allowance/Concession should be given to some of the departments, to whom the patients are more going, specially those patients who can not support the fee or charges. b- Institutional Contracts: - One of the good ways for the enhancement of income is to contract with other organizations for providing medical services to their employees or staff. It is necessary for the hospital to have a special budget for their employees, so the employees can get benefits from this budget in order to take free and subsided treatment.

c- Donations/Contributions: - The type of donation to the charitable hospitals is to make concession in taxation with donors. Fund raising through charity is a special occasion or case. How to Launch a Fund raising Campaign, to do this we have different techniques and methods: Face to face Solicitation: - It means that we have conduct face to face meeting with prospective or tentative donor or philanthropic personalities of the community.

Direct Mail: - Describing and briefing the subject through leaflets, broacher and pamphlets by mail. Legacies and Bequests: - Encouraging donor or stakeholders to run off legacies. Special Events/ Procedures: - Organizing special meetings, events to invite the donors and philanthropic people of the community to donate and by this way to raise the fund. Pay-roll deductions: - It is a kind of in-house fund raising method, in this method some amount of money is deducting directly from the salaries of the middle and upper rank officers.

Therefore; the above mentioned methods are the good way to raise the fund, so we have to adopt and choose one of them for our health organization to raise our fund in order to render good quality of medical services. And by this way we can offer good services to the needy patients who cant afford high medical charges, and eventually we will have a healthy community.

Investing funds:The funds which is not been utilized yet should be invested and the interest earned should be utilized or used for hospital operation, so in this way we will move swiftly to render good medical services.

Loans:This is also a good method for fund raising, to take some amount of loan from bank in order to run the daily operation of the hospital or nursing home, but the hospital should return the interest and benefits to the bank on time. So by this way we can render a good quality of medical services.

Equipment: As it is obvious and more apparent that most hospital or health facilities have expensive equipment remains out of the order or inventory list because of the insufficiency of the engineering department, improper maintenance, defective service contracts and so on. The expensive and costly equipment is under utilized because often the users do no have a clear understanding of the capital cost of the equipment or machinery and the bond between these costs, capacity utilization and a fee charged from the patients. It is important to improve and enhance the quality of medical services without raising fees and other charges. And it is also possible to increase the quality of services by improving the utilization and usage of the existing equipments and machinery. Thus the engineering department of the hospital or health facility is the most and critical department, because they are mostly involved in the maintenance and repairing the equipments and machinery, A planned and scheduled maintenance can reduce the chance

of breakdown and damage in of machinery and deterioration in normal routine hospital activities. All the staff of the hospital must understand about the usage and operation of electrical/mechanical appliances and equipments. It is a clear fact that the engineering department is so neglected, so the hospital management should in take all these concerns regarding the engineering department, their problems should be solved in a better way for the betterment of hospital services. The breakdown and even the collapse of the equipments and other instruments are common in all hospitals, so the collapse pave the way for the idling of instruments, so in the result the test are not doing properly and the income will also decreased and hence at the end the results of the patients test is also delayed. The majority of the machinery and the instruments which are so important they are mainly imported from the other countries, so in case of the breakdown and failure the spare parts of these equipments is not easily found in the market, so we have make the maintenance program for these equipments.

Space: Space also plays a dominant role in the productivity of hospitals, as we have seen some of the hospital have so small space while other has a plenty of space. The poor use of space, and defective layouts of equipment cause unnecessary movements of personnel and hospital staff, patients and materials. For the better planning of hospitals we need a coordinated thinking of medical specialists, engineers and architects specializing in the hospital field.

Health Management Information System (HMIS)

The healthcare industry is continuously evolving and becoming more technologically advanced. The need for information managers in this field is escalating rapidly. The major provides a solid foundation of knowledge about management in the healthcare industry and, specifically, the management of information systems within the healthcare field. Emphasis is on managing and advancing the application of information technology and systems to improve the effectiveness of healthcare delivery in a variety of settings. This major meets the industrys desire for professionally educated individuals in the converging healthcare fields of people and information management. Graduates with a degree in Healthcare Information Systems Management will be able to:

Analyze the informatics processes as it relates to the healthcare enterprise Integrate information management processes with clinical processes to provide effective healthcare delivery

Develop a plan to integrate the convergence of various healthcare information technologies into a healthcare organization.

Identify the implications of federal regulations on healthcare IT

Compare and contrast the various process improvement strategies that can be used in a healthcare IT environment The reliable Management information system is the key to any organization for its better performance, prompt availability of the information can help the management in order perform the work with full accuracy and quality. Computers can help in this regard to improve the management information system.

Advantages of Computers: It provides less staff to operate and manage. Decrease the paper work and enhance the accuracy. It is easy to track, compile and get back the entered information. It can store large of data and information. It can provide only one click type of ease.

Possibility of computer usage in hospitals:Prior to introduce the computers to the hospital the possibility study should be done to find out the: Requirement for computerization. Requirement of software and hardware and costs. Degree of computerization compulsory.

It is so necessary that prior to introduce the computer to the hospitals, we must do and perform the feasibility study and survey with the help of ICT Manager or Officer.

The Profit/Advantage of Computerization;

The investment is easily can be phased.

There is chance for staff to be trained on the usage of computer, so in future there will be no difficulty with computers. The fear for using new technology will be overcome by this method.

In hospital the incorporated network is not present to be used by staff, but have their Personal computers which can not do the same work which is done through integrated network system.

Some of the Problems in Computerization:The below are the problems which is facing during computerization. The staff may fright from economizing due to computerization. Fear about new technology. Finance (Salary, profit, benefits and hazards).

Some Recommendations to overcome these problems:Phasing It will not just diminish the strain on the finance department, but it will help the staff to use the new technology and new computerized system. It is recommended that a single and small department should be computerized first, because it easy to measure the benefits or achievement of the computerization.

Training Whenever the office is going to be equipped by new technology, so it necessary that the relevant staff should be trained, because the staff are not familiar with the new technology , so it is the responsibility of the information and technology department to undertake the training on computerization. ICT should compare the advantage and disadvantage of the new technology and should compare the old manual and monolog system with the new digitalized and computerized system.

Finance Computerization is so important for the finance department, because the finance department is always engaged with sorting, analyzing and compiling the expenses and budget issues, so it is always recommended by the information and technology consultant the finance department should also be computerized. At the end we can say the in this world of transition and competition, only those organizations are stay alive who have the capacity of changing and adapting quickly and abruptly. Computerization facilitates more quick works and tasks, there is no department in the hospital which doesnt need computerization, and every department needs to be computerized.

Computerization:Computerization of the financial record is very crucial because we can sort, track and compile all the financial matter in a due time with more feasibility and easy way. And this is easy way of financial reporting. The computer software is available in the market, we can buy this software with ease, so we have use computer in the hospital to track and compile the financial records, calculation of balance sheets and budget.

Finance Personnel Large hospital must have a finance manager to control and audit all the financial issues, and it will help the hospital in financial management .While in Small hospital the Administrator can run the finance section also or they must be trained in finance. Generally the hospital must have a chartered professional accountant. So by this way all the financial issue will run smoothly.

Human Resource ManagementThe Human Resources Management (HRM) function includes a variety of activities, and key among them is deciding what staffing needs you have and whether to use independent contractors or hire employees to fill these needs, recruiting and training the best employees, ensuring they are high performers, dealing with performance issues, and ensuring your personnel and management practices conform to various regulations. Activities also include managing your approach to employee benefits and compensation, employee records and personnel policies. Usually small businesses (for-profit or non profit) have to carry out these activities themselves because they can't yet afford part- or full-time help. However, they should always ensure that employees have an dare aware of -personnel policies which conform to current regulations. These policies are often in the form of employee manuals, which all employees have. The goal of the management of human resources function is to identify and provide the right number of competent staff to meet the needs of patients served by the hospital.

Labour Management/Unionization:Labour Management is one of the most important and even a crucial part of Personnel Management. Since the emergence of unionization the management has faced with many challenges and obstacles. Some times these unions are creating many problems and headache in the hospitals, and we hope that they have contribute in a positive side such as trade unions and so far. The constructive and destructive role of unions depends on some factors, such as past management practices and leadership style, many union are emerging like a virulent and infectious disease who are not following the healthy personnel policies. External political and trade unions giving birth to such disruptive and virulent unions, which can only infect the people in the external environment, in addition they can help their members in the workplace, most unions and central Labour bodies are also active in their communities, helping to make conditions better for working people and their families, both union and non-union. Unions individually and collectively pressure the government on issues that impact working people such as minimum wage, hours of work, health and safety regulations and other employment standards. Unions have been at the forefront of struggles to preserve and protect health care, education and other important public services. Unions fight budget cuts and laws that help big business while eroding the quality of life in our communities. Unions support people in need by lobby in government on Employment Insurance, public pension plans, and welfare

to ensure that all people have a safety net underneath them. Unions have been a key player in educating the public about the negative impacts of globalization. On the other side union members enjoy better wages, better benefits and increased job security. But the biggest benefit is the strength that comes from solidarity. Unlike non-union workers, unionized workers are not alone when they have grievances.

Functions of Human Resource Management: Human resource planning Training and Development Employee Communication Staffing (recruitment and selection) Compensation and benefits Job design and Organization design Employee/Labour industrial relations Performance Appraisal

Employees training and development:Training and Development provides employees with background information about an employer. It can also teach you a new skill and can provide you with overall knowledge that can help you better perform your job. There are many different kinds of training. You can start by handing out a packet of information that people can use as a handbook about the organization. If you are trying to teach a skill, a video or some type of visual aid can be very beneficial. Seminars comprise another form of training. These can be used to teach any size group and are very helpful in providing a vast amount of information in a short period of time. Other types of training can involve on-the-job observation in which you watch what others are doing and learn while they work. With all these different types of training, people can choose the best training for their organization. Since it is important to provide clear, accurate and up to date training, it is also important to revamp your training styles every couple of years. This will make it so your employees enjoy the training they are going through and that they are learning information that will be beneficial not only to themselves but also to the employer.

Benefits of Training and development:1. Increased job satisfaction and morale among employees 2. Increased employee motivation 3. Increased efficiencies in processes, resulting in financial gain 4. Increased capacity to adopt new technologies and methods

5. Increased innovation in strategies and products

Updating Medical Knowledge:It is so necessary to keep the medical staff updated and trained in order to fit them for the emergence of new technology in the medical field, Participation in medical seminars, workshops, and joining medical communities and reading the medical books, journals and literature is essential but it is not enough. There is also advance in training technology such as the software and hard wares (videos, projectors, and other instruments). Hospitals and other health facilities require professional and expert training manager and instructors on their staff, and it is so hard that these organizations have trained and skilled expertise.

Some Key Issues to be addressed:

1. Trained/Skilled Staff: Hospitals need trained and skilled technologists and staff, as it is obvious that many hospitals have no professional technologists because they are not paid satisfactory. The professional technologists have their own private laboratories in the city and they can earn more than monthly salary of the hospitals, so if the hospitals are welling to attract and absorb the professionals in hospital so they must pay for them a good wage salary and other bonuses. These medical technicians who are working in the hospitals must be trained and they need these trainings, these training programs must be undertaken by different medical association. 2-Waste Control: The wastage management is the crucial step in the hospitals, and it is so important that the staff should be aware of the cost of wastages. Hospital waste refers to all waste generated, discarded and not intended for further use in the hospital. Classification of hospital waste (1) General waste: Largely composed of domestic or house hold type waste. It is non-hazardous to human beings, e.g. kitchen waste, packaging material, paper, wrappers, plastics.

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Pathological waste: Consists of tissue, organ, body part, human foetuses, blood and body fluid. It is hazardous waste. Infectious waste: The wastes which contain pathogens in sufficient concentration or quantity that could cause diseases. It is hazardous e.g. culture and stocks of infectious agents from laboratories, waste from surgery, waste originating from infectious patients. Sharps: Waste materials which could cause the person handling it, a cut or puncture of skin e.g. needles, broken glass, saws, nail, blades, scalpels. Pharmaceutical waste: This includes pharmaceutical products, drugs, and chemicals that have been returned from wards, have been spilled, are outdated, or contaminated. Chemical waste: This comprises discarded solid, liquid and gaseous chemicals e.g. cleaning, house keeping, and disinfecting product. Radioactive waste: It includes solid, liquid, and gaseous waste that is contaminated with radio nuclides generated from in-vitro analysis of body tissues and fluid, in-vivo body organ imaging and tumour localization and therapeutic procedures.

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Biomedical wasteAny solid, fluid and liquid or liquid waste, including it's container and any intermediate product, which is generated during the diagnosis, treatment or immunisation of human being or animals, in research pertaining thereto, or in the production or testing of biological and the animal waste from slaughter houses or any other similar establishment. All biomedical waste are hazardous. In hospital it comprises of 15% of total hospital waste.

Rationale of hospital waste managementHospital waste management is a part of hospital hygiene and maintenance activities. In fact only 15% of hospital waste i.e. "Biomedical waste" is hazardous, not the complete. But when hazardous waste is not segregated at the source of generation and mixed with nonhazardous waste, then 100% waste becomes hazardous. The question then arises that what is the need or rationale for spending so much resources in terms of money, man power, material and machine for management of hospital waste ? The reasons are: Injuries from sharps leading to infection to all categories of hospital personnel and waste handler. nosocomial infections in patients from poor infection control practices and poor waste management. risk of infection outside hospital for waste handlers and scavengers and at time general public living in the vicinity of hospitals.

Risk associated with hazardous chemicals, drugs to persons handling wastes at all levels. "disposable" being repacked and sold by unscrupulous elements without even being washed. drugs which have been disposed of, being repacked and sold off to unsuspecting buyers. risk of air, water and soil pollution directly due to waste, or due to defective incineration emissions and ash.

Approach for hospital waste managementBased on Bio-medical Waste (Management and Handling) Rules 1998, notified under the Environment Protection Act by the Ministry of Environment and Forest (Government of India).

Segregation of wasteSegregation is the essence of waste management and should be done at the source of generation of Bio-medical waste e.g. all patient care activity areas, diagnostic services areas, operation theatres, labour rooms, treatment rooms etc. The responsibility of segregation should be with the generator of biomedical waste i.e. doctors, nurses, technicians etc. (medical and paramedical personnel). The biomedical waste should be segregated as per categories mentioned in the rules.

Collection of bio-medical wasteCollection of bio-medical waste should be done as per Bio-medical waste (Management and Handling) Rules. At ordinary room temperature the collected waste should not be stored for more than 24 hours.

TransportationWithin hospital, waste routes must be designated to avoid the passage of waste through patient care areas. Separate time should be earmarked for transportation of biomedical waste to reduce chances of it's mixing with general waste. Desiccated wheeled containers, trolleys or carts should be used to transport the waste/plastic bags to the site of storage/ treatment. Trolleys or carts should be thoroughly cleaned and disinfected in the event of any spillage. The wheeled containers should be so designed that the waste can be easily loaded, remains secured during transportation, does not have any sharp edges and is easy to clean and disinfect. Hazardous biomedical waste needing transport to a long distance should be kept in containers and should have proper labels. The transport is done through desiccated vehicles specially constructed for the purpose having fully enclosed body, lined internally with stainless steel or aluminium to provide smooth and impervious surface which can be

cleaned. The drivers compartment should be separated from the load compartment with a bulkhead. The load compartment should be provided with roof vents for ventilation.

Treatment of hospital wasteTreatment of waste is required: to disinfect the waste so that it is no longer the source of infection. to reduce the volume of the waste. Make waste unrecognizable for aesthetic reasons. make recycled items unusable.

a-General wasteThe 85% of the waste generated in the hospital belongs to this category. The, safe disposal of this waste is the responsibility of the local authority. b- bio-medical waste: 15% of hospital waste Deep burial: The waste under category 1 and 2 only can be accorded deep burial and only in cities having less than 5 lakh population. Autoclave and microwave treatment Standards for the autoclaving and microwaving are also mentioned in the Biomedical waste (Management and Handling) Rules 1998. All equipment installed/shared should meet these specifications. The waste under category 3,4,6,7 can be treated by these techniques. Standards for the autoclaving are also laid down. Shredding: The plastic (IV bottles, IV sets, syringes, catheters etc.), sharps (needles, blades, glass etc) should be shredded but only after chemical treatment/microwaving/autoclaving. Needle destroyers can be used for disposal of needles directly without chemical treatment. Secured landfill:: The incinerator ash, discarded medicines, cytotoxic substances and solid chemical waste should be treated by this option. Incineration: The incinerator should be installed and made operational as per specification under the BMW rules 1998 and a certificate may be taken from CPCB/State Pollution Control Board and emission levels etc should be defined. In case of small hospitals, facilities can be shared. The waste under category 1,2,3,5,6 can be incinerated depending upon the local policies of the hospital and feasibility. The polythene bags made of chlorinated plastics should not be incinerated.

Safety measures
5.1 All the generators of bio--medical waste should adopt universal precautions and appropriate safety measures while doing therapeutic and diagnostic activities and also while handling the bio-medical waste.

5.2 It should be ensured that: Drivers, collectors and other handlers are aware of the nature and risk of the waste. Written instructions, provided regarding the procedures to be adopted in the event of spillage/ accidents. protective gears provided and instructions regarding their use are given. Workers are protected by vaccination against tetanus and hepatitis B.

Training
Each and every hospital must have well planned awareness and training programme for all category of personnel including administrators (medical, paramedical and administrative). All the medical professionals must be made aware of Bio-medical Waste (Management and Handling) Rules 1 To institute awards for safe hospital waste management and universal precaution practices. Training should be conducted to all categories of staff in appropriate language/medium and in an acceptable manner.

Coordination between. hospital and outside agencies

Municipal authority : As quite a large percentage of waste (in India up to 85%), generated in Indian hospitals, belong to general category (non-toxic and non-hazardous), hospital should have constant interaction with municipal authorities so that this category of waste is regularly taken out of the hospital premises for land fill or other treatment. Co-ordination with Pollution Control Boards: Search for better methods technology, provision of facilities for testing, approval of certain models for hospital use in conformity with standards 'aid down. To search for cost effective and environmental friendly technology for treatment of bio-medical and hazardous waste. Also, to search for suitable materials to be used as containers for bio-medical waste requiring incineration/autoclaving/ microwaving. Development of non-PVC plastics as a substitute for plastic which is used in the manufacture of disposable items

3 Optimum Utilization: Many of the hospitals have small number of technician and these technicians are busy in other clerical works so this is the big problem in the hospitals. Those laboratories have many problems which is facing the above said problem. The laboratories which is owned by the pathologists the so these pathologists are also busy with its administrative responsibilities. So it is important for the hospitals to train extra staff for the administrative and clerical works in order to improve the quality of the work in laboratories. In another hand the computerization of record and documents can reduce the paperwork load on the staff, the other benefit of the computerization and compilation of the data and information is to facilitate subsequent and ultimate analysis and tracking of the information.

4- Maximum utilization of Lab Service; Some of the steps for the development of the laboratory services are as follows. Making links with small hospitals and nursing. It is impossible for the patient to wait for long hours to get the result of their lab exam. They have to go to the laboratories at specific time. It is also possible that technician go to the home of the patients and to collect the sample from the patients and after the lab exam the result should be given back to the patient, so by this way the patients can charged for the services. Many of the patients are willing to pay for their lab exams. Relations with general practitioners who can collect the sample from the patient and then these samples are checked in the laboratory after examining it is given back to the patient. It is good to have a 24 hours service instead of having fixed time collection of sample, because in 24 hours service program take and give the results and reports quickly, so in this way their will be no delay in treatment of the patient. It is also possible that laboratories can give the results of the laboratory tests via phone to the medical or pathology specialist in the urgent cases, so in this there will be also no delay in the treatment of the patient.

5-Radiology Services: As it is obvious to all of us by moving this world forward and advanced in technology and physics so the radiology also moved with this advancement and the advancement of the radiological services also need more capital or financial investment. The cost of operation is also increasing with the consumption of inputs such as x-ray films, chemicals which is used for the washing and cleaning of films. But the radiology department center is the big department in the hospital for that the cost or the expenses of this department is high from the other departments, on the other hand its profit is also high in contrast to other departments. So it is most important to keep this department managed and well equipped because the surplus or the profit which are coming from this department should be spent on the less income department by this way we can run the hospital daily expenses. In many hospitals the radiology departments are situated in a very important place because the patients can not move with films in the front of the departments and wards. So for that the radiology departments are located from the beginning in a very strategic place. 6-Pathology Services: In general the pathology services are the cornerstone of the medical field and it is playing a great role in diagnosis of different pathologies and diseases. Pathological laboratories have a crucial role in the diagnosis and detection and eventually in treatment of the patients. The course of treatment and the cost of the medicine is quietly related to the out come of the pathological tests, so the management and maintenance of this department has a great importance. The load of work increased on pathological laboratories is increased every patient should go prior to his treatment to medical or pathological laboratories, so by this the laboratories are overloaded, this overload is more in those laboratories who are attached to the hospital or in hospital territory, and in contrast there is less load on those laboratories which are outside the hospital or private laboratories. The hospitals and laboratories which are located in surrounding area can enter into common understanding. Routinely the hospitals are collecting the samples from the patient and after the examination they are giving reports to the patients back. So in this way the load will be decrease on the laboratories and hospitals. 7-School Health Services:School Health Services fosters the growth, development and educational achievement, students by promoting their health and well being. It monitors health status and identifies and addresses the unmet needs of students, families and school personnel. It builds public and private partnerships to ensure quality services that are effective, culturally appropriate, and responsive to the diverse, changing needs of students and their communities, and most of all school health services have a major role to play in preventive health. Health education is important for the school children for the better and bright future of the nation. It is known to all, that once child learn something in early childhood from his parents/family or teachers so he/she repeating that thing throughout his/her life. The

school health education not merely ensures a healthy generation, but also promotes preventive health care awareness among the society. Most of the school have the facility of health services for their students, and they have dental/skin checkups, it the school doctor find some problem, so they prescribe some medicine for the students, but they are not following the case with the parents of the child

School Health Services should cover the following steps:-Regular checkups of the students. -Education of the children in preventive health and care. -Encouragement of the children to know about the symptoms and signs of the local disease in order to alert to early symptoms of health problems. -And the most important, the doctor should follow-up the disease of the children with their parents.

8-Management of Blood Banks: Blood is the part of life that is given to those who need it by those who have the resource to satisfy the need. Emergencies occur every minute. For each patient requiring blood, it is an emergency and the patients could have set back if blood is not available. And also the surgeries need blood, and also the blood is also required in blood disease, such as leukemias, thalassemia, and a blood cancer.

The main tasks of blood banks are as follows:-Collection of Blood -Testing of the blood. -Storage of Blood. -Supply of Blood to the hospitals and other health facilities.

How we can collect a Blood:1-Voluntary/intentional donors: - This kind of blood collection is done by the voluntary organization, they are establishing blood camps in different organization and institutions and they persuade the people to donate with the poor and venerable patient and save their life.

2-Professional Donors: they are the private blood banks, even they collect the blood voluntarily or they buy the blood and then they sale the blood.

Overcoming certain problems;1. the overcrowding problem 2. hospital safety 3. Cut Practice in medical field

1- Overcrowding in Hospitals and its Management:What are the primary causes of hospital overcrowding? The primary cause is a mismatch between the supply of beds, poor flow of patients through beds, and demand. As demand increases and the bed supply shrinks, flow through hospitals becomes impaired. The most important driver has been the increasing age of patients coming into hospitals. As patients get older, they tend to consume more resources for the same kind of medical conditions. For example, if someone comes in to have their knee replaced at 50 years old, and he is otherwise well, he'll have a short, uneventful medical stay. At 75, with chronic obstructive pulmonary disease, length of stay is likely to be longer and there's more risk of complications. In the past 20years, expectations have changed. We tend to be more invasive in our approach to older patients. And that typically drives up costs.

We can shortly discuss the main causes of overcrowding, and basically it is divided in to parts IPD/Ward: The admission of those patients who needs its treatment in OPD. Some of the patients escaping from work, so they are insisting on unnecessary admission. Delay in the treatment of the patient due to insufficient resources of the hospitals. Delay in discharging of patients. Unnecessary or unscheduled absence of doctors or other medical services.

OPD (Out-Patient Department): Hospital Management should always be in strives to facilitate the patients in putting proper direction signs in corridors or lawns. Irregularities in the attendance of doctors/nurses and other medical staff. Absence and poor functioning of inquiry services. Rhythmic visiting of patients, who have already been visited by the same ward doctor

There are two broad strategies for managing access block resulting from hospital overcrowding reducing hospital demand and optimizing hospital bed capacity. a-Reduce hospital demand Diversion/substitution: The major focus of this strategy has been to divert patients to community services and provide more services in the community that traditionally occur in hospital (e.g. hospital outreach programs, hospital in the home, and improved after-hours general practice services). Reducing expectations: Reducing community expectations of what a public hospital system can provide. Access block cannot be controlled without some limits being placed on the provision of services. Demand for health care is elastic and potentially unlimited, especially in an essentially free health care system. There must be public debate about what is essential versus what is desirable, and how much the community is willing to pay. Prevention: There is potential to reduce demand by disease prevention strategies, and improved management of patients with chronic ill health.

b-Optimize hospital bed capacity Balancing elective and emergency workload :Contrary to popular opinion, the emergency workload is highly predictable across metropolitan areas. Elective treatment must be tailored to match the capacity allowed by predicted emergency work. Better discharge: Moving patients quickly from acute hospitals to more appropriate facilities increases hospital bed availability. Access to rehabilitation, residential aged care and community outreach programs is an essential component of an efficient and well managed health system. Addressing physical, social and psychological issues through care coordination in the emergency department and after hospital discharge can also help reduce hospital length of stay and readmission.

Increased bed numbers: It is important to note that access block does not correlate well with the absolute number of hospital beds. Increasing the number of hospital beds temporarily alleviates access block, but does not solve the problem the beds quickly fill and the problem recurs. Nevertheless, governments must fund an adequate number of beds to provide the health care that the community demands.

2-Safety Management:

a. Hazard Recognition: Hazard identification is the process used to identify all possible situations in the hospital where people (patient, staff, visitors etc) may be exposed to injury, infections or disease. The risk management authorities undertakes periodic evaluation of safety precautions to be followed by each department. For hazard recognition the following steps will be undertaken:

1. Both Clinical and Non-clinical audits will be undertaken on a periodical basis to identify the measures taken to prevent/reduce the impact of the potential hazards. 2. All the staff of the hospital will be encouraged to routinely assess all activities to identify potential hazards. 3. Departmental Heads and Managers will identify hazards within their specific area of control. The same should be notified to the appropriate hospital authorities for immediate corrective actions. b. ELECTRICAL SAFETY: The following measures are undertaken to ensure Electrical safety: 1. Routine Inspection of the power outlets through out the hospital by the electrician. 2. Trip Switches are located in different parts of the hospital to prevent short circuits. 3. Periodic inspection of wires to ensures that they are in appropriate conditions. 4. Before any electrical appliance is brought into RML Hospital, a safety inspection is provided.

5. Electrical equipment not required during night are switched off. 6. Areas around electrical switchboards must be kept clear for a distance of at least 1 meter. 7. ABC type fire extinguisher will be located adjacent to electrical switchboards.

c. Power Loss: The Hospital may experience temporary power losses due to 1. Storms 2. Power company disruptions, or damage to the service lines entering the hospital. 3. Malfunctioning of the internal electrical wire system of the hospital. d. Immediate Action: In the event of power loss, every effort should be made to immediately turn off all electrical equipment (if required) within an employees work area before power is restored to protect the equipment. e. Reporting Power Losses: In general, the loss of power or the disruption in normal electrical service should be reported immediately to the Electrician. Maintenance staff will investigate the scope and condition of power loss and proceed to correct the matter accordingly. f. Biological Hazard: Two primary sources for biological hazards has been identified which are: 1. Infectious Sharp objects. 2. Blood and Body fluid spills. g. Infectious Sharp Objects:

Sharps are any medical or non-medical equipment that is capable of cutting and/or puncturing the skin. Sharps' injuries represent the major occupational cause of accidents involving potential exposure to blood borne illnesses.

i. The Hospitals policy on Sharps Handling is:

Any equipment designated as a sharp must be handled and disposed of safely

Sharps are to be handled carefully at all times. Sharps are designated as clinical waste .

ii. PROCEDURE

Sharps must be disposed of at point of use. Used needles:

o o o o

must not be recapped after use unless using an appropriate device. must not be removed from syringes by hand. must not be bent, broken or otherwise manipulated by hand. must be destroyed immediately after its use.

Used disposable sharps are disposed of in a designated, clearly marked, puncture resistant container. Reusable sharps are disposed of in a clearly labeled, puncture resistant container for transport to the reprocessing area (CSSD). Sharp sections on intravenous giving sets are cut off and disposed of in the sharp's container. The remainder is disposed of in the general waste. This only applies to giving sets that have no visible blood in the line. This does not apply to IV sets that have been used for cytotoxic drugs. Sharps containers must be sealed and replaced.

h. Blood and Body Fluid Spills: i. The Hospitals policy on Blood and Body Spills is:

Blood and body fluid spills must be cleaned up immediately or as soon as possible. Standard precautions must be used when cleaning up spills of blood or body fluids. Gloves and other personal protective equipment appropriate for the task must be worn.

ii. Hands must be washed properly after the spill has been cleaned up. iii. Procedure The following points should be taken into account while cleaning up body fluids: Type of body fluid Size of spill Surface type area involved

iv.

Impervious Surfaces:
a. Wipe the spill up using absorbent paper towel. b. Wash the area with water and detergent. c. If there is a likelihood of bare skin contact with the surface, the area is disinfected with sodium hypochlorite solution.

v. Operating theatres
a. Spills should be attended to as soon as it is safe to do so. b. Area to be disinfected with sodium hypochlorite.

vi. Bathrooms and toilets

a. Spill are hosed off into sewerage system and are flushed with water and detergent. b. The area is disinfected with sodium hypochlorite. I-Fire protection: Incidents of fire has been termed as CODE RED. In an incident of fire the staff has been instructed not to shout the word FIRE instead of that the word CODE RED to be used for informing the other staff about the incidence of fire. The two-fold objectives of the Fire Safety Plan are : i. Fire Prevention: To prevent the incidence of fire by implementing appropriate measure to control fire hazards in the building and by the maintenance of the building facilities provided for the safety of the occupants.(patients, staff ,visitors etc)

a. The hospital has been declared No Smoking zone. b. Smoke Detection Devices are placed in different parts of the hospital, incase of the fire, on detecting smoke the devices are activated and an hoofer is alarmed in the security office. c. Fire Extinguisher: Fire extinguishers, in appropriate sizes and types (ABC), are provided throughout the hospital in every floor of the hospital. Extinguishers are inspected as required by a qualified contractor. The theft of or tampering with an extinguisher should be reported immediately to the Maintenance Incharge.

ii. Emergency Evacuation: To establish a systematic method of safe and orderly evacuation of an area or building, by and of its occupants, in case of fire or other emergency.

3-Cut Practice in medical field , so how it can be discouraged and curtailed:

As it is obvious to every doctor that, all doctors qualified to practice modern medicine take the classical Hippocratic Oath before beginning their professional career, The idealistic values learned during the period of training get shaken up when the doctor steps out from a world of practice of medicine to one of medical practice. Here he sees practical adjustments that he is required to make in his clinical and therapeutic decisions and encounters open offers of referral of patients for a predetermined and regularized practice of fee- sharing (cut practice) Which is unethical practice.

Cut practice (Malpractice) occurs in many forms:

Giving a share of fees to the referring doctor. Referring patients for unnecessary consultations or tests to ensure a kickback from the consultant or laboratory. Giving expensive gifts periodically to the referring doctor. Appointing junior specialists to a super specialty hospital so that procedural work is always referred by them to you. Unnecessary admissions in nursing homes/hospitals. Sponsoring of a conference or payment of travel expenses by a company in return for the use of its equipment or prescription of its drugs.

The basic problem is that, that the patients are neither aware of their rights in getting neither information nor do they take any action against the doctors if they know that the doctors are mal practicing.

Basis for charging fees:Every doctor determines his/her professional fees on the basis of experience, wisdom and self-perception of the level of skills required for a particular treatment. Fees thus vary widely from doctor to doctor. Hence a particular amount cannot be termed unreasonable as long as the patient is aware of the sum to be paid before the service is rendered. What the treating doctor does with the fee after it is received by him is entirely and solely his concern and the patient or any other person has no say in it. Hence if a doctor decides to give a portion of his fees to another person (medical or non-medical) it is entirely legal and ethical to do so provide this is done openly and after obtaining a receipt.

Various specialized procedures - such as endoscopy, angiography, angioplasty - form lucrative sources of income and are therefore frequently advised even when the stated indications are not scientifically valid. (At times it is difficult for a doctor to say that the procedure advised by another was not required because on most such issues, opinions published in the medical literature support both points of view. There is truly no substitute for ones own competence and conscience acting as an internal judge and counsel.)

How we can control this mal-practice or cut practice: Public Education or awareness on such mal-practices is the first step of controlling. In the absence of a clear, logical, bold and community oriented health care policy on the part of the government and a lobby of strong, honest, clear thinkers representing the medical profession in the corridors of power, the present situation is unlikely to change in the near future. To avoid this mal-practice we have to have strong local or national medical association or federations, with the strong code of ethics. Themselves medical doctors should talk and conduct meetings to prohibit and condemn the mal-practice. Consumer protection act needs to be implemented in order to stop this cut or mal-practice. The monthly salary and other benefits of full time doctors especially in teaching hospitals should be such that they are able to maintain a decent standard of living commensurate with their position and seniority. There will then be no need or incentive for unethical ways of earning extra income. Each general practitioner must charge a publicly stated fee from the patient for the act of medical examination, making a diagnosis and recommending appropriate treatment or referral to an appropriate consultant or hospital. A body of experts in each hospital or nursing home should monitor the performance of various procedures to ensure that they are based on scientifically valid indications

Doctor Patient Contact:The contact or relationship between the doctor and patient should so transparent, and this relationship and contact is so important in order to satisfy the patient. And he will satisfy from the relation and behave of the doctors because the patients are waiting for hours, and even the patients are waiting for doctors appointments for weeks, and when they visit the doctor, so the doctor just see them for a minute, so this will disappoint the patient, so in this case the doctor has no fault because he is overcrowded by patients and he has no enough time to give to all patient.

Points for the satisfaction of patient Enough time should be given to the patient to define his illness and doctor should take the full history from the patient. The doctor should give full information regarding the patients illness or disease. The patient is willing to know about his/her problem so the doctor should strive to give necessary information regarding his illness.