07AMBHM24 - Hospital Operation-II (Supportive Services) - v4

Hospital Operation-II (Supportive Services)
MBA Second Year

(Hospital Management)
Paper No. 2.4
School of Distance Education

Bharathiar University, Coimbatore - 641 046
CONTENTS
Page No.
UNIT I
Lesson 1 Understanding Supportive Services

Lesson 2 Nutrition and Dietary Services 1
Lesson 3 Pharmacy 19
Lesson 4 Medical Records 30
UNIT II
Lesson 5 Hospital Engineering and Maintenance 39
Lesson 6 Maintenance Programs in Hospitals 49
Lesson 7 Electrical Supply 57
Lesson 8 Water Supply 70
Lesson 9 Medical Gas Pipelines 80
Lesson 10 Plumbing 88
Lesson 11 Sanitation 97
Lesson 12 Air-Conditioning System 106
Lesson 13 Hot Water and Steam Supply 113
Lesson 14 Communication System 121
Lesson 15 Biomedical Engineering Department 130
UNIT III
Lesson 16 Laundry Services 141

Lesson 17 Housekeeping Services 151
Lesson 18 Energy Conservation Methods 159
Lesson 19 Cost Containment Measures 171
UNIT IV
Lesson 20 Transportation Services 183

Lesson 21 Mortuary Services 192
Lesson 22 Hospital Security Services 201
UNIT V
Lesson 23 Disaster Management 211

Lesson 24 Fire Protection 232
Lesson 25 Engineering Hazards 241
Lesson 26 Radiology Hazards 248
Model Question Paper 256
HOSPITAL OPERATION-II (SUPPORTIVE SERVICES)
SYLLABUS
UNIT I
Nutrition and dietary services - pharmacy services - Medical records services.
UNIT II
Facilities Engineering - Maintenance of Civil Assets- Electrical supply and water
supply - Medical gas pipeline - plumbing and sanitation - Air conditioning system -
Hot water and steam supply - Communication system - Biomedical engineering
department in modern hospital.
UNIT III
Laundry services - Housekeeping services - Energy conservation methods- Cost
containment measures in a hospital.
UNIT IV
Transportation services - Mortuary services - Hospital security services.
UNIT V
Disaster management - Fire Hazards - Engineering Hazards - Radiology hazards.
LESSON UNIT I 7
Understanding Supportive
Services
1
UNDERSTANDING SUPPORTIVE SERVICES
CONTENTS
1.0 Aim and Objectives
1.1 Introduction
1.2 Need and Significance of Supportive Services
1.3 Supportive Services – Meaning
1.4 Types
1.5 Functions of Supportive Services
1.6 Let us Sum up
1.7 Lesson End Activity
1.8 Keywords
1.9 Questions for Discussion
1.10 Suggested Readings
1.0 AIMS AND OBJECTIVES

After studying this lesson, you should be able to:
z Understand the meaning of supportive services
z Understand the need and significance of supportive services
z Know the types and functions of supportive services
1.1 INTRODUCTION
In this millennium era, health care sectors face great gaps with increasing knowledge
and awareness of health problems on one hand and disparities in access to medical
treatment on the other. The number of well-managed health care units both in private
and pulic sectors is very few in number because of many reasons say inadequacy in
financial resources, lack of people experts and lack of resource materials in the field.
“The foremost aim of the hospital management is to strengthen the preventive,
promotive, curative and rehabilitation aspects of health care to reach the population in
the remotest area of the country and development of healthcare manpower resources
by providing good quality of medical education.”
The Ministers of Health of countries of South East Asia Region adopted the
declaration on Health Development in the South East Asia Region in the 21st century
at their 15th meeting in Bangkok. Thailand in August 1997.
The World Health Report 2000. Health systems: Improving performance by WHO
rightly states that:
“From the safe delivery of the healthy baby to the care with dignity of the frail-
elderly, health systems have a vital and continuing responsibility to people throughout
6 the lifespan. They are crucial to the healthy development of individuals, families and
Hospital Operation-II
(Supportive Services) societies everywhere.”
From all the above statements it is obvious that Health systems as a whole comprises
of all the organizations, institutions and resources that are primitive to health actions.
This may be any effort in direction to personal health care, public health services
whose primary purpose is to improve health.
1.2 NEED AND SIGNIFICANCE OF SUPPORTIVE

SERVICES
Today total hospital administration at all levels say tertiary, secondary, community
and primary level are facing a large number of problems to cope with new and
emerging developments in the 21st century. Hospital care is multidimensional. It is a
service provided by a coordinated group of professional, technical, supportive and
other workers under the direction of a physician. The quality of care received by
patients is affected by the adequacy of the hospital facilities and their maintenance.
This dynamic society, the hospital occupy a unique place to accommodate explosion
of science into medicine, new treatment techniques, new equipment and proliferation
of services. Besides all, the development of socio politico, cultural and educational
systems have made the people conscious of their rights and they demand the modern
and best means of medical and health care to be made available to them. All these
have made today’s hospital more complex in nature.
And to manage such a complex administrative, supportive services in the right
quantity, at the right place, by the right man, in the right way becomes very essential.
Here supportive services are the one which make the work of experts possible by all
means.
1.3 SUPPORTIVE SERVICES – MEANING

Generally the different departments of the hospital can be grouped according to zones
as follows:
(a) Outermost zone, which is the most community oriented:
primary health care support areas
out-patient department
emergency department
administration
admitting office, reception
(b) Second zone, which receives workload:
diagnostic X-ray
laboratories
pharmacy
(c) Middle zone between outer and inner zones:
operating department
intensive care unit
delivery
nursery
7
(d) Inner zone, in the interior but with direct access for the public: Understanding Supportive
Services
wards and nursing units
(e) Service zone, disposed around a service yard:
dietary services
laundry and housekeeping
storage
maintenance and engineering
mortuary
motor pool.
In each of these zones, any hospital renders two types of services: Medical care
services and Supportive services. Medical care, goes to the core where the actual
purpose of patient care, i.e., consultation, examination, treatment, diagnostic, curative,
preventive measures are undertaken for a problem / disease etc. Whereas Supportive
services, as the name implies renders supports to the medical care service. It
smoothens the overall job, by monitoring the right flow of treatment right from the
patient’s entry into the hospital, till the exit stage. Thereby supportive services,”
identifies the needs and wants of the patients, offers wide variety of additional service
apart from diagnostic, curative measures and thereby providing effective and efficient
delivery of quality patient care support and service”.
1.4 TYPES
Today strong debate exists in defining the different types of supportive services
provided by the hospitals. Finally, experts came to the conclusion that each hospital is
a distinct entity and as such each has to be tailored to their own specific aims to be
accomplished, the specific tasks to be performed, the volume of services to be
rendered and the type of community to be served.
The following list enumerates the different types/variety of supportive services
offered by today’s hospitals in general:
z Nutrition and Dietary services
z Pharmacy
z Medical records services
z Electrical and water supply
z Medical gas and pipeline
z Plumbing and Sanitation
z Air conditioning system
z Hot water and steam supply
z Communication system
z Maintenance and engineering department
z Laundry services
z House keeping services
z Energy conservation service
z Transportation service
z Mortuary service
8 z Hospital security and safety
(Supportive Services) z Disaster management
z Laboratories
z Radiology department
z Public relations and Marketing
z Sterilization department
z Materials management department
z Volunteer department
1.5 FUNCTIONS OF SUPPORTIVE SERVICES

z Providing supportive services results in effective coverage that matches the needs
of the individuals to the entities that serve them.
z Enhances coping and participation in care by providing emotional support to the
patients.
z Provides counseling to the patients and educates them rather than giving them
mere consultation.
z Acts as a liaison in linking the patient’s family with the medical team.
z Precedes and succeeds the medical care services through its pre-post planning
preparations.
z Facilitates easy and smooth access to all hospital resources.
z Acts as a great risk management tool reporting and coping with all the disasters
that might happen in the future.
z Preserves and maintains the physical assets of the campus facilities.
z Providing a healthy and a secure environment.
z Integrates teams involving both Inpatient and Out – Patient.
z Directly supports the instructional, research and public service activities.
z Helps in attainment of strategic objectives and the delivery of quality, economic
health care services.
z Initiates and enforces organization wide policies and procedures that support the
accomplishments of the hospital’s aims, objectives and programs.
z Supports overall efforts to improve customer satisfaction.
z Helps in evaluating, assessing and documenting for future progress.
z Helps in meeting the expectations of customers and to meet the challenge for
future growth.
z Ensures excellent interdepartmental relationships.
z Providing expertise in use of various machines and equipments.
9
Check Your Progress Understanding Supportive
Services
1. Define Supportive Services.
………………………………………………………………………………
………………………………………………………………………………
2. Briefly describe the World Health Report 2000.
………………………………………………………………………………
………………………………………………………………………………
1.6 LET US SUM UP

The importance of supportive services in hospitals is becoming widely accepted
nowadays allover the world and recently in India too. This is because of medical
tourism, quality patient care etc. In this lesson, we have discussed what is a supportive
service, its meaning and its definition. The need and significance of supportive service
to a hospital has been discussed. The different types of supportive services and its
functions have been covered.
1.7 LESSON END ACTIVITY

A person is going to start a hospital; he doesn’t know anything about the hospital
sector. How will you justify about the need of supportive services.
1.8 KEYWORDS
Medical Care: Consultation, examination, treatment, diagnostic, curative, preventive
measures undertaken for a problem/disease etc.
Supportive Services: Services that renders support to the medical care service.
1.9 QUESTIONS FOR DISCUSSION

1. Enumerate the need and significance of supportive services.
2. Define supportive services and its types.
3. State the functions of supportive services.
Check Your Progress: Model Answers

1. Generally the different departments of the hospital can be grouped
according to zones as follows:
Outermost zone, which is the most community oriented
Second zone, which receives workload
Middle zone between outer and inner zones
Inner zone, in the interior but with direct access for the public
Service zone, disposed around a service yard
2. The World Health Report 2000. Health systems: Improving performance
by WHO rightly states that:
“From the safe delivery of the healthy baby to the care with dignity of the
frail-elderly, health systems have a vital and continuing responsibility to
people throughout the lifespan. They are crucial to the healthy
development of individuals, families and societies everywhere.”
10
Hospital Operation-II 1.10 SUGGESTED READINGS
(Supportive Services)
Hayward, Cynthia Chi Plan TM, A Space Planning Guide for Healthcare Facilities,
Chi Systems Inc., 1995.
Interstitial Space in Health Facilities-A Research Study Report, Health and Welfare
Canada, 1979.
Spear, M. "Current Issues: Designing the Universal Patient Care Room" Journal of
Health Care Design, Vol. IX, 1997.
Strauss, J. J. Facility Planning with Flexibility in Mind. Proceedings Manual, 1993.
International Conference and Exhibition on Health Facility Planning, Design and
Construction, 1993.
Zuckerman, A. M., and C. Hayward. Healthcare 2000-Planning for the Hospital of the
Future. Proceedings Manual, 1993 International Conference and Exhibition on Health
Facility Planning, Design and Construction, 1993
Facilities Standards for the Public Buildings Service, P100 by the General Services
Administration (GSA).
FEMA 452 Risk Assessment—A How-To Guide to Mitigate Potential Terrorist
Attacks Against Buildings International Building Code.
Mitigation Planning How-To Guide Series, FEMA 386 Series.
The National Strategy for "The Physical Protection of Critical Infrastructure and Key
Assets", The White House. February 2003.
Protection of Federal Office Buildings Against Terrorism by the Committee on the
Protection of Federal Facilities Against Terrorism, Building Research Board, National
Research Council. Washington, DC: National Academy Press, 1988.
Understanding Your Risks: Identifying Hazards and Estimating Losses, FEMA 386-2.
United for a Stronger America: Citizen's Preparedness Guide (PDF 647 KB, 30 pgs)
Uses of Risk Analysis to Achieve Balanced Safety in Building Design and Operations
by Bruce D. McDowell and Andrew C. Lemer, Editors; Committee on Risk Appraisal
in the Development of Facilities Design Criteria, National Research Council.
Washington, DC: National Academy Press, 1991.
websites
The Infrastructure Security Partnership (TISP).
13
LESSON Nutrition and Dietary
Services
2
NUTRITION AND DIETARY SERVICES
CONTENTS
2.0 Aims and Objectives
2.1 Meaning
2.2 Location
2.3 Design
2.4 Food Distribution
2.5 Functions
2.6 Components
2.7 Functional Areas
2.8 Organization
2.9 Facilities and Space Requirements
2.10 Related Issues
2.11 Let us Sum up
2.13 Keywords

z Understand the meaning of nutrition and dietary services
z Know the location and design of nutrition and dietary services
z Acquire knowledge on food distribution services and its functions
z Know the components of dietary department along with its functional area
z Understand the organizational setup of the dietary department
z Know the facilities and space requirements at this sector
z Gain knowledge regarding the issues in the dietary department
2.1 MEANING
Nutrition and Dietary Department in all the hospitals plays a vital role not only in the
patient’s health care but also in making the choice of the particular hospital. As a
major department it is headed by a specialist who is either a professional manager or a
chief dietitian. Apart from parenteral feeding, hospitals should provide dietary
services for those in special need of them i.e., infants and other patients unable to eat
1 normal meals. These services should be provided whether or not the local custom is
(Supportive Services) for the family to provide regular meals for the patient. The dietary department of the
hospital should advise staff and patients about:
z special diets-that include or exclude specific ingredients,
z modified diets-containing increased or reduced amounts of certain components,
such as carbohydrate or fat,
z normal diets.
Decisions concerning special and modified diets should be considered on the basis of
the therapeutic programme decided upon for the patient. All meals should be
composed with the aim of achieving appropriate nutrition, within the limits of the
hospital budget, local food habits, and cultural and religious restrictions. The hospital
and the primary health care centers have the responsibility of giving patients and
relatives information on proper nutrition and well-balanced diets. Dietary education
should be provided not only during therapeutic care, but on all suitable occasions, and
should deal with normal nutrition as well as special diets. A list of food choices may
help to illustrate nutritional principles. Such lists should be organized according to
traditional food groups and consideration should be given to different ethnic
backgrounds that dictate specific feeding patterns.
2.2 LOCATION
The dietary department should be located next to the kitchen or anywhere on the
ground floor, directly accessible from the service court to receive daily deliveries of
meat, vegetables and dairy products. Direct deliveries to the refrigerated section
eliminate traffic through corridors and cooking areas. The direction of the prevailing
wind must also be considered. The location of the dietitians depends on the main
activities. In case that the dietitian is involved in clinical nutrition, it can be
convenient to locate the dietitian in the kitchen or next to the kitchen. If the dietitian is
involved in primary health care, their location within these services should be
considered. When a kitchen is designed, not only the location and the type of the
kitchen should be taken into account but also the hygienic rules and regulations should
be considered from the start.
Kitchens must be located such that heat and odours are not directed towards areas of
high population. They should also not be located under wards, especially those for
non-ambulant patients, as a fire safety precaution. The planning and design of the
kitchen is left to the countries depending upon methods of cooking, social and other
religious considerations.
2.3 DESIGN
The design and physical facilities of the food service department should be given due
considerations as it directly affects the standard of food service, and indirectly lead to
adverse effects in increasing the labor costs and reducing the morale of the employees.
Certain things like storage rooms far from the work area, poor arrangements of the
preparation and production areas for work flow and a long traveling distance for
prepared food lower the employees efficiency levels and increase unnecessary steps
resulting in increased costs.
Proper planning with adequate space and facilities to perform the work in each of the
functional areas is a must. The following fig illustrates a typical food service
department plan.
1
2.4 FOOD DISTRIBUTION Nutrition and Dietary
Services
There are basically two types of food distribution service:
z central tray service (centralized food distribution) and
z bulk service (decentralized)
The central tray service (centralized food distribution) and bulk service
(decentralized) both have advantages and disadvantages.
In the central tray service, patients' trays are prepared in the main kitchen, loaded onto
conveyors or carts, open or insulated, and transported to the various wards. Soiled
dishes are collected and returned to a central dishwashing area. This system requires
fewer staff and initial equipment costs are lower than with a decentralized system;
however, the food usually cools during transport and loses some of its quality.
In the bulk service, food is brought to the wards in heated carts. Trays are prepared in
a sub-kitchen in each ward and loaded onto a cart, which is rolled alongside the bulk
cart; each tray is served from the bulk cart at the patient's room. Dishes are washed in
the sub-kitchen. This system is the most suitable in hospitals where the corridor
systems are long, to ensure that the food that reaches the patients is still hot and fresh;
however, it requires additional space in the wards for washing and storing trays, plates
and cutlery.
Check Your Progress 1
Define the following:
1. Central tray service
……………………………………………………………………………..
……………………………………………………………………………..
2. Location of kitchen
……………………………………………………………………………..
……………………………………………………………………………..
2.5 FUNCTIONS
The functions of food service department are as follows:
z Serving the best possible nutritional food, consistent with the budget.
z Establishing standards for planning, preparing and serving food.
z Standards must be established before setting up food purchase specifications.
z Framing policies, layouts and equipment requirements.
z Checking whether purchases and supplies are with regard to specifications.
z Confirming the quality and quantity of supplies.
z Properly arranging to store, produce, portion, assemble and distribute food.
z Providing proper education and counseling regarding nutrition and diets to be
followed.
z Providing proper training to the die tics interns
z Giving proper instructions to nurses, medical students interns and residents about
principles of nutritional and diet therapy.
z Providing proper platform to facilitate research in this area.
z Acting coordinative with intra and inter departments.
1
Hospital Operation-II 2.6 COMPONENTS
The dietary department has the following main components:
z food refrigeration and storage,
z cooking,
z serving,
z special diets,
z dishwashing; and
z dining.
The department should contain the following facilities, unless commercially prepared
diets and service, meals and/or disposable items are used:
z food preparation centre
z food serving facilities, for both patients and staff
z dishwashing facilities (or room)
z pot-washing facilities
z refrigerated storage-3-day supply
z day storage-3-day supply
z cart-cleaning facilities
z cart storage area
z waste disposal facilities
z dining facilities (1.5 m2 per seated person)
z dietitian 's office
z janitor's cupboard storage for housekeeping supplies and equipment,
z with a service sink.
Some of these activities can be combined, so as to save space, without compromising
the norms of cleanliness.
2.7 FUNCTIONAL AREAS

The major functional areas of the food service department, according to the sequence
in the workflow, are described below:
a) Receiving Area and Control Station: The dietary department requires a
substantial amount of supplies and materials. The receiving area should be large
enough for handling bulk supplies. The receiving manager inspects and checks all
the supplies both for quantity and quality. The receiving area should be equipped
with scales to weigh materials and supplies.
b) Storage and Refrigeration Rooms: This room should be adjacent or close to the
receiving area. Dry storage is for staples and refrigerated storage for perishables.
Hospitals generally store several days to meet any eventuality. wooden or steel
racks and platforms are used for storage. Big hospitals have coolers and
refrigerators with varying degrees of temperature for meat, meat products,
poultry, diary products, eggs, fruits and vegetables. The refrigerators should have
a thermometer in each unit to check temperature daily.
c) Preparation and Production Areas: Pre-production rooms are engaged in 1
Nutrition and Dietary
activities like sorting, peeling, slicking, Chopping and washing may be done prior Services
to cooking . A double sink with draining, worktops, peelers and grinders are the
necessary facilities and equipment. Separate rooms for cooking vegetarian food
and non vegetarian has to be provided as some foods may produce disagreeable
odours. Food in hospitals is prepared using progressive approach. Here food is
prepared in small batches at regular intervals during serving time especially for
freshness and the food remains hot.
d) Serving Room: This is a place for assembling food trays. It receives prepared
food and after the trays are assembled they are loaded on to tray carts or trolleys
and sent to the patient floors. It is imperative that the serving area be close to the
elevators. The equipments and facilities in the serving room include refrigerators,
tabletops and cupboards for storing trays, dishes ,cutlery and other articles for
assembling. At last the dietitian is responsible for proper identification, accuracy
and temperature of foods and ensuring that the food is served purposefully.
e) Food Delivery: Many hospitals distribute foods in individual hot food containers
carried in open food carts. Smaller hospitals may serve them in ordinary Tiffin
carriers. Nowadays food trolleys that can be plugged into an electrical outlet to
keep the food hot are now available. The hot bulk cart contains hot food in bulk
that is dished on to the patient trays on the patient floors. Whatever may be the
method used due care must be taken to see that there is no delay in serving.
f) Special Diet Kitchen: The special diets should be prepared under the supervision
of a qualified dietitian. It is always advisable to locate this type of kitchen in the
main kitchen or close to it, as it derives its supplies from the main kitchen and
transports the trays through the same tray carts. It also requires pots, pans, vessels
etc. like the main kitchen but on a smaller scale. Added to all these it requires
scales for weighed diets.
g) Dish Washing Area: This tough job is made more easier nowadays with large
modern dishwashing machines. Here a continuous stream of soiled dishes are
loaded at one end and clean dishes unloaded at the other. In smaller hospitals it is
generally done manually in the scullery. Drainage and plumbing should be well
engineered. Soiled dishes are brought to the dishwashing area, after collecting the
waste in a garbage receptacle, dishes are checked and loaded for washing. After
which they are reloaded for further use.
h) Pot Washing Area: Here the work is done only manually by hand. It is best done
in a separate room. The place must have deep sinks, abundant supply of hot and
cold water and drying racks.
i) Cafeteria: Most hospitals take due care to non-patients, staff, visitors and patient
bystanders. But while designing a cafeteria some factors has to be duly considered
like number and the kind of group to be served, whether separate dinning has to
be provided for medical staff, officers, VIPs, Types and extent of food selection
,kind of service, size of dining room and number of shifts, method of clearing
table etc. cafeteria usually works like a fast food business where the customers
buy coupons at the counter, pick up food items in exchange for them, carry their
trays to the tables and eat.
1
Hospital Operation-II Check Your Progress 2
1. Serving room
……………………………………………………………………………..
……………………………………………………………………………..
2. Cafeteria
……………………………………………………………………………..
……………………………………………………………………………..
2.8 ORGANIZATION
In deciding who the head person is the size of the hospital plays a vital role. There is
no doubt that in all hospitals Dietitian is the chief of the food service department. But
again in larger hospitals professional managers with degree in management and food
service are becoming very common. In smaller hospitals, the dietitian may serve a
dual role as both dietetic supervisor and department manager.
The Nutrition and Dietary department is largely responsible to the administrator and
the department also has a close relationship with medical staff. It has two main
divisions:
z Administration of the department and Food production
z Therapeutic food service and instructions to patients and their counseling.
The bulk of workers are unskilled in this department. The trend in hospitals is to
employ workers at the lowest salary level. Dietary aids if properly trained can perform
a variety of functions such as checking supplies, writing requisitions, checking and
reporting census, making out time schedules, and making charge slips.
Therapeutic nutrition requires a qualified dietitian to assist in patient therapy. Because
it is necessary that a specially prepared diet be written for every individual patient.
2.9 FACILITIES AND SPACE REQUIREMENTS

The following facilities and space are required:
z Food service manager’s office: It should offer an overall part of the department
and should be properly ventilated and soundproofed.
z Secretarial, clerical office: With necessary space for file cabinets and other
equipments, seating for visitors, vendors etc.
z Office space for Chief Dietitian and Staff dietitians: Many hospitals locate it on
the patient floors so that they can be available quickly to the medical staff and
patients.
z Receiving Area
z Storage and Refrigeration Area
z Pre-production preparation area
z Cooking area
z Special diet kitchen
z Tray assembly area
z Dishwashing area
z Pot washing area
z Trolley, Cart washing area 1
Nutrition and Dietary
z Deep sinks and Hand washing area Services
z Garbage disposal facilities
z Storage with racks and cabinets
z Employee facilities like lockers, staff toilet
z Dining hall
z Cashier counter
z Seating facilities
z Drinking water
z Special dinning rooms for officers, medical staff, special guests
z Coffee shop/snack bar.
2.10 RELATED ISSUES

Many issues may arise in relation to the Dietary Department like:
a) conflicts between the food service staff and the nursing service staff in relation to
cancellation or changes in preparation etc.
b) conflicts between food service and nursing department as who should pass and
pick up patient trays.
c) No Hospital can please everyone in their menus. Complaints are common and
frequent.
d) Situation becomes even more worse in relation to cost containment.
e) Dietitians have to talk with the patients especially in the matter of special diets
which may not be pleasing to the eyes.
f) All hospitals cannot provide subsidized food to its employees because of raising
cost and this may disappoint many employees.
g) Petty theft may occur and is more common too.
h) Bigger frauds can take place at the materials management level.
2.11 LET US SUM UP

Good Food is very important as it plays a vital role in the treatment and is a part of the
total care. This chapter gives a detailed account of Nutrition and Dietary services, its
meaning and the location of the department in a hospital in the beginning. The total
design with the sketch of its functional areas is also explained. The Food distribution
services and its components were also discussed. The actual facilities along with its
space requirements are studied, ending up with the related issues to the particular
department.

Give your view points or suggestions for the further improvements in nutrition and
dietary services in a hospital.
2.13 KEYWORDS
Nutrition and Dietary Department: That provides dietary services for those in special
need of them.
Bulk Service: When food is brought to the wards in heated carts.
Cafeteria: A fast food centre where the customers buy coupons and pick up food
(Supportive Services) items in exchange for them.

1. Explain the meaning and the location of the dietary department.
2. Bring out the design and functional areas along with organizational setup of food
service department.
3. Explain the facilities and the space requirements in the food service department.
4. Enumerate the issues in the dietary department and their causes.

CYP 1
1. Central tray service: Patients' trays are prepared in the main kitchen,
loaded onto conveyors or carts, open or insulated, and transported to the
various wards. Soiled dishes are collected and returned to a central
dishwashing area. This system requires fewer staff and initial equipment
costs are lower than with a decentralized system.
2. Kitchens must be located such that heat and odours are not directed
towards areas of high population. They should also not be located under
wards, especially those for non-ambulant patients, as a fire safety
precaution.
CYP 2
1. Serving room: This is a place for assembling food trays. It receives
prepared food and after the trays are assembled they are loaded on to tray
carts or trolleys and sent to the patient floors.
2. Cafeteria: Most hospitals take due care to non-patients, staff, visitors and
patient bystanders. Cafeteria usually works like a fast food business
where the customers buy coupons at the counter, pick up food items in
exchange for them, carry their trays to the tables and eat.
2.15 SUGGESTED READINGS

Hayward, Cynthia. ChiPlanTM A Space Planning Guide for Healthcare Facilities. Chi
Systems Inc., 1995.
Interstitial Space in Health Facilities-A Research Study Report. Health and Welfare
Canada, 1979.
Spear, M. "Current Issues: Designing the Universal Patient Care Room." Journal of
Strauss, J. J. Facility Planning with Flexibility in Mind. Proceedings Manual, 1993
Construction, 1993.
Facility Planning, Design and Construction, 1993.
21
LESSON Pharmacy
3
PHARMACY
CONTENTS
3.1 Introduction
3.2 Scope
3.3 Role and Significance of Hospital Pharmacy
3.4 Functions
3.5 Drug Distribution and Information
3.6 Location
3.7 Design and Functional Areas
3.8 Organization and Staffing
3.10 Working Conditions
3.11 The Job
3.12 Issues in Pharmacy
3.13 Future of Pharmacy
3.14 Let us Sum up
3.16 Keywords

z Understand the meaning and the role of pharmacy in today’s world
z Know the functions of pharmacy
z Analyze the major factors affecting the location of pharmacy
z Learn the organization and staffing functions in pharmacy
z Know working conditions in the field
z Get aware of issues in the pharmacy and its causes
z Evaluate the future trends in pharmacy
3.1 INTRODUCTION
The word Pharmacy is derived from a Greek word 'pharmakos' which means drug.
Pharmacy is the health profession that links the health sciences with the chemical
2 sciences, and it is charged with ensuring the safe and effective use of medication .All
(Supportive Services) large acute hospitals have an on-site pharmacy department which has the key purpose
of ensuring that patients can receive the right medicine at the right time by an efficient
and economical system. Today most pharmacists would agree that they have a wider
responsibility in ensuring that they apply pharmaceutical expertise to help maximize
drug efficacy and minimize drug toxicity.
Many hospitals adopted important changes in pharmacy practice during the 60s and
70s. The revolutionary feature of these developments was the presence of the
pharmacist on the ward. This enabled some pharmacy practitioners to become an
active part of the clinical team, a practice that is common place today. Hospital
pharmacies can usually 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.
3.2 SCOPE
The scope of pharmacy practice includes more traditional roles such as compounding
and dispensing medications, and it also includes more modern services related to
patient care, including clinical services, reviewing medications for safety and efficacy,
and providing drug information. Pharmacists, therefore, are the experts on drug
therapy and are the primary health professionals who optimize medication use to
provide patients with positive health outcomes. The term is also applied to an
establishment used for such purposes.
Clinical pharmacists are ideally placed to influence prescribing by hospital doctors
because they have the appropriate knowledge about therapeutics and are in regular
contact with prescribes. Hospitals have adopted two main strategies to influence
prescribing. These are the development of hospital policies around the prescribing
process and postgraduate training of individual pharmacists to improve their skills in
therapeutics and knowledge of the clinical process.
3.3 ROLE AND SIGNIFICANCE OF HOSPITAL

PHARMACY
During the colonial period, those trained to handle drugs were called “dispensers”.
Such dispensers functioned as dispensers of medicines, sanitary officers, medical aids
and anesthetists in operating theatres. Today, the professional role of the pharmacist in
hospitals and community pharmacies is changing from a focus on preparation,
dispensing and sale of medications to one in which pharmacists assist the public to get
the best possible results from medications through patient education, physician
consultation, and patient monitoring. Pharmacists play a vital role in assisting even the
job of a doctor and following are the roles performed by today’s pharmacist:
a) Medication distribution and Control:
Medication orders
Formulatory development
Medication administration
Extemporaneous compounding
Compounding sterile products
Unit dose packaging
Medication storage
Minimizing adverse drug reactions 2
Pharmacy
Eliminating medication errors
Managing drug product recalls
Drug delivery system
Automated dispensing machines
b) Controlling drug samples:
Cytotoxic and hazardous drug products
Controlled substances
Non approved substances
Medication storage area inspections
Disaster services
Medical emergency management
c) Optimizing medication therapy:
Medication histories
Medication orders
Therapy monitoring
Bacterial resistance
Collaborative Pharmacists
Medication consultation
Medication use evaluation
Medication use policy development
Pharmaceutical care provision
Clinical plans
Immunization programs.
d) Drug information and Education:
Information request
Reference materials for drugs
Medical therapy monograph’s
Patient education
Dissemination of drug information
e) Research:
Policies and procedure
Distribution and control
Institutional review board
Scientific contribution
Pharmacy research
Medical research
Multi disciplinary research.
2
Hospital Operation-II 3.4 FUNCTIONS
a) Pharmacists play critical role in reducing medication discrepancies. Involving
pharmacists in obtaining and assessing a patient’s medication history before
elective surgery can significantly reduce medication discrepancies upon hospital
admission.
b) Pharmacists, nurses, surgeons and university researchers partnered together to
develop a multidisciplinary practice model to prevent patient medication
discrepancies after surgery.
c) The intervention involved pharmacists, working with nurses in the surgical pre-
admission clinic, to interview and assess patients’ home medication history. These
assessments were used to support surgeon prescribing of patients’ home
medications with a postoperative home medication order form. If needed, the
pharmacist would follow-up with the patient’s community pharmacy or family
physician to clarify their medication regimen to ensure accuracy.
d) Provided inpatient and discharge counseling on drug therapy.
e) Co-ordinate the use of patients' own drugs, discharge planning and patient
education alongside the clinical pharmacist.
f) Transcribed, endorsed or annotated prescriptions to confront issues of risk
management and reduce medication errors.
g) Ensured adequate storage of pharmaceuticals at ward level to comply with legal
and ethical considerations.
h) Ordering specialized and non-formulary drugs and Checking ward Controlled
Drug stocks weekly.
i) Audited performance monthly and produced an annual report for submission to
the clinical management team
j) Identified problems in administration, physical limitations and other problems that
could have an impact on medicines administration.
3.5 DRUG DISTRIBUTION AND INFORMATION

Given the right training, hospital pharmacy technicians were capable of dealing with
most drug information queries and of knowing when to refer inquirers to the drug
information pharmacist. Skills required to be a drug information technician were
knowing the available sources of drug information, good communication and
telephone messaging skills, an ability to keep good documentation, and knowing when
to refer queries to a pharmacist. The sort of queries that a technician could
competently answer related to administration and dosages, adverse effects, availability
and supply, identification of foreign drugs, drug interactions, and intravenous
incompatibilities. All of this information has to be well-documented so a technician
could competently give it out.
Generally pharmacies distributes the drugs to nursing units where they are
administered to inpatients. And this could be divided into three divisions as, Drugs
sent to the nursing unit for floor stock inventory, drugs that are sent to nursing units
specified for individual patients as prescribed by the doctors and are charged to them
and Prescription drugs that are dispensed by the pharmacy on the strength of a
prescription given by a physician.
3.6 LOCATION
Many factors has to be considered in determining the location of a pharmacy like:
1. The pharmacy must be located so that it is: 2
Pharmacy
accessible to the out-patient department,
convenient for dispensing, and
accessible to the central delivery yard.
2. Traffic within the department must be economical and flexible.
3. Its size is determined by its organization and operational policies.
4. Provision for security of dangerous drugs must be ensured.
5. Provision for control of fire must be ensured, as many inflammable substances are
stored there. Bulk quantities should not be held in the pharmacy but should be
drawn from a remotely located store for dangerous goods.
6. Finishes must be impervious to acid and alkali and easy to clean.
7. The corridors must allow easy turning of wheeled vehicles.
The pharmacy will sometimes keep controlled drugs, poisons and other drugs liable to
misuse. These are subject to statutory regulations, which the designer should beware
of in planning the rooms, and provision should be made for an alarm system to guard
against intrusion and theft. The planning of the pharmacy should also include space
for preparing sterile water, unless this is to be done in the central sterile supply
department or elsewhere.
An ideal location would be the ground floor close to the outpatient department and to
elevators servicing the patient areas. It is always usual that any place accommodation
to pharmacy will always be found inadequate ,hence pharmacy should have at least
one outside wall to allow for expansion and must always be an adjacent area that can
be relocated easily.
1. Define pharmacy.
……………………………………………………………………………..
……………………………………………………………………………..
2. Where a pharmacy can be located?
……………………………………………………………………………..
……………………………………………………………………………..
3.7 DESIGN AND FUNCTIONAL AREAS

There is no hard and fast rules in designing a pharmacy. Each hospital has its own
way of patterning the pharmacy. By adhering to the specified norms each hospital has
to plan the following functional areas:
z Medication storage
z Packing and compounding
z Consultation space
z Office and meeting space
z Automation and computerization
z Record maintenance
z Cytotoxic and Hazardous drug products
2 All the above could be grouped into four main functional areas: the dispensing area,
(Supportive Services) the production or preparation area, the administrative area and the storage area.
3.8 ORGANIZATION AND STAFFING

Chief Pharmacist is always the head of the pharmacy with B Pharm or P Pharm degree
qualification added with experience. He works under a medical director or a medical
superintendent. are highly-trained and skilled healthcare professionals who perform
various roles to ensure optimal health outcomes for their patients. Pharmacists are
represented internationally by the International Pharmaceutical Federation (FIP). They
are represented at the national level by professional organisations such as the Royal
Pharmaceutical Society of Great Britain (RPSGB), the Pharmacy Guild of Australia
(PGA), the Pakistan Pharmacists Society PPS) and the American Pharmacists
Association (AphA).
Every pharmacist has to register with the pharmacy council without which he cannot
practice. In addition there may be pharmacy aids or helpers, storekeeper and a
pharmacy clerks.
The number of pharmacists working in hospitals had been reduced because of the rise
in pharmacist posts at health authorities, primary care groups and general practitioner
practices. Workload changes had resulted from the reduction in the length of hospital
stays, increased day surgery rates and reductions in waiting lists, all of which had
produced significant increases in clinical workload.

Any type of pharmacy requires space for the following facilities:
a) Dispensing area: Under this section proper care should be given for Patient
waiting area, Patient dispensing counter, active storage .Pickup and receiving
counter, area for review and recording of drugs orders, compounding area. work
counters, refrigerated storage, etc.
b) Manufacturing area: This section needs area for bulk compounding, provision
for packing and labeling, provision for quality assurance activities, Clinical sinks
and hand washing facilities.
c) Administrative area: Here reception and clerk-typist’s area is mandatory. Along
with Chief pharmacists office, space for assistant chief pharmacist ,clinical
pharmacists, waiting area for visitors, medical representatives and salesmen,
conference room-cum-library, space for staff facilities like , lockers, lounge, duty
room etc.
d) Storage area: Separate space foe bulk storage, active storage, refrigerated storage,
volatile and alcohol storage, secured storage for narcotics and controlled drugs,
storage for general supplies, equipment, files, stationery etc.
3.10 WORKING CONDITIONS

Hospital pharmacies are normally neat, clean, and well-organized. Pharmacy
Technicians work under the close supervision of licensed pharmacists. Although the
work is often repetitive, it is highly precise, demanding good judgment, accuracy, and
constant attention to detail. The work also requires extreme care in handling and
storing drugs and chemicals. Physical demands may include moving heavy boxes and
delivery carts, weighing up to 40 pounds.
3.11 THE JOB

Hospital pharmacy technicians, also called Pharmacy Assistants, perform a wide
range of clerical and technical tasks necessary to the operation of a hospital pharmacy.
They enable the licensed pharmacists to concentrate on professional functions, such as 2
providing medical staff and patients with information and advice. Pharmacy
The primary responsibility of most technicians is to prepare, package, and distribute

medications prescribed by physicians for hospitalized patients. Orders for such
medications are written by physicians on the patient's chart. Copies of these "chart
orders" are sent daily from all the nursing stations to the pharmacy. After pharmacists
review the order for errors or potential problems, technicians transcribe the relevant
information about the patient and the prescribed medications onto the patient's profile.
These profiles are the basic source of information used by technicians for filling
medication orders and must be continually updated as new orders are received.
Transcribing to the profile from the chart order requires an understanding of medical
and pharmaceutical terminology and abbreviations. Profiles are sometimes generated
by computer, using data entered by technicians combined with data already stored in
the computer.
Unit dose distribution: The most common method used by technicians for preparing
and distributing prescribed medications is known as "unit dose distribution." Each
day, technicians assemble a complete 24-hour supply of medications for every
hospital patient. Individual doses of each drug are separately packaged and labeled.
All of these unit-doses are then placed in the patient's medication cassette. Commonly
used medications are usually pre-packaged in unit-dose form by drug manufacturers,
so that technicians need only select the right package. When pre-packaged unit-doses
are not available, technicians must measure or count the prescribed amount from bulk
containers and create the package themselves -- generally with the aid of a unit-dose
packaging device. When unit doses are to be administered by injection, technicians
transfer the medication from vials, using aseptic techniques, to the appropriate number
of sterile, disposable syringes.
IV Additives: Another form in which medications are frequently administered to
hospital patients is through intravenous (IV) solutions. To prepare these IV
admixtures, technicians measure and add drugs or nutrients (IV additives) to
commercially prepared intravenous solutions. All mathematical calculations must be
accurate and very precise, and extreme care must be taken to maintain sterile
conditions and aseptic techniques.
Inventory control: Inventory control is another area of responsibility for some
Technicians. Technicians keep track of medications, chemicals, and other supplies,
and prepare orders for additional quantities when stock gets low. They also receive
incoming goods, check invoices Against quantities received, and put supplies into
storage.
Additional duties performed by Pharmacy Technicians may include delivering drugs
and pharmaceutical supplies to nursing stations, keeping pharmacy work areas clean
and orderly, assisting in the processing of health insurance forms, and responding to
telephone questions or requests from other hospital personnel.
1. Working conditions of pharmacy
……………………………………………………………………………..
……………………………………………………………………………..
2. Inventory control
……………………………………………………………………………..
……………………………………………………………………………..
2
Hospital Operation-II 3.12 ISSUES IN PHARMACY
a) Separation of prescribing from dispensing: In most jurisdictions pharmacists are
regulated separately from physicians. Specifically, the legislation stipulates that
the practice of prescribing must be separate from the practice of dispensing. These
jurisdictions also usually specify that only pharmacists may supply scheduled
pharmaceuticals to the public, and that pharmacists cannot form business
partnerships with physicians or give them "kickback" payments. However, the
American Medical Association (AMA) Code of Ethics provides that physicians
may dispense drugs within their office practices as long as there is no patient
exploitation and patients have the right to a written prescription that can be filled
elsewhere. In some countries in Asian region ,doctors are allowed to dispense
drugs themselves and the practice of pharmacy is sometimes integrated with that
of the physician, particularly in traditional Chinese medicine.
The reason for the majority rule is the high risk of a conflict of interest.
Otherwise, the physician has a financial self-interest in "diagnosing" as many
conditions as possible, and in exaggerating their seriousness, because he or she
can then sell more medications to the patient. Such self-interest directly conflicts
with the patient's interest in obtaining cost-effective medication and avoiding the
unnecessary use of medication that may have side-effects.
b) Theft in Pharmacy: The most theft prone area in a hospital is pharmacy and can
be costly, difficult to check and may even go unnoticed. losses ma be substantial
and may continue for a long time without being discovered. A sound system of
controls acts as a deterrent and creates fear in the employees that frauds and theft
will be detected and punished.
3.13 FUTURE OF PHARMACY

In the coming decades, pharmacists are expected to become more integral within the
health care system. Rather than simply dispensing medication, pharmacists will be
paid for their patient care skills. This shift has already commenced in some countries;
for instance, pharmacists in Australia receive remuneration from the Australian
Government for conducting comprehensive Home Medicines Reviews. In the United
Kingdom, pharmacists and nurses who undertake additional training are obtaining
prescribing rights. They are also being paid for by the government for medicine use
reviews. In the United States, pharmaceutical care or Clinical pharmacy has had an
evolving influence on the practice of pharmacy. Moreover, the Doctor of Pharmacy
(Pharm.D.) degree is now required before entering practice and many pharmacists
now complete one or two years of residency or fellowship training following
graduation. In addition, consultant pharmacists, who traditionally operated primarily
in nursing homes are now expanding into direct consultation with patients, under the
banner of "senior care pharmacy."
A time of change: As with many health professions, pharmacy has gone through great
change over recent years. Pharmacists have adapted and changed their ways of
working to build capacity within the health service and to reflect the needs of a
changing patient population and the rapidly increasing complexity and cost of
healthcare. Hospital pharmacists have been at the forefront of change, adapting new
ways of working and embracing new technology in order to modernize service
delivery.
New Ways of Working in Hospital Pharmacy

Hospital pharmacists working in your constituency are leading the way in developing
new approaches to the provision of excellent services for patients.
z Skill mix development: Clinical pharmacy – where pharmacists work directly 2
with patients to help get the best outcomes from treatment – was first developed in Pharmacy
hospitals in the late 70’s and is now a core function that is being practised in
primary care. Hospital pharmacy has led the way in developing the roles of
pharmacy technicians to undertake more of the technical functions of the service
so as to allow hospital pharmacists to take on the more patient-focused clinical
roles. It is important that the new Strategic Health Authorities continue to support
pharmacy technician training to underpin this.
z Modernising ward medication systems: Dispensing for discharge is a system of
working that sees patients keeping their own medicines in their bedside locker
while they are in hospital. Previously, patients’ medicines were disposed of when
they came into hospital and new medicines were dispensed for the duration of
their hospital stay. In addition, all medicines are labeled with full instructions,
which means patients can take their own medicines which are then readily
available when the decision is made to send the patient home from hospital.
z Pharmacist prescribing: A key and well established role of clinical pharmacists
in hospital has been to advise doctors on what medicines and doses to prescribe.
Supplementary prescribing is now established in hospitals. This means that
pharmacists and other authorized health professionals can prescribe medicines
according to a pre-agreed treatment plan. Recent changes in legislation allow
pharmacists to become independent prescribes and so undertake more prescribing
roles in the treatment of acute illness. This will improve access to medicines and
free doctors’ time.
z Medicines management at the primary-secondary interface: Hospital
pharmacists are helping to develop joint working with primary care. Many health
economies have area prescribing committees with prescribing policies and joint
formularies common across primary and secondary care. A key requirement is
effective transfer between hospitals and primary care of information about
patients’ medicines to facilitate continuity of care and reduce the likelihood of
readmission due to treatment failure. A robust IT infrastructure which allows
pharmacists in primary and secondary care appropriate access to patient
information is essential to support an integrated approach to medicines
management across the whole health community.
z Governance: Managing the clinical and financial risks of treatment with
medicines. Ensuring the safe, cost-effective use of medicines presents a challenge
in primary and secondary care, as medicines are involved in nearly every health
intervention. Pharmacists are the only healthcare professionals trained specifically
as experts on all aspects of medicines and their use. Pharmacists play an essential
role in and make a unique contribution to ensuring rational choice and safe,
effective and economic use of medicines.
z New Technology: Automated Dispensing. Automated (robotic) dispensing
systems are now in use in many acute hospitals and have been shown to reduce
dispensing errors, save storage space and make hospital pharmacies more
efficient. This reduces patient waiting times and allows highly trained staff to use
their time more effectively, advising patients on the best use of their drugs and
promoting safe, rational and cost effective prescribing.
z Use of IT: Hospital pharmacists have used this information very successfully to
develop local and wider collaborative strategies for medicines procurement,
prescribing and use, and consequently ensured effective use of hospital drug
budgets. However, in most hospitals, prescriptions are still handwritten, which not
only increases the risks of misinterpretation, but is inefficient because of the need
to move prescription charts around the hospital.
Electronic prescribing will reduce prescribing errors by providing decision support to
(Supportive Services) prescribes, reduce the risk of errors in interpretation by eliminating handwritten
documents, and allow almost immediate transmission of prescription details to the
pharmacy. It will also allow detailed information on drug treatment to be
automatically linked directly with a wealth of other information about patient care,
and shared with colleagues in primary care.
3.14 LET US SUM UP

All large acute hospitals have an on-site pharmacy department which has the key
purpose of ensuring that patients can receive the right medicine at the right time by an
efficient and economical system. In this chapter Pharmacy in hospitals is being delt
with in detail. Were topics like meaning, Scope, Role and Significance and Functions
are studied. The Drug distribution and Information, its location, design, organization
and staffing parameters are also dealt with. Facilities and Space requirements for a
pharmacy, its Working conditions and the nature of the job are also explained .In
addition Issues in pharmacy and its future trend are examined.

Visit various pharmacies and list the pros and cons in their services. Give your
suggestions to improve their services.
3.16 KEYWORDS
Pharmacy: The health profession that links the health sciences with the chemical
sciences.
Unit Dose Distribution: The most common method used by technicians for preparing
and distributing prescribed medications.

1. Give the meaning, scope, role and significance of pharmacy.
2. Explain the various functions of pharmacy.
3. Explain various factors determining the selection of location.
4. Enumerate organisation and staffing parameters in pharmacy.
5. Explain the working conditions and nature of job prevailing in the field of
pharmacy.
6. Examine the future trends in pharmacy.

CYP 1
1. The word Pharmacy is derived from a Greek word 'pharmakos' which
means drug. Pharmacy is the health profession that links the health
sciences with the chemical sciences, and it is charged with ensuring the
safe and effective use of medication.
2. The pharmacy must be located so that it is:
accessible to the out-patient department,
convenient for dispensing, and
accessible to the central delivery yard.
Contd…
29
Pharmacy
An ideal location would be the ground floor close to the outpatient department
and to elevators servicing the patient areas.
CYP 2
1. Hospital pharmacies are normally neat, clean, and well-organized.
Although the work is often repetitive, it is highly precise, demanding
good judgment, accuracy, and constant attention to detail. The work also
requires extreme care in handling and storing drugs and chemicals.
2. Technicians keep track of medications, chemicals, and other supplies, and
prepare orders for additional quantities when stock gets low. They also
receive incoming goods, check invoices Against quantities received, and
put supplies into storage.

Statement of principles and standards of good practice for hospital pharmacy in the
United Kingdom. Royal Pharmaceutical Society of Great Britain; 1995.
Heppler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care.
Am J Hosp Pharm. 1990;47:533–543. [PubMed]
Cotter SM, Barber ND, McKee M. Survey of clinical pharmacy services in United
Kingdom National Health Service hospitals. Am J Hosp Pharm. 1994;51:2676–2684.
[PubMed]
Calder G, Barnett JW. The pharmacist in the ward. Pharm J. 1967; 198:584–586.
Baker J. Seventeen years experience of a voluntary based drug rationalization
programme in hospital. Br Med J. 1988;297:465–469. [PubMed]
Cousins HD, Luscombe D. Re-engineering pharmacy practice (1). Forces for change
and the evolution of clinical pharmacy practice. Pharm J. 1995;255:771–776.
Swallow RD, Remington H, Standing VF. Ward pharmacy a positive contribution to
control costs. Pharm J. 1985; 235:722–723.
Collier J, Foster J. Management of a restricted drugs policy in hospitals: the first five
years experience. Lancet. 1985;i:331–333. [PubMed]
Petrie JC, Scott AK. Drug formularies in hospitals. Br Med J. 1987;294:919.
[PubMed]
Ridley, H. Drugs of choice: a report on the drug formularies used in NHS hospitals.
Social Audit London; 1986.
32
LESSON
4
MEDICAL RECORDS
CONTENTS
4.1 Meaning and Definition
4.2 Location
4.3 Scope
4.4 Functions
4.5 Medical Records – Format
4.6 Medical Records – Contents
4.7 Administrative Issues
4.8 Types of Forms
4.9 Standardization in Record Keeping
4.10 Let us Sum up
4.12 Keyword

z Know the meaning of medical records
z Understand the need and functions of medical record
z Know the various formats of medical record used
z Describe the purpose of record keeping
4.1 MEANING AND DEFINITION

Patient care includes a chronological record of care and treatment, namely medical
records. Accurate and adequate medical records are essential for clinical, legal, fiscal
and research purposes and is based on the principle “people forget, but records
remember”. Medical Records Department (MRD) has become an essential department
of every hospital. Printed performs developed by hospitals are widely used to achieve
regularity and uniformity in the recording and presentation of information. A smooth
and uninterrupted supply of well-designed forms is a must for efficient medical record
keeping.
The medical record is a storehouse of knowledge concerning the patient. It is a
yardstick by which the quality of work done by the physician and hospital personnel
may be measured. Despite recent interest and innovation in medical record design and 31
use, medical records have been deemed ‘chaotic repositories of information’. The Medical Records
methods of data collection are almost always disparate, idiosyncratic and of doubtful
consistency, having developed as much by tradition and in response to ad hoc
demands as by any general or logical approach to the satisfaction of data needs.
In short “A medical record, health record, or medical chart is a systematic
documentation of a patient's medical history and care.” The term 'Medical record' is
used both for the physical folder for each individual patient and for the body of
information which comprises the total of each patient's health history. Medical records
are intensely personal documents and there are many ethical and legal issues
surrounding them such as the degree of third-party access and appropriate storage and
disposal. Although medical records are traditionally compiled and stored by health
care providers, personal health records maintained by individual patients have become
more popular in recent years.
4.2 LOCATION
The best location for a Medical Record Room is immediately adjacent to the
Admitting Section for ease of filing of records of new patients and for ease of retrieval
of records of returning patients. Though this location is in a very public zone,
controlled access to the room itself is paramount so that records are not touched by
any other personnel except the ones directly assigned to be responsible for them. It is
therefore recommended that it be a “room within a room” which means that the
Medical Record Room be accessed through a door inside the Admitting Section.
Being a room that very often outgrows all other administrative areas, but is devoted to
inanimate and non-moving documents, prudence must be exercised in the
determination of its size in relation to the other areas. In order that this size does not
become so grossly large as to cause imbalance in space provision, the whole file of
patient records is usually fragmented, the active records retained at the Medical
Record Room in the public zone and the inactive or dead records kept in a Medical
Record Storage somewhere in the inner areas of the hospital. It is important to make
sure that this storage space is located with the consideration that it is a high-fire-load
space and must be distant from the wards.
4.3 SCOPE
The information contained in the medical record allows health care providers to
provide continuity of care to individual patients. The medical record also serves as a
basis for planning patient care, documenting communication between the health care
provider and any other health professional contributing to the patient's care, assisting
in protecting the legal interest of the patient and the health care providers responsible
for the patient's care, and documenting the care and services provided to the patient. In
addition, the medical record may serve as a document to educate medical
students/resident physicians, to provide data for internal hospital auditing and quality
assurance, and to provide data for medical research. Personal health records combine
many of the above features with portability, thus allowing a patient to share medical
records across providers and health care systems.
4.4 FUNCTIONS
The following are the important functions of the department:
z Maintaining the records properly for accurate and timely production, processing,
checking, indexing, filing and retrieval of medical records.
z Maintaining records of births, deaths, reports of communicable diseases etc.
32 z Planning a department in such a way that includes patients original clinical
(Supportive Services) records and also the primary and secondary records and indexes.
z Developing a statistical reporting system that includes ward census.
z Preparing consolidated daily census, outpatient department activities and statistics
in relation to services such as radiology, clinical laboratories and pharmacy.
z Coding all diagnoses and operations according to international classification of
diseases for statistical purposes.
z Safeguarding the information in the medical records against theft, loss,
defacement, tampering or use by unauthorized persons.
4.5 MEDICAL RECORDS – FORMAT

Traditionally, medical records have been written on paper and kept in folders. These
folders are typically divided into useful sections, with new information added to each
section chronologically as the patient experiences new medical issues. Active records
are usually housed at the clinical site, but older records (e.g., those of the deceased)
are often kept in separate facilities.The advent of electronic medical records has not
only changed the format of medical records but has increased accessibility of files.
Define Medical Records.
…………………………………………………………………………………..
…………………………………………………………………………………..
4.6 MEDICAL RECORDS – CONTENTS

Although the specific content of the medical record may vary depending upon
specialty and location, it usually contains the patient's identification informations like:
z the patient's health history -what the patient tells the health-care providers about
his or her past and present health status, and
z the patient's medical examination findings -what the health-care providers observe
when the patient is examined.
z Other information may include lab test results:
medications prescribed;
referrals ordered to health-care providers;
educational materials provided; and
what plans there are for further care, including patient instruction for self-care
and return visits.
In some places, billing information is considered to be part of the medical record.
a) Demographics: Demographics include patient information that is not medical in
nature. It is often information to locate the patient, including identifying numbers,
addresses, and contact numbers. It may contain information about race and
religion as well as workplace and type of occupational information. It may also
contain information regarding the patient's health insurance. It is common to also
find emergency contacts located in this section of the medical chart.
b) Medical history: The medical history is a longitudinal record of what has
happened to the patient since birth. It chronicles diseases, major and minor
illnesses, as well as growth landmarks. It gives the clinician a feel for what has 33
happened before to the patient. As a result, it may often give clues to current Medical Records
disease states. It includes several subsets detailed below:

i) Surgical history: The surgical history is a chronicle of surgery performed for
the patient. It may have dates of operations, operative reports, and/or the
detailed narrative of what the surgeon did.
ii) Obstetric history: The obstetric history lists prior pregnancies and their
outcomes. It also includes any complications of these pregnancies.
iii) Medications and medical allergies: The medical record may contain a
summary of the patient's current and previous medications as well as any
medical allergies.
iv) Family history: The family history lists the health status of immediate family
members as well as their causes of death (if known). It may also list diseases
common in the family or found only in one sex or the other. It may also
include a pedigree chart. It is a valuable asset in predicting some outcomes for
the patient.
v) Social history: The social history is a chronicle of human interactions. It tells
of the relationships of the patient, his/her careers and trainings, schooling and
religious training. It is helpful for the physician to know what sorts of
community support the patient might expect during a major illness. It may
explain the behavior of the patient in relation to illness or loss. It may also
give clues as to the cause of an illness (i.e., occupational exposure to
asbestos).
vi) Habits: Various habits which impact health, such as tobacco use, alcohol
intake, recreational drug use, exercise, and diet are chronicled, often as part of
the social history. This unit may also include more intimate details such as
sexual habits and sexual preferences.
vii) Immunization history: The history of vaccination is included. Any blood tests
proving immunity will also be included in this unit.
viii) Growth chart and developmental history: For children and teenagers, charts
documenting growth as it compares to other children of the same age is
included, so that health-care providers can follow the child's growth over
time. Many diseases and social stresses can affect growth and longitudinal
charting and can thus provide a clue to underlying illness. Additionally, a
child's behavior (such as timing of talking, walking, etc.) as it compares to
other children of the same age is documented within the medical record for
much the same reasons as growth.
c) Medical encounters: Within the medical record, individual medical encounters
are marked by discrete summations of a patient's medical history by a physician,
nurse practitioner, or physician assistant and can take several forms. Hospital
admission documentation or consultation by a specialist often take an exhaustive
form, detailing the entirety of prior health and health care. Routine visits by a
provider familiar to the patient, however, may take a shorter form such as the
Problem-Oriented Medical Record (POMR), which includes a problem list of
diagnoses. Each encounter will generally contain the aspects below:
i) Chief complaint: This is the problem that has brought the patient to see the
doctor. Information on the nature and duration of the problem will be
explored.
ii) History of the present illness: A detailed exploration of the symptoms the
patient is experiencing that have caused the patient to seek medical attention.
34 iii) Physical examination: The physical examination is the recording of
(Supportive Services) observations of the patient. This includes the vital signs and examination of
the different organ systems, especially ones that might directly be responsible
for the symptoms the patient is experiencing.
iv) Assessment and plan: The assessment is a written summation of what are the
most likely causes of the patient's current set of symptoms. The plan
documents the expected course of action to address the symptoms (diagnosis,
treatment, etc.).
d) Orders: Written orders by medical providers are included in the medical record.
These detail the instructions given to other members of the health care team by the
primary providers.
e) Progress notes: When a patient is hospitalized, daily updates are entered into the
medical record documenting clinical changes, new information, etc. These are
entered by all members of the health-care team, doctors, nurses, dietitians, clinical
pharmacists, respiratory therapists, etc. They are kept in chronological order and
document the sequence of events leading to the current state of health.
f) Test results: The results of testing, such as blood tests (e.g., complete blood
count) radiology examinations (e.g., X-rays), pathology (e.g., biopsy results), or
specialized testing (e.g., pulmonary function testing) are included. Often, as in the
case of X-rays, a written report of the findings is included in lieu of the actual
film.
g) Other information: Many other items are variably kept within the medical record.
Digital images of the patient, flowsheets from operations/intensive care units,
informed consent forms, EKG tracings, outputs from medical devices (such as
pacemakers), chemotherapy protocols, and numerous other important pieces of
information form part of the record depending on the patient and his or her set of
illnesses/treatments.
4.7 ADMINISTRATIVE ISSUES

Medical records are legal documents and are subject to the laws of the country/state in
which they are produced. As such, there is great variability in rule governing
production, ownership, accessibility, and destruction.
a) Production: Usually written records must be marked with the date and time and
scribed with indelible pens without use of corrective paper. Errors in the record
should be struck out with a single line and initialed by the author. Orders and
notes must be signed by the author. Electronic versions require an electronic
signature.
b) Ownership: The data contained within the medical record belongs to the patient,
whereas the physical form the data takes belongs to the entity responsible for
maintaining the record. Therefore, patients have the right to ensure that the
information contained in their record is accurate. Patients can petition their health
care provider to remedy factually incorrect information in their records.
c) Accessibility: The most basic rules governing access to a medical record dictate
that only the patient and the health-care providers directly involved in delivering
care have the right to view the record. The patient, however, may grant consent
for any person or entity to evaluate the record. The full rules regarding access and
security for medical records are set forth under the guidelines of the Health
Insurance Portability and Accountability Act (HIPAA). The rules become more
complicated in special situations.
Capacity: When a patient does not have capacity (is not legally able) to make
decisions regarding his or her own care, a legal guardian is designated. Legal
guardians have the ability to access the medical record in order to make 35
medical decisions on the patient’s behalf. Medical Records
Medical emergency: In the event of a medical emergency involving a non-

communicative patient, consent to access medical records is assumed unless
written documentation has been previously drafted
Research, auditing, and evaluation: Individuals involved in medical research,
financial or management audits, or program evaluation have access to the
medical record. They are not allowed access to any identifying information,
however.
Risk of death or harm: Information within the record can be shared with
authorities without permission when failure to do so would result in death or
harm, either to the patient or to others. Information cannot be used, however,
to initiate or substantiate a charge unless the previous criteria are met.
d) Destruction: In general, entities in possession of medical records are required to
maintain those records for a given period. Medical records are required for the
lifetime of a patient and legally for as long as that complaint action can be
brought. Generally, any recorded information should be kept legally for 7 years,
but for medical records additional time must be allowed for any child to reach the
age of responsibility (20 years). Medical records are required many years after a
patient’s death to investigate illnesses within a community.
e) Abuses: The outsourcing of medical record transcription and storage has the
potential to violate patient-physician confidentiality by possibly allowing
unaccountable persons access to patient data. Falsification of a medical record by
a medical professional is a felony in most United States jurisdictions.
Governments have often refused to disclose medical records of military personnel
who have been used as experimental subjects.
4.8 TYPES OF FORMS

Broadly Forms used in medical record keeping can be divided into two as: Forms used
for Patient care and Forms used for administrative purposes. These two categories can
be further sub divided as shown below:
Forms used for Patient Care

(A) Core Forms: basic medical record forms:
i) Records kept by Doctors in words: It includes Face Sheet, Discharge
Summary (MR-2), General History & Physical, Examination (MR-3),
Progress Record (MR-4), Doctor’s Orders (MR-5), Consultation Record (MR-
9)
ii) Operative Notes: It includes Operation Record (MR-7), Anaesthesia Record
iii) Records kept by nurses: It includes Intake Output Chart (MR-6),
Temperature, Pulse, Respiration Chart (MR-10), Nurses Daily Record (MR-
8), Consent Form.
(B) Diagnostic Forms: Laboratory Forms, including Hematology, Microbiology,
Clinical Chemistry, Tissue report forms (Histopathology), Other investigation
report forms e.g., X-ray, ECG etc. , Special Investigation Report Forms e.g.,
Radio isotope studies, MRI, Pulmonary Function test, Clinical Immunology.
Hormone assay, Bone densitometry request forms etc.
36
Hospital Operation-II (C) Department Specific forms:
i) For outpatients: Specialty Clinic Proforma, e.g., Diabetes Clinic proforma in
Endocrinology, Liver Clinic Proforma in Gastro enterology etc.
ii) For inpatients: Special forms for NICU, Nephrology, Orthopaedics, Urology,
Paediatric Surgery etc.
Forms for Administrative Purposes

It includes forms like Admission slip, Medical & Fitness Certificate, Reimbursement
forms, estimates etc.)
1. Surgical History
……………………………………………………………………………….
……………………………………………………………………………….
2. Family History
……………………………………………………………………………….
……………………………………………………………………………….
4.9 STANDARDIZATION IN RECORD KEEPING

Standardization needs to be carried out in the following broad areas:
1. Standardization of the number and types of forms: There are a large number of
forms for similar purposes in use in tertiary hospital. The Medical Records
Committee has to take the initiative to standardize forms. A coordinated effort of
physicians, nurses and medical record personnel, is required to standardize forms
in a hospital. Those forms which are of an inescapable nature, can be retained,
contents of some forms can be combined and those found useless or irrelevant,
discontinued. This way, the number of forms can be brought down to the
minimum.
2. Standardization of content: The information needed from the form is the first
requirement in deciding the content of the form. A form number identifies the
form, serves as a reference in a design procedure and helps in issuing quantities of
the form from the store on request. Since the form title and number are part of the
form identification, they should be placed together in one standard position. There
is an urgent requirement of allotting form numbers to the forms in use at the
hospital. All the data that must go on the form must be listed and classified into
logical groupings of items that have common relationship, and then sequence the
groups in a logical flow.
3. Standardization in terms of size: Desirable from the point of view of economy
and practicability. A4 size can be taken as a standard size for the basic forms and
81/2” × 51/2” size taken as standard size for the majority of the investigation
forms, Admission slip, Discharge slip, ECG requisition etc. as it too can be
derived from A4 size.
4. Standardisation in terms of colour: Standardisation in terms of use of colour in
forms should be left to the Medical Records or Forms Committee. Basic
philosophy of using coloured forms is to identify the forms used in different areas
of the Hospital. However, indiscriminate use of colour in medical record form can
be counter productive.
5. Standardisation in terms of quality of paper: Quality or weight of paper to be 37
used for printing forms will depend upon, handling, retention period and method Medical Records
of storage. In the tertiary super specialty hospital, the inpatient records are kept
for 10 years and the medico legal case records are stored indefinitely. The quality
of paper should be such that the records should be in good condition at the end of
the prescribed retention period.
6. Standardisation of inventory: Standard inventory control of printed forms is not
practicable in the hospital because there are multiple agencies for purchasing
printed forms. One single agency needs to be earmarked for the procurement of
the forms irrespective of the place of use and source of funds for their
procurement. Buffer stock and Reorder level for each form needs to be calculated
to prevent potential stock out situations.
4.10 LET US SUM UP

It is very essential to maintain the medical records in all hospitals to have control over
various phenomenon. In this lesson we have clearly discussed about the concepts,
functions of medical records. We also examined the type of forms used and their
purposes. It is clear that with the help of adequate records it possible to avoid various
issues in hospital sector.

"Medical records are very essential documents in health care sector." Do you agree?
In what way?
4.12 KEYWORD
Medical Records: A systematic documentation of a patient's medical history and care.

1. Define Medical Records and Explain Functions?
2. Briefly explain the scope of medical record keeping?
3. Explain the types of forms.
4. What are the contents of medical records?
5. Explain the standardization procedure of medical records?

CYP 1
The term 'Medical record' is used both for the physical folder for each
individual patient and for the body of information which comprises the total
of each patient's health history.
CYP 2
1. Surgical History: The surgical history is a chronicle of surgery performed
for the patient. It may have dates of operations, operative reports, and/or
the detailed narrative of what the surgeon did.
2. Family History: The family history lists the health status of immediate
family members as well as their causes of death (if known). It may also
list diseases common in the family or found only in one sex or the other.
38
Hospital Accreditation Standards, Lebanon, 2003 Department: Medical
Records/Content/Management (Admissions/Collection/Billing)
Journal of the Academy of Hospital Administration-Standardising Medical Records
Forms: A Study at a Tertiary Super Specialty Hospital Author(s): A. Chattooga, S.
Satpathy, R.K. Sarma
Hayward, Cynthia. ChiPlan TM, A Space Planning Guide for Healthcare Facilities.
Canada, 1979.
Strauss, J.J. Facility Planning with Flexibility in Mind. Proceedings Manual, 1993
Construction, 1993.
LESSON UNIT II 43
Hospital Engineering
and Maintenance
5
HOSPITAL ENGINEERING AND MAINTENANCE
CONTENTS
5.1 Definition
5.2 Need and Significance
5.3 Guidelines in the Planning and Design of a Hospital
5.4 Principles in Hospital Engineering
5.5 Five Steps toward Efficiency
5.6 Main Challenges
5.7 Let us Sum up
5.9 Keywords

z Understand the meaning, need and significance of hospital engineering and
maintenance
z Know the guidelines in the planning and design of a hospital
z Know the principles in hospital engineering
z Analyze the challenges in facilities engineering and maintenance
z Learn steps towards efficiency
5.1 DEFINITION
Operations and Maintenance are the decisions and actions regarding the control and
upkeep of property and equipment. These are inclusive, but not limited to, the
following:
1. actions focused on scheduling, procedures, and work/systems control and
optimization; and
2. performance of routine, preventive, predictive, scheduled and unscheduled actions
aimed at preventing equipment failure or decline with the goal of increasing
efficiency, reliability, and safety.
Operational Efficiency represents the life-cycle, cost-effective mix of preventive,
predictive, and reliability-centered maintenance technologies, coupled with equipment
40 calibration, tracking, and computerized maintenance management capabilities all
(Supportive Services) targeting reliability, safety, occupant comfort, and system efficiency.
5.2 NEED AND SIGNIFICANCE

Effective Operations and Maintenance is one of the most cost-effective methods for
ensuring reliability, safety, and energy efficiency. Inadequate maintenance of energy-
using systems is a major cause of energy waste in both the federal government and the
private sector. Energy losses from steam, water and air leaks, uninsulated lines,
maladjusted or inoperable controls, and other losses from poor maintenance are often
considerable. Good maintenance practices can generate substantial energy savings and
should be considered a resource. Moreover, improvements to facility maintenance
programs can often be accomplished immediately and at a relatively low cost.
Need and significance of operations and maintenance was developed under the
direction of the mission:
z to reduce the cost and environmental impact of the federal government by
advancing energy efficiency and water conservation,
z promoting the use of distributed and renewable energy,
z improving utility management decisions at federal sites,
z Increase the safety of all staff, as properly maintained equipment is safer
equipment,
z Ensure the comfort, health and safety of building occupants through properly
functioning equipment providing a healthy indoor environment,
z Confirm the design life expectancy of equipment is achieved,
z Facilitate the compliance with federal legislation.
5.3 GUIDELINES IN THE PLANNING AND

DESIGN OF A HOSPITAL
A Hospital and other health facilities shall be planned and designed to observe
appropriate architectural practices, to meet prescribed functional programs. Following
are the factors to be considered in planning the facilities of a hospital:
1. Environment: A Hospital and other health facilities shall be so located that it is
readily accessible to the community and reasonably free from undue noise,
smoke, dust, foul odor, flood, and shall not be located adjacent to railroads, freight
yards, children's playgrounds, airports, industrial plants, disposal plants.
2. Occupancy: A building designed for other purpose shall not be converted into a
Hospital. The location of a Hospital shall comply with all local zoning ordinances.
3. Safety: A Hospital and other health facilities shall provide and maintain a safe
environment for patients, personnel and public. The building shall be of such
construction so that no hazards to the life and safety of patients, personnel and
public exist. It shall be capable of withstanding weight and elements to which they
may be subjected:
Exits shall be restricted to the following types: door leading directly outside
the building, interior stair, ramp, and exterior stair.
A minimum of two (2) exits, remote from each other, shall be provided for
each floor of the building.
Exits shall terminate directly at an open space to the outside of the building.
4. Security: A Hospital and other health facilities shall ensure the security of person 41
and property within the facility. and Maintenance
5. Patient Movement: Spaces shall be wide enough for free movement of patients,
whether they are on beds, stretchers, or wheelchairs. Circulation routes for
transferring patients from one area to another shall be available and free at all
times:
Corridors for access by patient and equipment shall have a minimum width of
2.44 meters.
Corridors in areas not commonly used for bed, stretcher and equipment
transport may be reduced in width to 1.83 meters.
A ramp or elevator shall be provided for ancillary, clinical and nursing areas
located on the upper floor.
A ramp shall be provided as access to the entrance of the Hospital not on the
same level of the site.
6. Lighting: All areas in a Hospital and other health facilities shall be provided with
sufficient illumination to promote comfort, healing and recovery of patients and to
enable personnel in the performance of work.
7. Ventilation: Adequate ventilation shall be provided to ensure comfort of patients,
personnel and public.
8. Auditory and Visual Privacy: A Hospital and other health facilities shall observe
acceptable sound level and adequate visual seclusion to achieve the acoustical and
privacy requirements in designated areas allowing the unhampered conduct of
activities.
9. Water Supply: A Hospital and other health facilities shall use an approved public
water supply system whenever available. The water supply shall be potable, safe
for drinking and adequate, and shall be brought into the building free of cross
connections.
10. Waste Disposal: Liquid waste shall be discharged into an approved public
sewerage system whenever available, and solid waste shall be collected, treated
and disposed of in accordance with applicable codes, laws or ordinances.
11. Sanitation: Utilities for the maintenance of sanitary system, including approved
water supply and sewerage system, shall be provided through the buildings and
premises to ensure a clean and healthy environment.
12. Housekeeping: A Hospital and other health facilities shall provide and maintain a
healthy and aesthetic environment for patients, personnel and public.
13. Maintenance: There shall be an effective building maintenance program in place.
The buildings and equipment shall be kept in a state of good repair. Proper
maintenance shall be provided to prevent untimely breakdown of buildings and
equipment.
14. Material Specification: Floors, walls and ceilings shall be of sturdy materials that
shall allow durability, ease of cleaning and fire resistance.
15. Segregation: Wards shall observe segregation of sexes. Separate toilet shall be
maintained for patients and personnel, male and female, with a ratio of one (1)
toilet for every eight (8) patients or personnel.
16. Fire Protection: There shall be measures for detecting fire such as fire alarms in
walls, peepholes in doors or smoke detectors in ceilings. There shall be devices
for quenching fire such as fire extinguishers or fire hoses that are easily visible
and accessible in strategic areas.
42 17. Signage: There shall be an effective graphic system composed of a number of
(Supportive Services) individual visual aids and devices arranged to provide information, orientation,
direction, identification, prohibition, warning and official notice considered
essential to the optimum operation of a Hospital and other health facilities.
18. Parking: A hospital and other health facilities shall provide a minimum of one (1)
parking space for every twenty-five (25) beds.
19. Zoning: The different areas of a Hospital be grouped according to zones as
follows:
Outer Zone: areas that are immediately accessible to the public: emergency
service, outpatient service, and administrative service. They shall be located
near the entrance of the Hospital:
Second Zone: areas that receive workload from the outer zone: laboratory,
pharmacy, and radiology. They shall be located near the outer zone.
Inner Zone: areas that provide nursing care and management of patients:
nursing service. They shall be located in private areas but accessible to guests.
Deep Zone: areas that require asepsis to perform the prescribed services:
surgical service, delivery service, nursery, and intensive care. They shall be
segregated from the public areas but accessible to the outer, second and inner
zones.
Service Zone: areas that provide support to hospital activities: dietary service,
housekeeping service, maintenance and motor pool service, and mortuary.
They shall be located in areas away from normal traffic.
20. Function: The different areas of a hospital shall be functionally related with each
other:
The emergency service shall be located in the ground floor to ensure
immediate access. A separate entrance to the emergency room shall be
provided.
The administrative service, particularly admitting office and business office,
shall be located near the main entrance of the hospital. Offices for hospital
management can be located in private areas.
The surgical service shall be located and arranged to prevent non-related
traffic. The operating room shall be as remote as practicable from the entrance
to provide asepsis. The dressing room shall be located to avoid exposure to
dirty areas after changing to surgical garments. The nurse station shall be
located to permit visual observation of patient movement.
The delivery service shall be located and arranged to prevent non-related
traffic. The delivery room shall be as remote as practicable from the entrance
to provide asepsis. The dressing room shall be located to avoid exposure to
dirty areas after changing to surgical garments.
The nurse station shall be located to permit visual observation of patient
movement. The nursery shall be separate but immediately accessible from the
delivery room.
The nursing service shall be segregated from public areas. The nurse station
shall be located to permit visual observation of patients. Nurse stations shall
be provided in all inpatient units of the hospital with a ratio of at least one (1)
nurse station for every thirty-five (35) beds.
Rooms and wards shall be of sufficient size to allow for work flow and patient
movement. Toilets shall be immediately accessible from rooms and wards.
The dietary service shall be away from morgue with at least 25-meter 43
distance. and Maintenance
21. Space: Adequate area shall be provided for the people, activity, furniture,
equipment and utility.
5.4 PRINCIPLES IN HOSPITAL ENGINEERING

1. Awareness of Building Vulnerability and Protection - Implementing protective
measures with proactive team: As part of a team of design professionals,
engineers, architects, building owners, commissioning agents, etc. are in a key
position to make recommendations to reduce the severity of chemical, biological,
and radiological attacks. While each building has its own unique vulnerabilities,
there arise a position to implement means to protect building occupants’ health,
welfare, comfort and safety. The team can help educate others about various
building features and how to use those features to minimize risk as part of a
comprehensive disaster plan. These features may be simple, be expensive or
compromise the design or function of a building. It is the responsibility to
recommend solutions or measures that are less expensive and less intrusive. These
measures may also provide enhanced protection against natural and accidental
incidents.
2. Know your building. How is it intended to operate?: Look at the mechanical,
electrical, fire protection, security and life-safety systems. Buildings can provide
only temporary protection against an external threat. A delayed response to the
operation of mechanical equipment can potentially create a fatal environment
inside the building within minutes. Eventually, every location within a building
could become contaminated. Some questions to be keep in mind are:
What is the condition of mechanical equipment?
What are the filtration types and efficiencies for the mechanical equipment?
Are the equipment access doors and panels appropriately sealed?
Are all dampers (return air, outside air, bypass, fire and smoke) functioning
properly and seal tightly when closed?
How quickly does the HVAC (heating, ventilating and air conditioning)
system respond to manual fire detection, fire alarm or fire-suppression device
activation?
Are all air devices connected to their associated ductwork systems?
How is the building zoned?
Does it have smoke control?
Where are the air-handling units for each zone?
Is the roof accessible by landscaping or other structures?
How secure are the entries and lobby?
What are the pressure relationships between adjoining spaces/zones?
Are building entryways under negative or positive pressure?
Does the building have tunnels or sky bridges to other buildings?
Are there other airflow paths throughout the building such as stairwells,
elevator shafts and utility chases?
3. HVAC (heating, ventilating and air conditioning) System-Controls: Many
energy management and building control systems regulate pressure and airflow of
44 the mechanical equipment. Will the system be required to circulate 100 percent of
(Supportive Services) the building air or introduce 100 percent outdoor air in the event? Is shutting off
the HVAC and exhaust systems a better solution to avoid introduction of an
external agent? Can control of pressure and airflow relationships between spaces
prevent the spread of an agent released in a building and provide a safe means of
progress? Will manual override of the controls be necessary for exhaust systems
in loading docks, mailrooms and lobbies? Will some spaces like clean rooms,
pressure isolation rooms, laboratories require constant ventilation in the event of
an external agent? These decisions need to be made with your team during the
design and coordination process.
4. Location of Outside Air Louvers: Are they publicly accessible by handrails,
loading docks or retaining walls? Intake louvers can be protected by extending
them 12 feet above an accessible level and provided with a sloped metal mesh top
to keep objects from being thrown into the inlet. If publicly accessible intakes
cannot be relocated or extended, then see-through barriers also be monitored or
placed in conspicuous places to reduce risk. Publicly accessible return air grilles
within a building that are not easily observed by security are also vulnerable.
Relocating these grilles to inaccessible or observable locations or directing the
public away from them is an option. CCTV (closed-circuit television) or
increasing security near these grilles, as well as removing furniture and visual
obstructions near them can also serve as a protective measure.
5. Infiltration: Tight construction of the building envelope can reduce infiltration
(air leakage) into a building. Controlling the building pressurization will also
reduce the amount of infiltration and is more effective with a tight building.
Loading docks, lobbies, storage areas and mailrooms pose a greater challenge and
should be physically isolated from the rest of the building. HVAC systems serving
these areas should maintain a negative space pressure relative to the rest of the
building to prevent dispersion of any released contaminant. To maintain this
pressure relationship, well sealed walls from floor to roof, including all wall
penetrations, should physically isolate these areas.
6. Filters: Filters rated MERV 13 or 14 (Minimum Efficiency Reporting Value)
filter out more than 90 percent of all particles larger than one micron in size.
Installing filters with this efficiency could rapidly remove most of the anthrax
bacillus particles, whether released inside or outside a building. Filtration can
significantly reduce the number of inhaled particles and is perhaps the best
affordable alternative at the present time to protect against anthrax or other
bacterial attack weapons. Depending on the application, pre-filters, final filters,
HEPA (High Efficiency Particulate Air) filters (to remove particulate toxins and
liquid aerosols), and activated Carbon Adsorption filters (to remove toxins in a
vapor or gaseous form) can be used.
7. Detection: Currently, the type of detection capabilities required implementing
changes in the operation of an HVAC system are beyond what is available at a
reasonable cost, especially for biological agents. The current strategy is to try and
evaluate if a CBR release is imminent or has already occurred. It is important not
to implement changes in the operation of the HVAC system without
understanding the system performance, as it exists and how the change will affect
the airflow relationships within the building and building envelope.
8. Identifying Energy Waste: Building systems should be integrated by al means .
For instance, lights produce heat, which in turn produces additional cooling load.
Operating lights efficiently makes the HVAC system work less. There are many
things building operators can do to identify energy waste and improve energy
efficiency for a variety of systems.
9. Electrical System: Is the building served by one single distribution circuit from a 45
utility substation? Power disruptions can be avoided if the system has power and Maintenance
supplied from two different sources and automatically or manually transferred in
the switchgear. Back-up generators can be installed onsite for operation of critical
functions. The local utility company may also have procedures in place to provide
backup power to essential services or replacement of long lead-time equipment.
10. Flood: Critical building operations (locations of mechanical and electrical
equipment) should not be located in areas of the building where accidental or
natural flooding can occur. Flood doors and barriers can be designed to assist in
the prevention of flooding portions of the occupied building or services.
Backwater valves can also be installed in the storm sewer system to prevent the
public storm system from backing up into the building.
11. Water: Ice-making and potable water equipment/storage should be secured and
monitored from unauthorized entry. Potable and non-potable water lines in the
building should also be inspected for vulnerability. Water service can become
contaminated or disrupted.
12. Sewer: An alternative method for waste disposal needs to be in place in the event
that the public sanitary sewer service is shut down or becomes disrupted. A
storage facility or treatment plant can also provide an option for temporary
disposal.
13. Fire Protection: On-site water storage for fire protection can reduce the
dependency on public supplies. Additional support can be provided if there is staff
trained with fire fighting capabilities.
14. Communications: Communication devices should be in place for essential
communications if a facility become disrupted. Wireless communications are not
reliable if the main services or relay stations are disabled. Consideration of a
backup provider can allow some PCS devices to remain active .Telephone, cable
and fiber optic systems will also be lost if the main facility or distribution system
is disrupted. Shortwave and citizens band radio could be a reliable communication
alternative.
15. Natural Gas: An alternate fuel supply, such as fuel oil or propane, can allow
continued operation for a limited time. This service can become disrupted by an
explosion, pipeline break or loss of service from the station due to natural or
terrorist activities. Provisions should be made for a single disconnection point of
these utilities, marked clearly and readily available to first responders.
16. Administration, Maintenance and Training: Staff training and system
maintenance are critical in minimizing the damage from any natural or manmade
disaster. Emergency policies and procedures should be in place, comprehensive,
and readily available to staff for reference. Existing procedures should be updated
to consider a variety of scenarios of an internal and external attack and how to
communicate instructions to the building occupants. Direction should be given to
any safe areas, use and selection of protective equipment or evacuation of specific
locations. Staff with specific responsibilities should hold regularly scheduled
practice drills with key staff and new staff members to ensure the highest success
in an actual event. Preventative maintenance schedules should be implemented
and followed for cleaning, replacement, maintaining all system components.
Proper procedures will ensure that these systems will operate as intended.
17. Mobile Alternatives: If your facility requires transportation so emergency
personnel can provide assistance, then solutions are available to provide a safe
area in a van or other type of vehicle where respirators are not necessary. Special
breathing apparatuses are also available for individual masks while performing
tasks away from the vehicle.
46 18. Safe Areas: Safe areas may be rooms or floors within a building that have been
(Supportive Services) designed for over-pressurization and equipped with a collective-type filtration
system. This area will provide refuge with breathable air. The mechanical systems
for these areas can operate continuously, or serve as standby. Portable shelters are
also available to provide protection.
19. Security Issues:
Limit access to all centralized systems that make your building function as
desired Controlled access to any life safety equipment, zone valves, domestic
water systems, etc., is susceptible to tampering.
To deter tampering of any building operation system by outside maintenance
personnel, their visit should be accompanied by a building staff member
throughout the visit and work inspected upon completion. Otherwise, comfort
can be ensured by relying on a trusted contractor.
Securing access of entries, roof, mechanical areas, storage, loading docks and
outdoor air intakes. When restricting roof access, the fire and life safety
egress should also be reviewed.
Physical security measures such as x-ray equipment of packages and
increased security personnel are optional and could inconvenience the
staff/patients/guests.
What assets require extraordinary protection?
Outside lighting should be sufficient and properly located to allow monitoring
of activities. A minimum quantity of these fixtures should be on emergency
power.
Strict access of building information should be maintained. This includes, but
is not limited to, mechanical, electrical, fire and life safety, medical gas,
vertical transportation, security system plans/types/schematics and emergency
operational procedures.
Secure areas can be monitored and/or protected by physical security, Closed
Circuit Television (CCTV), keyed locks, keycards, alarms or intrusion
detection sensors. Access to keys, keycards and key codes should be
restricted.
Storage tanks for fuels, water or medical gases should be protected from small
arms fire.
5.5 FIVE STEPS TOWARD EFFICIENCY

Step 1: Educate yourself
Learn which system parameters can be adjusted without much disturbance and which
ones can’t.
Step 2: Determine priorities for operating and maintaining your building

Formulate a plan to obtain optimal building performance with the aid of a consultant,
if necessary, and then do your best to execute the plan.
Step 3: Be patient
Most problems concerning system integration don’t appear overnight and aren’t
quickly resolved. Rash decisions often bring about new problems.
Step 4: Find someone you trust

Form relationships with consultants who familiarize themselves with the r building.
This will keep future costs down, because they will have prior knowledge about the
systems when investigating new issues that arise.
Step 5: Get a second opinion 47
This isn’t just good medical advice. Some consultants understand system integration, and Maintenance
some don’t. Take time to “test” several consultants with small assignments, and give
the more difficult assignments to the one that performs best based on your criteria.
Check Your Progress
1. Operation and Maintenance
……………………………………………………………………………….
……………………………………………………………………………….
2. Safe Area
……………………………………………………………………………….
……………………………………………………………………………….
3. Signage
……………………………………………………………………………….
……………………………………………………………………………….
5.6 MAIN CHALLENGES

Facility operators are challenged each day to stay on top of the many systems in their
buildings. Inherit problems always exist in Operations and maintenance detailing
everything from the type of wrench to use for replacing sprinkler heads to how often
water cooled chiller tubes needs cleaning. Some of the very common challenges that
are experienced in the field include:
z Lack of proper system effectiveness and integration.
z System effectiveness ensures systems operate as designed.
z System integration is how well systems operate and communicate with each other.
z Many systems don’t operate as designed, which leads to difficulty for the building
operations team.
z The constant need for problem solving by building operators often dissuades
proper system and equipment maintenance.
z This creates a “snowball” effect in which systems and equipment degrade and
begin to cause more problems.
A strict maintenance schedule that includes equipment cleaning is one of the best
ways to maintain overall hospital efficiency.
5.7 LET US SUM UP

Hospital engineering and maintenance plays a vital role in this field to ensure security
and safety. In this lesson we discussed on meaning, need and significance of hospital
engineering and maintenance and we learned the important guidelines in the planning
and design of a hospital which is very essential phenomenon. We also acquired
knowledge on the principles in hospital engineering and challenges in facilities
engineering and maintenance.
48
(Supportive Services) 5.8 LESSON END ACTIVITY
Think yourself as an administrator of a healthcare sector and point your views
regarding the Engineering and maintenance of equipments.
5.9 KEYWORDS
Operation and Maintenance: Actions regarding the control and upkeep of property
and equipment.
Natural Gas: An alternate fuel supply to allow continued operation for a limited time.

1. “Hospital engineering and maintenance is very essential”. Discuss.
2. Enumerate the guidelines in the planning and design of a hospital.
3. What are the principles of hospital engineering?
4. Explain the challenges in facilities engineering and maintenance.

1. Operations and Maintenance are the decisions and actions regarding the
control and upkeep of property and equipment.
2. Safe Areas: Safe areas may be rooms or floors within a building that have
been designed for over-pressurization and equipped with a collective-type
filtration system. This area will provide refuge with breathable air.
3. Signage: There shall be an effective graphic system composed of a
number of individual visual aids and devices arranged to provide
information, orientation, direction, identification, prohibition, warning
and official notice considered essential to the optimum operation of a
Hospital and other health facilities.

Hayward, Cynthia. ChiPlanTM A Space Planning Guide for Healthcare Facilities. Chi
Systems Inc., 1995.
Canada, 1979.
Construction, 1993.
53
LESSON Maintenance Programs
in Hospitals
6
MAINTENANCE PROGRAMS IN HOSPITALS
CONTENTS
6.0 Aim and Objectives
6.1 Introduction
6.2 Objectives of Maintenance
6.3 Need and Significance
6.4 Benefits of Maintenance
6.5 Types of Maintenance
6.6 Future Challenges
6.7 Let us Sum up
6.9 Keywords
6.0 AIM AND OBJECTIVES

z Understand the need and significance of maintenance program
z Know the benefits and types of maintenance programs
z Have view the future challenges in the maintenance program
6.1 INTRODUCTION
Past and current maintenance practices in both the private and Government sectors
would imply that maintenance is the actions associated with equipment repair after it
is broken. The dictionary defines maintenance as follows: “the work of keeping
something in proper condition; upkeep.” This would imply that maintenance should
be actions taken to prevent a device or component from failing or to repair normal
equipment degradation experienced with the operation of the device to keep it in
proper working order.
6.2 OBJECTIVES OF MAINTENANCE

1. Administration: To ensure effective implementation and control of maintenance
activities.
2. Work Control System: To control the performance of maintenance in an efficient
and safe manner such that economical, safe, and reliable plant operation is
optimized.
50 3. Conduct of Maintenance: To conduct maintenance in a safe and efficient manner.
(Supportive Services) 4. Preventive Maintenance: To contribute to optimum performance and reliability
of plant systems and equipment.
5. Maintenance Procedures and Documentation: To provide directions, when
appropriate, for the performance of work and to ensure that maintenance is
performed safely and efficiently.
6. Maintenance Training: To develop and improve the knowledge and skills
necessary to perform assigned job functions.
6.3 NEED AND SIGNIFICANCE

It has been estimated that Operation and Maintenance programs targeting energy
efficiency can save 5% to 20% on energy bills without a significant capital
investment. From small to large sites, these savings can represent thousands to
hundreds-of-thousands of rupees each year. Beyond the potential for significant cost
and energy/resource savings, a Maintenance program operating at its peak operational
efficiency has other important implications:
z Maintenance opportunities in large buildings do not have to involve complex
engineering analysis.
z A well-functioning Maintenance program is a safe program. Equipment is
maintained properly mitigating any potential hazard arising from deferred
maintenance.
z In most hospital buildings, the Maintenance staff are responsible for not only the
comfort, but also the health and safety of the occupants.
z While taking increased productivity as a concern indoor air quality issues within
these buildings accounts a lot ,where maintenance plays a vital role.
z Proper Maintenance reduces the risks associated with the development of
dangerous and costly situations.
z Properly performed Maintenance ensures that the design life expectancy of
equipment will be achieved and in some cases exceeded.
z Conversely, the costs associated with early equipment failure are usually not
budgeted for and often come at the expense of other planned Maintenance
activities.
z An effective Maintenance program more easily complies with federal legislation
such as the Clean Air Act and the Clean Water Act.
z A well functioning Maintenance program is not always answering complaints,
rather, it is proactive in its response and corrects situations before they become
problems.
z It minimizes callbacks and keeps occupants satisfied while allowing more time for
scheduled maintenance.
6.4 BENEFITS OF MAINTENANCE

The benefits of improved maintenance are staggering. Maintenance improvements
will affect plant margin and the bottom line, while improving many other areas with in
the plant. Some of the benefits of improved maintenance are:
z Financial Benefits:
Reduce operating capital and expenses
Reduce labor cost 51
Maintenance Programs
Reduce overtime cost in Hospitals
Enable better ROI information for projects and maintenance program

upgrades
z Documentation:
Improve documentation management and access
Improve history collection for machinery
Reduce duplicate or inaccurate data retrieval and reporting
z Benefits to Human Resources:
Improve maintenance labor efficiencies
Reduce labor conflict
Improve plant morale
Reduce absenteeism
Reduce “firefighting”
Improve plant communications
Improve employee self esteem
Improve maintenance and operational cooperation
Reduce stress
Improve cohesive plant-wide cooperative spirit
z Planning and Scheduling:
Reduce reactive maintenance and increase proactive maintenance
Improve planning and scheduling
Increase maintenance tool time with the current work force
z Production benefits:
Improve product quality
Optimize production rates
z Reliability:
Increase plant machinery reliability for consistent operations
Reduce downtime by the right PM at the right frequency
z Safety:
Reduce safety incidents
Reduce OSHA enforced corrections and fines
z Materials Management:
Reduce machinery parts cost
Reduce wasted time looking for parts and tools for projects
Reduce cost through best purchasing practices
z Training Program:
Improve maintenance professionalism
52 Improve maintenance knowledge and skills
(Supportive Services) Reduce lost knowledge from retirees or employees leaving
Improve quality of maintenance
6.5 TYPES OF MAINTENANCE

Generally in any hospital following types of maintenance programmes are undertaken:
z Reactive maintenance,
z Preventive maintenance,
z Predictive maintenance,
z Reliability centered maintenance.
a) Reactive Maintenance: Reactive maintenance is basically the “run it till it
breaks” maintenance mode. No actions or efforts are taken to maintain the
equipment as the designer originally intended to ensure design life is reached.
Studies says recently that the predominant mode of maintenance in India and their
breaks down the average maintenance program as follows:
more than 55% follows Reactive maintenance
about 31% follow Preventive maintenance
about 12% undertake Predictive maintenance and
2% follow other modes.
Note that more than 55% of maintenance resources and activities of an average
facility are still reactive.
Merits & Demerits of Reactive Maintenance: It can be viewed as a double-edged
sword. If we are dealing with new equipment, we can expect minimal incidents of
failure. If our maintenance program is purely reactive, we will not expend
manpower money or incur capitol cost until something breaks. Since we do not
see any associated maintenance cost, we could view this period as saving money.
The downside is reality. In reality, during the time we believe we are saving
maintenance and capitol cost, we are really spending more rupees than we would
have under a different maintenance approach. We are spending more money
associated with capitol cost because, while waiting for the equipment to break, we
are shortening the life of the equipment resulting in more frequent replacement.
We may incur cost upon failure of the primary device associated with its failure
causing the failure of a secondary device. This is an increased cost we would not
have experienced if our maintenance program was more proactive.
b) Preventive Maintenance: Preventive maintenance can be defined as follows:
Actions performed on a time- or machine-run-based schedule that detect,
preclude, or mitigate degradation of a component or system with the aim of
sustaining or extending its useful life through controlling degradation to an
acceptable level. By simply expending the necessary resources to conduct
maintenance activities intended by the equipment designer, equipment life is
extended and its reliability is increased. In addition to an increase in reliability,
money is saved over that of a program just using reactive maintenance. Studies
indicate that this savings can amount to as much as 12% to 18% on the average.
Advantages
Less number of staff are only needed.
Cost effective in many capital intensive processes.
Flexibility allows for the adjustment of maintenance periodicity.
Increased component life cycle. 53
Energy savings. in Hospitals
Reduced equipment or process failure.

Estimated 12% to 18% cost savings over reactive maintenance program.
Disadvantages
Increased cost due to unplanned downtime of equipment.
Increased labor cost, especially if overtime is needed.
Cost involved with repair or replacement of equipment.
Possible secondary equipment or process damage from equipment failure.
Inefficient use of staff resources.
Catastrophic failures still likely to occur.
Includes performance of unneeded maintenance.
Potential for incidental damage to components in conducting unneeded
maintenance.
c) Predictive Maintenance: Predictive maintenance can be defined as follows:
Measurements that detect the onset of a degradation mechanism, thereby allowing
causal stressors to be eliminated or controlled prior to any significant deterioration
in the component physical state.
Basically, predictive maintenance differs from preventive maintenance by basing
maintenance need on the actual condition of the machine rather than on some
preset schedule. The fundamental difference between predictive maintenance and
preventive maintenance, whereby predictive maintenance is used to define needed
maintenance task based on quantified material/equipment condition.
Advantages
Increased component operational life/availability.
Allows for preemptive corrective actions.
Decrease in equipment or process downtime.
Decrease in costs for parts and labor.
Better product quality.
Improved worker and environmental safety.
Improved worker moral.
Energy savings.
Estimated 8% to 12% cost savings over preventive maintenance program.
Disadvantages
Increased investment in diagnostic equipment.
Increased investment in staff training.
Savings potential not readily seen by management.
d) Reliability Centered Maintenance: Reliability Centered Maintenance (RCM)
magazine provides the following definition of RCM: “a process used to determine
the maintenance requirements of any physical asset in its operating context.”
Basically, RCM methodology deals with some key issues not dealt with by other
maintenance programs. It recognizes that all equipment in a facility is not of equal
54 importance to either the process or facility safety. It recognizes that equipment
(Supportive Services) design and operation differs and that different equipment will have a higher
probability to undergo failures from different degradation mechanisms than
others. In a nutshell,
“RCM is a systematic approach to evaluate a facility’s equipment and resources to
best mate the two and result in a high degree of facility reliability and cost-
effectiveness”.
Advantages
Can be the most efficient maintenance program.
Lower costs by eliminating unnecessary maintenance or overhauls.
Minimize frequency of overhauls.
Reduced probability of sudden equipment failures.
Able to focus maintenance activities on critical components.
Increased component reliability.
Incorporates root cause analysis.
Disadvantages
Can have significant startup cost, training, equipment, etc.
Savings potential not readily seen by management.
How to Initiate Reliability Centered Maintenance: The road from a purely reactive
program to a RCM program is not an easy one. The following is a list of some basic
steps that will help to get moving down this path:
1. Develop a Master equipment list identifying the equipment in your facility.
2. Prioritize the listed components based on importance to process.
3. Assign components into logical groupings.
4. Determine the type and number of maintenance activities required and periodicity
using:
a. Manufacturer technical manuals
b. Machinery history
c. Root cause analysis findings - Why did it fail?
d. Good engineering judgment
5. Assess the size of maintenance staff.
6. Identify tasks that may be performed by operations maintenance personnel.
7. Analyze equipment failure modes and effects.
8. Identify effective maintenance tasks or mitigation strategies.
6.6 FUTURE CHALLENGES

Computerized Maintenance Management System: A Computerized Maintenance
Management System (CMMS) is a type of management software that performs
functions in support of management and tracking of O&M activities. CMMS systems
automate most of the logistical functions performed by maintenance staff and
management. CMMS systems come with many options and have many advantages
over manual maintenance tracking systems.
Advantages 55
z Work order generation, prioritization, and tracking by equipment/component. in Hospitals
z Historical tracking of all work orders generated which become sortable by

equipment, date, person responding, etc.
z Tracking of scheduled and unscheduled maintenance activities.
z Storing of maintenance procedures as well as all warranty information by
component.
z Storing of all technical documentation or procedures by component.
z Real-time reports of ongoing work activity.
z Calendar- or run-time-based preventive maintenance work order generation.
z Capital and labor cost tracking by component as well as shortest, median, and
longest times to close a work order by component.
z Complete parts and materials inventory control with automated reorder capability.
z PDA interface to streamline input and work order generation.
z Outside service call/dispatch capabilities.
Disadvantages
While CMMS can go a long way toward automating and improving the efficiency of
most O&M programs, there are some common pitfalls. These include the following:
z Improper selection of a CMMS vendor. This is a site-specific decision. Time
should be taken to evaluate initial needs and look for the proper match of system
and service provider.
z Inadequate training of the O&M administrative staff on proper use of the CMMS.
These staff need dedicated training on input, function, and maintenance of the
CMMS. Typically, this training takes place at the customer’s site after the system
has been installed.
z Lack of commitment to properly implement the CMMS. A commitment needs to
be in place for the start up/implementation of the CMMS. Most vendors provide
this as a service and it is usually worth the expense.
z Lack of commitment to persist in CMMS use and integration. While CMMS
provides significant advantages, they need to be maintained.
Check Your Progress
Write short notes on the following:
1. Maintenance
……………………………………………………………………………….
……………………………………………………………………………….
2. Objectives of maintenance
……………………………………………………………………………….
……………………………………………………………………………….
3. Computerized Maintenance Management System
……………………………………………………………………………….
……………………………………………………………………………….
56
Hospital Operation-II 6.7 LET US SUM UP
To ensure safety and reliability it is essential to have maintenance programs. From
this lesson we understand the need and importance of maintenance programs which
are helpful in evaluating the performance and in turn improves the overall system.

Device your own maintenance programme for a hospital .What type of maintenance
do you think is suitable for a hospital?
6.9 KEYWORDS
Maintenance: Actions taken to prevent a device or component from failing.
Preventive Maintenance: Actions performed on a time-or machine-run-based
schedule.
Predictive Maintenance: Measurements that detect the onset of a degradation
mechanism.

1. Explain the need and importance of maintenance program.
2. “Maintenance programs are helpful in evaluating the performance”. Elucidate.
3. What are the future challenges in maintenance program?

1. Maintenance: Maintenance means actions taken to prevent a device or
component from failing or to repair normal equipment degradation
experienced with the operation of the device to keep it in proper working
order.
2. Objectives of Maintenance:
Administration
Work Control System
Conduct of Maintenance
Preventive Maintenance
Maintenance Procedures and
Maintenance Training
3. Computerized Maintenance Management System: A type of
management software that performs functions in support of management
and tracking of O&M activities. CMMS systems automate most of the
logistical functions performed by maintenance staff and management.
CMMS systems come with many options and have many advantages over
manual maintenance tracking systems.

Guidelines for Seismic Vulnerability Assessment of Hospitals.
Hospital Engineering Trends, A newsletter dedicated to healthcare-related engineering
issues for hospital, Guidelines on Prevention and Control of Hospital Associated
Infections © World Health Organization 2002.
61
LESSON Electrical Supply
7
ELECTRICAL SUPPLY
CONTENTS
7.1 Introduction
7.2 Functions of Electrical and Instrumentation Services
7.3 Major Electrical Systems and Components
7.4 Effective Electrical Preventative Maintenance Program
7.5 Issues and Challenges
7.6 Let us Sum up
7.8 Keywords

z Know the functions of electrical and instrumentation services
z Know major electrical systems and components
z Know about the electrical preventive maintenance program
z Have a view of the challenges and issues in this field
7.1 INTRODUCTION
Recent studies reveal that over 20% of the nation’s electricity consumption is related
to various types of lighting products and systems. Advanced energy saving
technologies are readily available to reduce both the connected load and energy
consumption, but are only effective if they are properly installed, calibrated, and
maintained. Improvements in electrical efficiencies are so rapid that it can be cost-
effective to implement upgrades, retrofits or redesigns to systems.
7.2 FUNCTIONS OF ELECTRICAL AND

INSTRUMENTATION SERVICES
a) Analyze Power Systems:
Load Flow, System Reserve for Future Loads
Voltage Drop and Fault Current
Protective Coordination
58 Large Motor Starting Impact
(Supportive Services) Energy Saving Potential, Cost and Return
Power Quality Analysis
System Failure Analysis
b) Power System Design:
Detailed Engineering and Design
Coordination with the Utility
One-Line Diagrams
Plans and Specifications
c) Facility Electrical Design:
Power, Control, and Instrumentation Plans and Details
Lighting Systems Design
Life Safety Systems
Equipment Specifications, Bid Requests, and Bid Analysis
Installation Specifications, Bid Requests, and Bid Analysis
d) Design Control and Instrumentation:
P & I Diagrams
Motor Elementaries
I/O Wiring Diagrams
Loop Diagrams
Plant Network Design
Controls Integration
Instrument Data Sheets
Relay Logic
PLC Programming and Documentation
MMI Programming
Logic Programs
Stand Alone Instrument Systems
e) Document Existing Power Systems:
Measure Existing Loads
Update One-Line Diagrams
Record Sizes and Ratings of the System Components
Plot Coordination of Protective Devices
f) Design Expansions to Existing Power Systems:
Check Impact of New System on Existing System
Provide Master Plan that Allows for Additional Expansion
Detail Engineering, Plans and Specifications
Bid Requests, Bid Analysis and Shop Drawing Review
g) In-House Design Tools: 59
Electrical Supply
EDSA Design Software
AutoCAD Drafting
Extensive Library of Symbols, Standard Details, and Blocks
Master Database Networked to All Computer Stations
Extensive Library of Specifications, Standard Details and Data
PLC Programming and Documentation
7.3 MAJOR ELECTRICAL SYSTEMS AND COMPONENTS

1. Lighting: A lighting system consists of light sources, the ballasts or other devices
that regulate the power that drives electric lights, the luminaire housing with
components that hold the sources and direct and shield the light, and lighting
controls that manipulate the time or intensity of lighting systems.
Electric Light Sources: The electric light sources most common to hospital
buildings include incandescent/halogen, fluorescent, high intensity discharge and
light emitting diodes. Characteristics common to light sources include their
output, efficiency, life, color and distribution:
a) Electrical Lamps: The lamp is the source of electric light, the device that
converts electric power into visible light. Selecting the lamp types is at the
heart of a high-quality lighting plan, and central to visual performance, energy
conservation, and the appearance of a space.
b) Fluorescent Lamps: generate their light by using electricity to excite a
conductive vapor of mercury and an inert gas. The resultant ultraviolet light
strikes a phosphor coating on the inside of the tube, causing it to glow. The
elements used in the phosphor coating control the lamp’s color. Fluorescent
lamp advantages, disadvantages, and appropriate uses.
Advantages:
Very high efficacy – T8/T5 lamps are 80 to 98 lumens per watt
Flexible source with a wide range of colors, (75 to 98 CRI), sizes, and
shapes
Very long lamp life: 20,000 to 30,000 hours
Cool operation
Low diffused surface brightness
Disadvantages:
Require a compatible ballast
Dimming requires a more expensive ballast
Temperatures can affect start-up, lumen output, and lamp life
Not a point source if narrow beam distribution is required
Appropriate Uses: Fluorescent and compact fluorescent lamps are appropriate
for most of the applications that federal facilities managers encounter in their
buildings allows the designer to potentially reduce the number of fixtures,
lamps, and ballasts in an application, making it less expensive to maintain.
c) Compact Fluorescent Lamps (CFLs): Fluorescent lamps with a single base
and bent-tube construction. Originally designed for the retrofitting of standard
incandescent, the first CFLs had a screw-type base. While screw base lamps
60 are still available, commercial applications typically use lamps with a 4-pin
(Supportive Services) base. This prevents the future replacement of a screw-based CFL with a much
less efficient incandescent lamp. CFL lamps have a wide range of sizes and
attractive colors, and can be used in most FEMP applications that formerly
used incandescent.
Advantages:
Good substitution for most incandescent lamps
High efficacy – 56 to 71 lumens per watt.
Flexible source with a wide range of sizes and shapes, and good color
rendering
Long lamp life: 10,000 to 12,000 hours
Cool operation
Diffused surface brightness
Disadvantages:
Require a compatible ballast
Dimming requires a more expensive ballast
Temperatures can affect start-up, lumen output, and lamp life
d) Electrode Less Lamps: also called induction lamps, most commonly use
radio frequency to ionize mercury vapor at low-pressures, resulting in exciting
the phosphors inside the envelope to create a glow, similar to fluorescent
technology.
Advantages:
Very long life (100,000 hours) due to lack of electrodes to deteriorate
Good maintained lumen output over life
Low to high light output available (1,100 to 12,000 lumens per lamp)
Medium to high efficacy (40 to 60 lumens/watt)
Disadvantages:
Not interchangeable with other lamps and ballasts. No competition.
Only one manufacturer per lamp style (donut, reflector, globe).
Limited to diffuse distribution.
Limited wattages and lumen output for each style.
Requires magnetic core, which has shorter life than the lamp.
Appropriate Uses:
Locations where maintenance is expensive or difficult
Replacement reflector lamp for incandescent floodlight in high ceilings
Locations where high lumen output and diffuse distribution is desirable
e) Incandescent/Halogen Lamps: Generate their light by heating a tungsten
filament until it glows, in the presence of an inert gas such as argon or
nitrogen. A halogen lamp is a form of incandescent lamp that introduces
traces of halogen gas and a quartz envelope to burn hotter and prolong the
filament life. Consequently, they are whiter and are slightly more energy
efficient than standard incandescent.
Advantages: 61
Electrical Supply
Excellent color rendering and a warm appearance
Can be focused for use in reflector lamps
Compact size
No ballast required
Easily dimmed
Minimal ultra-violet emissions for conservation of light sensitive
materials
Disadvantages:
Low efficacy – Halogen is the best at 13 to 21 lumens per watt.
Shorter lamp life than alternatives – Halogen is the best at 3,000 to 6,000
hours
Lamp can get very hot
Low voltage transformers may be required for halogen lights
Point source is glary if not shielded.
Appropriate Uses:
Historic settings when CFL lamps cannot be used
Applications in which color rendering is extremely important
Displays where the narrowest beam control is necessary
f) Light Emitting Diodes (LEDs): are made of an advanced semi-conductor
material that emits visible light when current passes through it. Different
conductor materials are used, each emitting a distinctive wavelength of light.
LEDs come in red, amber, blue, green, and a cool white, and have limited
applications at this time.
Advantages:
Impact resistant
Operate best at cooler temperatures so good for outdoor applications
Small size
Low to medium efficacy, depending on the color. Red is highest, followed
by amber, green, white, and blue. A more efficient white light can be
created by combining red, green, and blue LEDs.
Monochromatic color for exit signs, signals, and special effects
Effective for rapid or frequent switching applications
Disadvantages:
Rapid lumen depreciation: White LEDs may last 12,000 hours or longer,
but “useful life” is only 6,000 hours, the point at which point light output
has reduced 50%.
Monochromatic color
Heat buildup
Cost
62 White LEDs are still bluish and provide low lumens per watt, similar to
(Supportive Services) incandescent. Both conditions are expected to improve rapidly over the
next 15 years.
Appropriate Uses:
Currently used primarily in exit signage, traffic signaling, and certain
special effects
Excellent for projecting words or an image – as in walk/don’t walk signs
or exit signs.
LED sources may have the greatest potential for technical improvements
and new applications in the next 15 years.
2) Ballasts, Transformers, and Power Packs: Electrical devices are needed to
provide the necessary high starting voltage, and then limit and regulate the
current to the electrical components during operations. All gas discharge lamps,
like fluorescent and High Intensity Discharge (HID), require ballasts .Ballasts
typically are designed to efficiently operate a specific lamp type, so lamps and
ballasts are chosen together.
3) Luminaire Housing: A luminaire is the entire lighting assembly that includes a
light source, a ballast to control the power, and a housing with components
necessary for light distribution and shielding of the source.
4) Control Devices: There is seldom just one way to accomplish the desired control
of Electricity, and a variety of equipment is available to the electrical designer. A
comprehensive strategy uses several of these control devices in concert,
responding to project-specific usage patterns:
a) Manual controls
Switches and switching patterns
Manual dimmers
b) Automatic controls
Occupancy sensors
Daylight sensors
Pre-set controls
Time controls
Centralized control management
a) Manual Controls: Manual controls allow the users to select the discharge
levels best suited to their immediate needs. Task lights located in
workstations should have manual controls. Spaces with variable activities,
such as training rooms, multi-purpose rooms, or conference centers, generally
require manual controls to enable the users to tailor the light for each different
activity.
Switches: Switching strategies can be used in combinations to offer
multiple levels of illumination, and multiple mixes of available light
sources. In its simplest application, open work areas can have several
zones of luminaires, so partially occupied rooms do not need to burn all
the lights. Three-way switches are typically used in multi-entry and
multi-zoned rooms to facilitate people moving from zone to zone.
i) Automatic Switches: Sentry-type switches that reset to the off
position are appropriate for use with manual-on/automatic-off
occupancy sensors.
ii) Bi-level Switching: two (or more) light levels within a space can be 63
attained with multi-lamp luminaires, factory pre-wired for easy Electrical Supply
connection to separate switches, which allows one lamp in each

fixture to be turned off, effectively “dimming” the lights. When
several light sources – e.g., overhead luminaries, wall washers, down
lights – are present, each type should be switched separately.
Manual Dimmers: Annual dimming is most useful to respond to specific
user needs – dimming the conference room lights for AV presentations,
raising the light level for the cleaning crew, changing the mood in a
cultural space. Manual dimmers can be wall box sliders or hand-held
remote controls.
b) Automatic Controls: Automatic controls provide benefits in user comfort and
energy conservation. Automatic controls can deliver reliable energy savings
without occupant participation, and when well designed, without their notice.
In addition, they can make adjustments to consumption levels throughout the
day, or in response to specific needs.
Advantages:
z Sufficient energy conservation possible.
z Energy savings are more predictable.
z Allows a comprehensive daylighting strategy.
z Subtle changes in light levels can be accomplished without occupant
participation.
z Flexible for accommodating changes in use or occupancy over the
moderate/long-term.
Disadvantages:
z Controls must be very reliable and predictable for user acceptance.
z May require expertise and/or training of maintenance personnel.
z Commissioning is required and adjustments may be necessary when
layouts change
z Moderate to high initial cost
Appropriate Uses:
z Dimming of electric lighting to support a daylighting strategy.
z Rooms with periods of no occupancy during the day (for occupancy
sensors) or have regular operating hours.
z Support spaces and outdoor areas with predictable needs.
(i) Occupancy Sensors: Occupancy sensors turn off the lights when they
detect that no occupants are present. The occupancy sensor includes a
motion sensor, a control unit, and a relay for switching the lights. The
sensor and control unit are connected to the luminaire by low voltage
wiring, with a transformer stepping down the current. There are three
commonly used types of occupancy sensors, defined by how they detect
motion: ultrasonic, passive infrared and dual-technology.
a) Ultrasonic Sensors (US): “Utilize a quartz crystal that emits high
frequency ultrasonic waves throughout the room.” Shifts to the
frequency of the wave (called Doppler effect) indicate that there is
motion/occupancy in the space. While this makes them effective at
detecting occupancy, it also makes them more vulnerable to “false-
on” readings caused by traffic in adjacent corridors and air currents.
64 b) Passive Infrared Sensors (PIR): “Respond to the infrared heat
(Supportive Services) energy of occupants, detecting motion at the “human” wavelength.”
They operate on a line-of-sight basis and do not detect occupants
behind partitions or around corners. They also are less likely to
detect motion as the distance increases. Therefore, they are useful
when a room is small or it is desirable to control only a portion of a
space.
c) Dual-Technology Sensors: Combine two technologies to prevent
both false-offs and false-ons. The most common one uses both
ultrasonic and passive infrared sensing to detect occupancy. The
sensor usually requires that both US and PIR sense occupancy
before turning on. The lights will remain on as long as either
technology detects someone. High quality occupancy sensors use
the dual technology, since it is more reliable than each of the
separate technologies used independently.
(ii) Multiple Level Control: Occupancy sensors are effective for multiple
level switching in spaces where full off is not acceptable, but occupancy
is not continuous. By using a two- or three-level ballast, or multi-lamp
fixtures with lamps wired separately, the lowest level may be allowed to
operate at most hours, but when occupancy is sensed, the light level
increases.
(iii) Pre-set Controls: Switching, dimming, or a combination of the two
functions can be automatically preprogrammed so that the user can select
an appropriate lighting environment (“scene”) at the touch of a button. A
“pre-set controller” and wiring plan organizes this. For example, the
occupant of a conference room could select one pre-set scene from a five-
button “scene selector” wall-mounted in the room, labeled “Conference,”
“Presentation,” “Slide Viewing,” “Cleaning,” and “Off.”
(iv) Time Controls: Time clocks are devices that can be programmed to turn
electrical components on or off at designated times. These are a useful
alternative to photoelectric sensors in applications with very predictable
usage, such as in parking lots. Simple timers are another option, turning
the lights on for a specified period of time, although there are limited
applications where this is appropriate, e.g., library stacks.
(v) Centralized Control Management. Automated Building Management
Systems (BMS): These are becoming more common in medium- and
large-sized facilities to control HVAC, electrical, water, and fire systems.
Incorporating lighting controls is a natural step in efficient management,
and centralized lighting control systems are available that can interface
with building maintenance systems while providing data on lighting
operation.
7.4 EFFECTIVE ELECTRICAL PREVENTATIVE

MAINTENANCE PROGRAM
Hospitals nowadays strive hard to go for Electrical Maintenance as uninterrupted
power supply is of utmost need for the smooth running of the hospital operation.
Studies have shown that failure rates for electrical equipment that are not part of a
preventative maintenance program are three times greater than those that are covered
by an EPM program. Which would you rather do? Schedule your system outage or
work under the stress of getting your facility back on line because of an electrical
system failure.
The National Fire Protection Association (NFPA) recognized the need for a suitable
document to address this issue. In 1968, the Technical Committee on Electrical
Equipment Maintenance was formed and NFPA 70B was created. It offers a plan to 65
reduce hazards resulting from failure or malfunction of electrical equipment and Electrical Supply
systems through the implementation of a preventative maintenance program. As we

all know, equipment deterioration is to be expected, but equipment failure is
unavoidable. With an effective EPM program, you can identify the factors that
contribute to this normal deterioration and provide means for successfully managing
them. In turn, this information can help to reduce the cost of operating your facility by
minimizing unscheduled outages due to costly breakdowns. Future troubles can be
identified and corrective actions taken before they can become major problems
requiring costly solutions.
Process of Electrical Maintenance

Step 1: Creating a Plan: The first step in the process is to create a plan based on the
components that are included in the electrical system. Identify the individual items
and gather technical information on them. This will become the basis upon which you
will develop the detailed plans and procedures for implementing your EPM.
Step 2: Providing necessary Staffing: The essential parts of an effective EPM are
qualified personnel to implement the plan, a regular schedule for routine inspections
and required tests, proper corrective actions based on accurate analysis of inspections
and testing and accurate record keeping. The best program in the world is useless
without well-qualified people to implement it.
A leader should be assigned the responsibility of ensuring that a program is in place
and is followed. This individual should be a qualified electrician with complete
knowledge of the electrical system and understand the impact to the facility in the
event of a failure. He should be provided a staff of qualified electricians to implement
the plan. If qualified people are not available in-house, consider hiring a qualified
maintenance contractor to be responsible for the maintenance and testing.
Step 3: Develop Program: Once the staff is in place, develop a program that identifies
all the specific components of the electrical system, establishes a priority based on the
critical nature of the equipment and settles on the exact scope of the work to be done
and frequency of its performance. Items which are most critical to the operation of
your facility, such as emergency generators or fire alarm systems, will require the
most frequent inspections and tests. Factors such as the physical condition, operating
parameters and equipment environment will also need to be considered.
Manufacturers’ recommendations will give you the suggested testing requirements
and the frequency of inspection. These recommendations are based on standard
operating conditions so your plan should reflect your specific site conditions
Step 4: Inspection and Testing: With your program in place, it’s time to do the work.
Some maintenance tasks require the equipment to be energized, but whenever possible
perform the maintenance and testing with the equipment de-energized. Coordinate any
shutdown with the building occupants. Some of the shutdowns may require
scheduling work for off hours between midnight and 6 a.m. or weekends or
transferring loads from the normal power system to emergency power.
Step 5: Determine Corrective Actions Required: Once you have completed your
inspection and testing, you can determine what corrective actions are required. It may
be as simple as doing a little “spring cleaning.” On the other hand, you may discover a
major disaster waiting to happen. Either way, you can act rather than react by
scheduling a shutdown to take corrective action and alleviate the need to operate in
crisis mode. Resources can be scheduled and occupants of the facility can be notified
of the shutdown and take appropriate actions. Technical data can be assembled and
reviewed while replacement parts needed to make repairs are gathered without paying
those rush shipping charges.
66 Step 6: Evaluation of Results: Finally, records need to be kept to allow evaluation of
(Supportive Services) results. Examination of the records will assist management in planning what future
budget allocations for EPM and emergency repairs. Records will also assist in the
evaluation of EPM parameters.
z Are your inspection frequencies correct?
z Is the staffing sufficient for the magnitude of the work?
z Do you have the correct replacement parts in sufficient quantities?
z Were there any unusual events that you had not accounted for?
Thorough record keeping will help you in answering these questions. With proper
analysis, you can plan the next cycle of inspections and tests to better meet the needs
of your facility.
Step 7: Updating the System: Update your EPM when changes are made to your
electrical system by adding new equipment to the maintenance schedules and updating
spare parts inventories. One consideration for those who are presently involved in or
planning an expansion is the importance of an EPM in the electrical system design.
Now is the time to think about these things - not when a failure has happened and it’s
too late. The old adage, “Plan your work and work your plan,” is never any truer than
it is here.
7.5 ISSUES AND CHALLENGES

In dealing with electrical equipment, the greatest concern is electrical shock, followed
by injury from falls from high mounting locations, ladders and lifts, and handling of
hazardous waste.
a) Electrical and Equipment Safety:
All electrical equipment should be properly grounded, including luminaires,
ballasts, starters, capacitors and controls, and be in accordance with the
National Electric Code.
Although maintenance personnel may handle routine maintenance such as
changing lamps or cleaning luminaires, all trouble-shooting and repair must
be handled by licensed electricians. All personnel must be properly trained
and equipped.
All maintenance personnel shall be provided with and instructed in the use of
proper tools and equipment such as protective hand tools, fall protection such
as safety belts or harnesses, hard hats, goggles, gloves, and testing tools.
All maintenance of electrical equipment must follow the lockout/tag out
standard. This standard applies to the control of energy during servicing
and/or maintenance of machines and equipment.
Special precautions should be taken near high voltages and lighting
components such as HID capacitors that may retain their electric change after
the system has been de-energized.
All forms of lifts, scaffolds, and ladders must meet standards for construction
and use. Portable scaffolds, telescoping scaffolds, and personnel lifts are
typically safer than ladders, by providing a firmer footing and space for tools,
replacement items, and cleaning materials. Ladders used for maintenance
should not be made from materials that conduct electricity, such as aluminum.
b) Hazardous Materials Handling:
Breakage of mercury-containing lamps – Mercury vapor is most hazardous
when lamps are operable. When a fluorescent or metal halide lamp containing
mercury gas is broken, the following safety procedure is recommended. Clear
the areas for 10 minutes; turn off AC so that mercury vapor does not spread;
flush the area with fresh air: use an N95 respirator mask and goggles and 67
gloves to sweep the particles into a glass jar. Double wrap in a paper bag. Electrical Supply
Dispose of as hazardous waste. Clean area and clothes. Discard gloves.

Hazardous waste lamps are classified as those failing the EPA Toxicity
Characteristic Leaching Procedure (TCLP) for landfills, and include
fluorescent, high pressure sodium, metal halide, mercury vapor, and neon
lamps (if they contain mercury). The EPA revised their rules about mercury-
containing lamps in 2000, allowing the following three options:
Mercury-containing lamps must pass the TCLP test.
Must be treated as hazardous waste in storage, handling, collection, and
transportation.
Must be managed under the universal waste rule i.e., recycled.
The universal waste rule allows for disposal of hazardous electrical equipment
in small quantities.
Magnetic ballasts with PCBs in the capacitors can still be found in older
installations, even though they were banned from being manufactured or
distributed after 1978. Ballasts that are not leaking can be recycled. Whether
or not the ballast is leaking fluid, the building manager should use a qualified
disposal contractor who is aware of all PCB related hazards.
The building manager and the waste or recycling contractor must keep proper
documentation and chain of possession records. Auditing the contractor and
reviewing the contractor’s closure plan for transition of materials if the
contractor goes out of business is recommended prior to signing a contract
and every few years afterwards.
c) Energy Efficiency, Savings, and Cost: Ways to maintain performance and
improve system efficiency through planned maintenance, response to complaints,
retrofit, and redesign.
d) Response to Complaints: Earlier the complaints are met lesser would be the
accidents and more would be the satisfaction of the occupants of hospitals.
Meeting the complaints at the earliest would prove the efficiency of the hospital
maintenance system in total.
e) Retrofit versus Redesign: Retrofit is typically described as replacement of
components in the same housing or location as the original electrical equipment .
Redesign is typically described as new Equipment in some new locations. On the
surface, retrofit may appear to be the cheapest and easiest path, but in fact is not
always the most cost-effective strategy.
Check Your Progress
1. Ultrasonic sensors
……………………………………………………………………………….
……………………………………………………………………………….
2. Automatic control
……………………………………………………………………………….
……………………………………………………………………………….
3. Time clocks
……………………………………………………………………………….
……………………………………………………………………………….
68
The electrical supply plays a vital role in hospitals as it quite essential for the smooth
working of hospitals. In this lesson we discussed various electrical services, electrical
systems and components and the electrical preventive maintenance program which
helps to provide security and safety in handling electrical appliances.

"Electrical appliances must be managed cautiously". How?
7.8 KEYWORDS
Lighting: A lighting system consists of light sources, the ballasts or other devices that
regulate the power that drives electric lights.
Compact Fluorescent Lamps (CFL): Fluorescent lamps with a single base and bent-
tube construction.
Passive Infrared Sensors: Detecting motion at the “human” wavelength.

1. Briefly state the functions of electrical and instrumentation services.
2. Explain the electrical preventive maintenance program.
3. What are challenges and issues faced and how to tackle such situations?

1. Ultrasonic sensors: Utilize a quartz crystal that emits high frequency
ultrasonic waves throughout the room. Shifts to the frequency of the wave
(called Doppler Effect) indicate that there is motion/occupancy in the
space.
2. Automatic controls: Automatic controls provide benefits in user comfort
and energy conservation. Automatic controls can deliver reliable energy
savings without occupant participation, and when well designed, without
their notice.
3. Time clocks: Time clocks are devices that can be programmed to turn
electrical components on or off at designated times. These are a useful
alternative to photoelectric sensors in applications with very predictable
usage, such as in parking lots.

Meador, R.J. 1995. Maintaining the Solution to Operations and Maintenance
Efficiency Improvement.
World Energy Engineering Congress, Atlanta, Georgia.
NASA. 1997a. Guide Performance Work Statement for Center/Installation Operations
Support Services.
National Aeronautics and Space Administration, Washington, D.C. Available URL:
www.hq.nasa.gov/office/codej/codejx/Coss1-27.doc.
NASA. 1997b. User’s Guide for Preparing Performance Work Statements for Center
Operations Support ,Services. National Aeronautics and Space Administration,
Washington, D.C. Available URL:
www.hq.nasa.gov/office/codej/codejx/cossug.doc 69
Electrical Supply
NASA. 1999. Guide Performance Work Statement for Subsection 32 – Energy/Water
Conservation Management Services. National Aeronautics and Space Administration,
Washington, D.C. Available URL:
www.hq.nasa.gov/office/codej/codejx/Add32-33.doc
PECI. 1997. Operations and Maintenance Service Contract. Portland Energy
Conservation, Inc., Portland, Oregon.
74
LESSON
8
WATER SUPPLY
CONTENTS
8.1 Introduction
8.2 Stages of Water Supply Management
8.3 Factors Contributing to the Quality of Water
8.4 Functions of Water Supply in Hospitals
8.5 Let us Sum up
8.7 Keywords

z Know various stages in water supply management
z Know the factors affecting the quality of water supply services
z Understand the relationship between water supply management and hospitals
8.1 INTRODUCTION
Effective functioning of health-care settings depends on a number of different
requirements, including safe and sufficient water, basic sanitation, adequate
management of health-care waste, appropriate knowledge and application of hygiene,
and adequate ventilation. Of all the above water component plays a vital role both in
maintaining and deteriorating health care.
Health-care associated infections affect between 5% and 30% of patients. The
associated burden of disease is extremely high, is a significant drain on health-sector
and household resources, and disproportionately affects vulnerable members of
society. Environmental health in health-care settings can significantly decrease the
transmission of such infections if properly planed and maintained. Health-care settings
also provide an educational opportunity to promote safe environments that are
relevant to the population at large, and thereby also contribute to safe environments at
home and in community settings, such as schools.
8.2 STAGES OF WATER SUPPLY MANAGEMENT

“Water Supply Management refers to planning and analyzing the existing situation,
technology choice, and thereby making the operations and maintenance functions
related to water supply and monitoring ongoing facilities in the hospital.” The above 71
definition could be broken down into following stages for water supply management: Water Supply
z forming members committee,

z analyzing the Existing situation and planning settings or improvements to existing
ones,
z technology choice, operation and maintenance,
z monitoring ongoing maintenance of facilities.
Step 1: Forming members committee: Managing the various and interdependent
aspects of environmental health at the level of the health-care setting should involve
all staff, as well as patients and careers. There should be a clearly identified body with
the authority and resources required to carry out steps in hospitals and other larger
settings, a committee may be required for planning, coordinating and monitoring
implementation of targets. Members of the committee should include managers,
clinicians, technical and ancillary staff. In smaller settings, such as basic health posts,
this role may be taken on by one staff member or volunteer, who should receive
support from environmental health officers or other infection control staff based at the
district level.
Step 2: Analyzing the existing situation and planning new settings or improvements
to existing ones:
1. Discuss any major aspects of the current situation where water supply, sanitation,
healthcare waste management and hygiene targets defined for the health-care
setting are not met. Write each one in large letters on a small piece of paper (e.g.
A6 size) or a postcard.
2. For each major problem, discuss its causes by asking “why?” For each of the
contributing problems identified, ask “why?” again, and so on until root causes for
each problem have been revealed and agreed. Write all the contributing problems
in large letters on a piece of paper or postcard and stick them on a wall, arranged
in a way that reflects their relation to each other and to the major problem.
3. For each of the contributing problems noted, discuss possible solutions. Check
that these solutions contribute to solving the major problems identified by asking
“what?” to identify the effects of the action. Some solutions proposed will
probably have to be abandoned because they are not realistic given current
conditions, or because they do not have sufficient impact on the major problems.
4. Once a number of feasible solutions have been agreed, they should be phrased as
objectives. For each objective, the group can then discuss and agree on a strategy,
how the objectives can be reached, responsibilities, who will do what, timing,
resources and requirements.
Step 3: Technology choice, operation and maintenance: Maintenance, repair and
eventual replacement of environmental health facilities should be taken into account
while they are being designed and built. As far as possible, facilities should be hard-
wearing, durable and possible to maintain without specialist skills or equipment.
Technology should be chosen taking account of local capacities for maintenance and
repair. In some cases, it may be necessary to choose a lower level of service to avoid
essential equipment that cannot be repaired when it breaks down. For example, it may
be better to keep an open, protected well, rather than equip it with a cover slab and
pump, until there is a reliable system in place for maintaining and repairing the pump.
Responsibilities for operation and maintenance should be clearly defined, and
appropriate expertise provided. Maintaining, repairing and replacing water supplies,
sanitation, ventilation systems and health-care waste facilities should be planned and
budgeted for from the beginning of a programme to improve health-care settings or
build new ones.
72 Step 4: Ongoing monitoring, review and correction: Maintaining acceptable
(Supportive Services) conditions requires ongoing efforts at all levels. The role of the infection control
committee in ensuring regular monitoring of environmental health conditions is
critical. For example, health-care settings should be included in regular water quality
surveillance and control programmes. A monitoring system should use a limited set of
indicators that are easily and frequently measured to identify problems and correct
them in a timely way. For example, water shortages at handwashing points may be
monitored by staff according to an organized schedule, and signalled immediately to
caretakers or maintenance staff, where these exist, for action. A periodic review of
environmental health facilities should also be carried out in a way that illustrates the
links between the various activities. As in assessments, reviews should seek to
identify causes for problems and then propose realistic solutions. Recording forms
should be developed at the level of the health-care setting, or at the district or national
level for standardized monitoring reports. This will allow data from all health-care
settings to be collated and compared.
8.3 FACTORS CONTRIBUTING TO THE QUALITY

OF WATER
Quality of service relies on many factors especially on five interrelated factors:
i) Technical
ii) Community
iii) Environmental
iv) Institutional framework
v) Managerial factors
vi) Financial factors
1. Technical factors:
Technology selection;
Complexity of the technology;
Technical capacity of the system to respond to demand;
The technical skills needed to operate and maintain the system;
The availability, accessibility and cost of spare parts;
2. Community factors:
The demand or perceived need for an improved service;
The feeling of ownership;
Community participation;
The capacity and willingness to pay;
Management through a locally organized and recognized group;
The financial and administrative capacity of management;
The technical skills to operate and maintain the service;
Socio-cultural aspects related to water;
Individual, domestic and collective behaviour regarding the links between
health, water, hygiene and sanitation;
73
3. Environmental factors: Water Supply
The quality of the water source;
Adequate protection of the water source/point;
The quantity of water and continuity of supply;
The impact of wastewater or excreta disposal on the environment;
4. Institutional factors:
legal framework;
roles of different stakeholders and ability/willingness;
regulatory framework;
national strategy;
availability of local artisans;
existing institutional set-up;
potential involvement of the private sector;
support from government, NGOs, external support;
training and follow-up;
availability and capacity of training;
stimulation of private sector;
skills requirement;
transferring know-how;
monitoring.
5. Managerial factors:
local economy;
managerial capacity and need for training;
living patterns and population growth;
capacity of the organization;
living standards and gender balance;
acceptance of the organizing committee by the household income and
seasonal variations;
community;
users’ preferences;
gender balance in committee;
historical experience in collaborating with different perception of benefits
from improved water supply;
partners;
the needs felt by the community;
village organization and social cohesion;
availability of technical skills;
ownership.
74 6. Financial factors:
(Supportive Services) capital costs;
ability and willingness to pay;
budget allocations and subsidy policy;
level of recurrent costs;
financial participation of users;
tariff design and level of costs to be met by the local economy;
community costs of spare parts and their accessibility;
payment and cost-recovery system to be put in place;
financial management capacity (bookkeeping, etc.) of the community.
8.4 FUNCTIONS OF WATER SUPPLY IN HOSPITALS

1. Ensuring essential measures to protect health:
Provide safe drinking-water from a protected groundwater source (spring,
well or borehole), or from a treated supply, and keep it safe until it is drunk or
used.
Untreated water from unprotected sources can be made safer by simple means
such as boiling or filtering and disinfection.
Provide water for handwashing after going to the toilet and before handling
food, before and after performing health care. This may be done using simple
and economical equipment, such as a pitcher of water, a basin and soap, or
wood ash in some settings.
Provide basic sanitation facilities that enable patients, staff and carers to go to
the toilet without contaminating the health-care setting or resources such as
water supplies. This may entail measures as basic as providing simple pit
latrines with reasonable privacy.
Provide safe health-care waste management facilities to safely contain the
amount of infectious waste produced. This will require the presence of colour-
coded containers in all rooms where wastes are generated.
Provide cleaning facilities that enable staff to routinely clean surfaces and
fittings to ensure that the health-care environment is visibly clean and free
from dust and soil.
Ensure that eating utensils are washed immediately after use. The sooner
utensils are cleaned the easier they are to wash. Hot water and detergent, and
drying on a stand are required.
Reduce the population density of disease vectors. Proper waste disposal, food
hygiene, wastewater drainage, and a clean environment are key activities for
controlling the presence of vectors.
Provide safe movement of air into buildings to ensure that indoor air is
healthy and safe for breathing. This is particularly important if health care is
being provided for people with acute respiratory diseases.
Provide information about, and implement, hygiene promotion so that staff,
patients and carers are informed about essential behaviours for limiting
disease transmission in health-care settings and at home.
2. Ensuring water quality: Water for drinking, cooking, personal hygiene, medical 75
activities, cleaning and laundry has to be safe for the purpose intended and hence Water Supply
ensuring quality of water is a must:

A water safety plan aimed at assessing and managing water systems, and
ensuring effective operational monitoring, should be designed, developed and
implemented to prevent microbial contamination in water and its ongoing
safety.
Drinking-water meets national standards concerning chemical guidelines and
radiological parameters.
All drinking-water is treated with a residual disinfectant to ensure microbial
safety up to the point of consumption or use.
There are no tastes, odours or colours that would discourage consumption or
use of the drinking-water.
Water that is below drinking-water quality is used only for cleaning, laundry
and sanitation and is labelled as such at every outlet.
Water of appropriate quality is supplied for medical activities as well as for
vulnerable patients, and standards and indicators have been established.
a) Microbial quality: Microbial quality is of overriding importance for infection
control in health-care settings. The water should not present a risk to health
from pathogens and should be protected from contamination inside the health-
care setting itself. Drinking-water supplied to health-care settings should meet
national standards and follow guidelines for drinking-water quality. In
practice, this means that the water supply should be from a protected
groundwater source, such as a dug well, a borehole or a spring, or should be
treated if it is from a surface water source. Rainwater may be acceptable with
disinfection if the rainwater catchment surface, guttering and storage tank are
correctly operated, maintained and cleaned. Legionella spp. are common
waterborne organisms, and devices such as cooling towers, hot-water systems
and spas that use mains water have been associated with outbreaks of
infections.
b) Chemical constituents: Chemical constituents may be present in excess of
guideline levels in water supplies, and it may not be possible, in the short
term, to remove them or to find an alternative source of water. In such
circumstances an assessment should be made of the risks caused to patients
and staff, given the levels of contamination, the length of exposure and the
degree of susceptibility of individuals. It may be necessary to provide
alternative sources of drinking-water for people most at risk.
c) Disinfection: Disinfection with chlorine is the most widely accepted and
appropriate way of providing microbial safety in most low-cost settings.
Bleaching powder, liquid bleach, chlorine tablets and other sources of
chlorine may be used, depending on local availability. To ensure adequate
disinfection, a contact time of at least 30 minutes should be allowed between
the moment the chlorine is added to the water and the moment the water is
available for consumption or use.
Mains supply water may need supplementary chlorination to ensure adequate
disinfection and a sufficient level of residual chlorine up to the point of
consumption or use. Many mains water supplies do not achieve adequate
water safety at the point of delivery, due to problems at the water treatment
works and contamination in the distribution system.
Stored water may also need supplementary chlorination before use. Water
must not be contaminated in the health-care setting during storage,
76 distribution and handling. Effective disinfection requires that the water has a
(Supportive Services) low turbidity. Filtration with ceramic (e.g. candle filters), chlorination and
other technologies that can be used on a small scale.
d) Drinking-water quality: Drinking-water should be acceptable to patients and
staff, or they may not drink enough, or may drink water from other,
unprotected sources, which could be harmful to their health. Particular care is
needed to ensure that safe drinking-water is supplied to immuno compromised
patients, because of their high susceptibility to infection. Provision of boiled
water may be desirable.
e) Water for cleaning: Water used for laundry and for cleaning floors and other
surfaces need not be of drinkingwater quality, as long as it is used with a
disinfectant or a detergent.
f) Water for medical purposes: Water used for some medical activities may need
to be of higher quality. For example, water used for haemodialysis should
meet strict criteria concerning microbial contamination and chemical
contaminants, including chlorine and aluminium, which are commonly used
in drinking-water treatment.
3. Ensuring adequate water quantity: Sufficient water is available at all times for
drinking, food preparation, personal hygiene, medical activities, cleaning and
laundry has to be ensured. This ensures not the abundant supply of water but only
adequate or minimum supply of water wherever necessary. The following lists the
minimum water quantities required in the health-care setting:
Outpatients 5 litres/consultation
Inpatients 40–60 litres/patient/day
Operating theatre or maternity unit 100 litres/intervention
Dry or supplementary feeding centre 0.5–5 litres/consultation
Wet supplementary feeding centre 15 litres/consultation
Inpatient therapeutic feeding centre 30 litres/patient/day
Cholera treatment centre 60 litres/patient/day
Severe acute respiratory diseases isolation centre 100 litres/patient/day
Viral haemorrhagic fever isolation centre 300–400 litres/patient/day
The figures should be used for planning and designing water supply systems. The
actual quantities of water required will depend on a number of factors, such as
climate, availability and type of water use facilities (including type of toilets),
level of care and local water use practices.
4. Water facilities and access to water: Sufficient water-collection points and water-
use facilities are available in the health-care setting to allow convenient access to,
and use of, water for medical activities, drinking, personal hygiene, food
preparation, laundry and cleaning.
a) Drinking-water points: Drinking-water should be provided separately from
water provided for handwashing and other purposes, even if it is from the
same supply. Drinking-water may be provided from a piped water system or
via a covered container with a tap where there is no piped supply. Drinking-
water points should be clearly marked.
b) Handwashing: Basic hygiene measures by staff, patients and carers,
handwashing in particular, should not be compromised by lack of water.
Waterless, alcohol-based handrubs may be used for rapid, repeated
decontamination of clean hands. Handrub dispensers can be installed at
convenient points, and can also be carried by staff as they move between 77
patients. However, handrubs may not be affordable, and they do not replace Water Supply
soap and water for cleaning soiled hands.

c) Handwashing facilities: Water points should be sufficiently close to users to
encourage them to use water as often as required. Alternatively, a
handwashing basin, soap and a jug of clean water may be placed on a trolley
used for ward rounds, to encourage handwashing as often as needed between
patient contacts.
d) Showering facilities: Although less important than handwashing in terms of
reducing disease transmission, showering may be important for the recovery
of certain patients, and may be required by staff and carers in contact with
infectious patients.
If piped hot water is available, measures should be taken to avoid the proliferation
of bacteria in the water system. For this reason, piped water and water from
showers should ideally be maintained below 20°C or above 50°C. Separate
showers may be needed for staff and patients, and for both sexes, to ensure that all
groups have adequate privacy and safety.
5) Excreta disposal: Adequate, accessible and appropriate toilets are provided for
patients, staff and careers:
a) There are sufficient toilets available: one per 20 users for inpatient settings; at
least four toilets per outpatient setting (one for staff, and for patients: one for
females, one for males and one for children).
b) Toilets are appropriate for local technical and financial conditions.
c) Toilets are designed to respond to local cultural and social conditions and all
age and user groups.
d) Toilets are safe to use.
e) Toilets have convenient handwashing facilities close by.
f) Toilets are easily accessible (that is, no more than 30 metres from all users).
g) There is a cleaning and maintenance routine in operation that ensures that
clean and functioning toilets are available at all times.
6. Wastewater disposal: Wastewater is disposed of rapidly and safely:
a) Wastewater is removed rapidly and cleanly from the point where it is
produced.
b) Wastewater drainage from health-care settings is built and managed to avoid
contamination of the health-care setting or the broader environment.
c) Rainwater and surface run-off is safely disposed of and does not carry
contamination from the health-care setting to the outside surrounding
environment.
i. Wastewater drainage systems: Wastewater is produced from washbasins,
showers, sinks, etc. (grey water) and from flushing toilets (black water). It
should be removed in standard waste drainage systems to off-site sewer
or on-site disposal systems. All open wastewater drainage systems should
be covered, to avoid the risks of disease vector breeding and
contamination from direct exposure. Small quantities of infectious liquid
wastes (e.g. blood or body fluids) be poured into sinks or toilets. Most
pathogens are inactivated by a combination of time, dilution and the
presence of disinfectants in the wastewater. Toxic wastes (e.g. reagents
78 from a laboratory) should be treated as health-care waste. They should
(Supportive Services) not be poured into sinks or toilets that drain into the wastewater system.
ii. Prevention of environmental contamination: The most appropriate
wastewater disposal option is connecting the health-care setting to a
properly built and functioning sewer system, which is, in turn, connected
to an adequate treatment plant.If the sewer does not lead to a treatment
facility, an on-site retention system with treatment will be necessary
before wastewater is discharged. In other situations, on-site disposal is
needed. For grey water, soakaway pits or infiltration trenches should be
used. These should be equipped with grease traps, which should be
checked weekly and cleaned, if needed, to ensure the systems operate
correctly. Pits or trenches should not overflow into the health-care setting
grounds or surroundings and create insect or rodent breeding sites. Black
water should be disposed of in a septic tank, with the effluent discharged
into a soakaway pit or infiltration trench. Grey and black water may be
treated in the same septic tank and soakaway system, although this
requires a larger septic tank than one used for black water alone.
iii. Rainwater and surface run-off: Rainwater and surface run-off may be
drained and disposed of separately if the system in place for wastewater
cannot cope with additional water from sudden heavy rains or rainwater
and surface run-off. In that case, it must be managed in a way that does
not carry contamination from the health-care setting to the outside
surrounding. Correct, separate drainage of rainwater is particularly
important for settings such as cholera treatment centres where there is a
high prevalence of enteric pathogens that might be washed out of the
isolation area into the local environment.
Check Your Progress
1. Water Supply Management
………………………………………………………………………………
………………………………………………………………………………
2. Microbial Quality
………………………………………………………………………………
………………………………………………………………………………
3. Water Safety Plan
………………………………………………………………………………
………………………………………………………………………………
8.5 LET US SUM UP

The safe and adequate water facility in the hospitals plays a significant role such as for
purpose of cleaning and other sanitary activities. In this lesson we discussed the
factors and functions of water supply which is an important aspect in the hospitals.

Expand the following statement, "Water supply is the major service of healthcare
sector".
79
8.7 KEYWORDS Water Supply
Water Supply Management: Planning and monitoring water supply facilities in the
hospital.
Wastewater: Water produced from washbasins, showers, sinks, and from flushing
toilets.

1. What are the stages of Water Supply Management?
2. Explain the factors contributing to the quality of improved water supply services.
3. Enumerate the functions of water supply in hospitals.

1. Water Supply Management: It refers to planning and analyzing the
existing situation, technology choice, and thereby making the operations
and maintenance functions related to water supply and monitoring
ongoing facilities in the hospital.
2. Microbial Quality: It means that the water supply should be from a
protected groundwater source, such as a dug well, a borehole or a spring,
or should be treated if it is from a surface water source. Rainwater may be
acceptable with disinfection if the rainwater catchment surface, guttering
and storage tank are correctly operated, maintained and cleaned.
3. Water Safety Plan: It is aimed at assessing and managing water systems,
and ensuring effective operational monitoring, should be designed,
developed and implemented to prevent microbial contamination in water
and its ongoing safety.

Department of Protection of the Human Environment Water, Sanitation and Health 20
Avenue Appia, CH-1211 Geneva 27, Switzerland.
Essential environmental health standards in health care Edited by John Adams, Jamie
Bartram, Chartier WHO Library Cataloguing-in-Publication Data World Health
Organization.
1. Environmental health — standards. 2. Health-care facilities — standards.
3. Health-care facilities — organization and administration. 4. Health policy.
5. Sanitation — standards. Developing countries. I. Adams, John. II. Bartram, Jamie.
III. Chartier, © World Health Organization 2008.
84
LESSON
9
MEDICAL GAS PIPELINES
CONTENTS
9.1 Introduction
9.2 Significance of Medical Gas Pipeline Systems
9.3 Medical Gas Pipeline System Products
9.4 Installation Procedures
9.5 Operation and Maintenance
9.6 Safety Issues in MGPs
9.7 Regulatory Requirements for Medical Gas Pipelines
9.8 Risk and Operational Management
9.9 Staffing
9.10 Operational Management Document
9.11 Let us Sum up
9.13 Keywords

z Know the significance of medical gas pipeline systems
z Know the installation procedure and their operation and maintenance
z Study the risk and operational management
z Understand the operational management documents
9.1 INTRODUCTION
The Medical Gas Pipeline Systems (MGPS) for medical gases and vacuum is a critical
part of the medical installation and the service in a hospital or special care centre.
Medical gases, such as oxygen, nitrous oxide and air as well as vacuum are used
nearly everywhere in healthcare facilities. So much so that the number of terminal
units in a 1,000- bed hospital can run up to 4,000, fed by tens of kilometres of piping.
This complex and extensive system eventually leads to a doctor and patient who
expect, or rather depend upon, the right gas at the right pressure and flow rate and
expect it to be available 100% of the time. Thanks to a long history of reliability of
MGPS in hospitals, healthcare workers and patients have enjoyed peace of mind.
81
9.2 SIGNIFICANCE OF MEDICAL GAS PIPELINE Medical Gas Pipelines
SYSTEMS
The fact is most hospitals have never experienced a problem with regard to medical
gas pipelines. Consider what would happen if this facility and its reliability was no
longer guaranteed. The questions that need to be answered include issues of what if
the MGPS failed, what if the gas to all terminal units stopped and what if the gas was
the wrong product. Just because it is yet to happen at the hospitals or health care
centers, do not be lulled into a false sense of security – it has actually happened at
others. The reliability of the MGPS is dependent on the correct application of
standards and procedures. To ensure the continuity of supply to patients, CEN and
ISO have defined the principle of ‘single fault condition’ – a condition that states that
the system must continue to provide uninterrupted supply given any single equipment
failure or abnormal circumstance.
9.3 MEDICAL GAS PIPELINE SYSTEM PRODUCTS

Medical Air Compressors
x Oil Free/Oil Less Air Compressors
x Reciprocating Skid
x Mount Compressor
x Reciprocating Tank
x Mount Compressor
x Scroll Medical Multiplex Packages
Medical Vacuum Systems

x Oil Lubricated Rotary Vane Tank Mount
x Oil Lubricated Rotary Vane Stack Mount
x Lubricated Rotary Van Vacuum Pumps
x Oil Less Vacuum Tank Mount

x Oil Less Vacuum Skid Mount
Air Treatment Centers (ATC)

z Medical Air Dryers – Desiccant
z Medical Air Dryer – Refrigerated
z Carbon Monoxide Monitor Aco-600
z Dew Point Monitor Aco-500
z After Coolers Aco-700
Medical Gas Pipeline Products
x Medical Gas Outlets
x Medical Gas Alarm Systems
x Medical Gas Manifolds
x Zone Valves
x Gas Control Panels
x Medical Gas Pipeline Accessories
x Medical Gas Retro Fit
82
Hospital Operation-II 9.4 INSTALLATION PROCEDURES
1. Installation of Piping: Piping must be free of all contamination and especially
any oil or other oxidizable material. Confirm this by visually inspecting the inside
of all pipes before they are hung. Look for plastic caps that may have been pushed
inside the pipe Ensure that pipes are tightly capped at all times and that valves
roughed in valve boxes and roughed in alarm panels are also kept capped. Piping
must be labelled on a daily basis. There should be labels at least once in each
room and each storey traversed by the pipeline. Area alarm sensing tube
connections and pressure switches should always be connected to the top of the
pipeline. Moisture in the pipeline will damage these components.
2. Cleaning and Degreasing: All tubing, valves and fittings shall be thoroughly
cleaned of grease, oil or other combustible material by washing in a hot solution
of Trisodium Phosphate .The equipment must then be rinsed with hot water and
allowed to dry in a well aired and dust free area. Hot Nitrogen is a useful drying
agent. All cutting tools that come in contact with the pipe must also be degreased.
These tools should not be used on anything other than Medical Gas piping unless
they are re-cleaned each time. After degreasing, piping must be tightly capped and
fittings and other equipment sealed in plastic bags until they are about to be used.
3. Nitrogen Purge: During the brazing of pipe connections the interior of the pipe
shall be purged continuously with Nitrogen. Use a flow meter with the regulator.
Allow the purge to run for sufficient time to expel all the oxygen before brazing
the first joint. Confirm that these are adequate by performing some sample joints
on a work-bench with varying flow rates. Cut open the sample joints and examine
them. There should be no oxidation on the inside of the joint. A flow meter can
save a lot of money by preventing unnecessarily high flow rates of Nitrogen. The
Nitrogen purge must be directed past the point of brazing. Do not turn off the
nitrogen purge until joints have cooled. A small hole in a plastic cap on the end of
the line being purged will prevent a pressure build up inside the line and allows
you to check for a flow with your hand. For maximum efficiency prepare as many
joints as possible in a progressive manner so that a minimum number of purges
have to be set up. It is preferable to work on only one system at a time.
4. Silver Brazing: The Standard requires that for copper-to-copper joints on pressure
gas, a flux less silver brazing alloy be used, such as "Sil-fos" or "Silflo". Improper
fluxing will contribute particulate - therefore avoid excessive use of flux. Wash
the outside of the tube and fittings with hot water after brazing to remove residual
flux. Too much heat, or an insufficient purge, or a combination of the two will
result in the formation of copper oxide particulate inside the pipe. All synthetic
and rubber components, which could be damaged by the heat of silver brazing,
should be wrapped in a wet rag or removed. Ball valve interiors should be
temporarily replaced with a short pipe stub of appropriate length to allow the
nitrogen purge to flow through. When brazing outlet stubs, the nitrogen purge
should be connected to each outlet individually, and allowed to flow back into the
pipeline. This helps prevent overheating outlet internal components.
5. After the lines are installed but before the wall outlets are installed, blow the pipes
free of any particulate that may be in them. The testing agency may be drawing
particulate filter samples as the work proceeds to ensure that proper purge and
brazing techniques are being used. In addition, random joints may be removed and
cut out for internal inspection. When new and existing systems are to be tied
together, it is advisable to have particulate filter tests performed on each section
before the tie-in. If headwalls or ceiling columns are being installed, it is
advisable to pipe up to the rough-in plate, and complete pressure testing up to
these points.
6. Pressure Testing: Some specifications require that all areas be pressure tested 8
upon completion. Where pre-piped headwall units are to be installed, two pressure Medical Gas Pipelines
tests will be required - one before the dry walling is started and the other after the
headwall unit is installed. The first test is required so that any leaks can be found
before the dry walling is started. The second test is required because the headwall
unit cannot be installed until after the drywall is complete. After the first test the
lines should remain under pressure with a gauge attached and the pressure in the
system shall be logged on a daily basis. Eventually each area must be leak tested.
A final 24-hour pressure test must be applied with all components connected,
including alarm sensors and finish outlets.
Pressurization of the lines after testing provides a twofold protection: one is that
contamination from the ambient air is kept out of the system and the second is that
the installer is warned immediately if any other trade, inadvertently or otherwise,
punctures the system. Do not pressurize components that are not rated for the
various test pressures such as vacuum gauges and switches, alarm panels, etc.
Manifolds and pump packages are not normally included in 24-hour pressure
tests.
7. Locating Leaks: If, after soap testing all the joints, a leak cannot be found, try to
eliminate the most likely locations such as threaded joints, gauges, pressure
switches, closed valves, etc. It is better to test against capped open valves than
closed valves. Dividing a leaking system into smaller sections and testing each
individually can save a great deal of time. Always keep pressure on the system
until the time for system tie-ins and certification. Common problems occur near
the end of projects where screws, particularly drywall type, are driven into the
copper tubing. This can create minute leaks, which are very hard to locate.
8. Cross-connection Testing: This test is performed by the medical gas installer and
later by the testing agency. To determine that no cross-connection exists between
piping systems used for different medical gases, the systems shall be tested as
follows:
a) The pressure in piping systems other than the system under investigation shall
be reduced to atmospheric.
b) Test the system with Nitrogen at a pressure of 50.
c) Test each individual station outlet of every piping system to determine that
the test gas is being dispensed only from the outlet of the system under
investigation.
d) After completing the foregoing tests on each system, the test gas shall be
disconnected and the system bled down to atmospheric pressure. The proper
gas shall immediately be connected to each system. Following this, each
system shall be purged a sufficient number of times to remove the test gas.
9.5 OPERATION AND MAINTENANCE

In the real world, normal operation includes maintenance of an MGPS, with three
sources of supply, for instance two bulk liquid oxygen tanks, plus one cylinder back-
up, three cylinder banks, two air compressors with cylinder back-up or three vacuum
pumps. Furthermore, any more complex equipment must have automated redundant
back-ups that all meet the latest standards and specifications.
Having defined this key principle, all other requirements for ensuring continuous
supply while equipment is out of service or being maintained by parallel pressure
regulators, by-passes and emergency and maintenance supply connections. This does
not necessarily mean increased costs of installation for healthcare facilities. A
carefully designed air compressor system with three smaller air compressors, or a
8 vacuum system with six to 10 small vacuum pumps can be more cost-effective in
(Supportive Services) electricity and maintenance costs.
Even if this approach were more expensive in terms of initial capital outlay it does not
take into account the hidden cost of rework, failure, major leaks, or poor maintenance.
Systems with suitable redundancy built in at the start are simpler to operate and
maintain.
9.6 SAFETY ISSUES IN MGPS

Since medical gas pipelines deliver medicinal gases for patient use, it is essential that
adverse events arising in the delivery of these gases are reported and acted upon
within the regulatory system. This control will only be enforced when MGPS are
regulated by the same competent authorities and directives that control other Medical
devices such as anesthetic and respiratory equipment.
A pure quality system or guideline cannot guarantee the user and supplier that this
obligation meets materio-vigilance requirements. Other reasons why standard
markings of MGPS means a safe and reliable system for patients and operators needs
to be considered are:
z the guidelines and regulations is the best formal process, ensuring that the MGPS
is installed to the standard;
z incidents most often occur during and after changes: the management of change is
part of the guideline requirements;
z MGPS systems are installed for many years – long term compliance to ISO is best
achieved and audited against the directive;
z many specific components of current MGPS are already medical devices, e.g.,
terminal units, pressure/flow regulators – only the copper tubing and a few other
components are not yet, but the directive includes these also;
z by applying risk assessment during the design and installation phases of a MGPS,
components that are not necessarily medical gas pipeline specific, such as medical
supply units are more effectively covered;
z the quality of installation can be measured against standards, instead of a set of
local specifications; and
z the commissioning, validation and verification procedures are standardized and
are therefore more cost effective and easier to audit.
9.7 REGULATORY REQUIREMENTS FOR MEDICAL GAS

PIPELINES
z three sources of supply are required for the continuity of supply;
z one or more reserve source(s) can be installed anywhere on the pipeline
distribution network, enhancing safety for the patient;
z both supplier, installer and user are required to apply risk management principles
for capacity and location of the sources of supply and the number of full cylinders
held in storage;
z for double-stage systems (i.e. where pressure is regulated in two steps) duplex
press regulators are required for all applications;
z the typical drawings are to be simplified to allow a maximum flexibility for
manufacturers in meeting each customer’s needs;
z the manufacturer of the complete system or the manufacturers of each component 8
of the medical gas pipeline system (i.e. supply systems, monitoring and alarm Medical Gas Pipelines
system and pipeline distribution system) shall provide the healthcare facility with
instructions for use;
z the manufacturer(s) of each component of the medical gas pipeline shall provide
operational management information to the healthcare facility to enable it to draft
its Operational Management Document;
z the system manufacturer(s) shall provide instructions to the healthcare facility for
recommended maintenance tasks and their frequency and a list of recommended
spare parts.
9.8 RISK AND OPERATIONAL MANAGEMENT

Risk Management: Each healthcare facility has its own specific layout for its MGPS.
Moreover, the capacity of the sources of supply should be calculated for the specific
needs of the healthcare facility – the different requirements for medical gases and
vacuum require a local study to ensure continuation of supply of the correct product.
The procedure for managing risk is to eliminate it as far as possible by design, in other
words, to make the system inherently safe. If this is not entirely possible, then the next
step is to define procedures and training to control the remaining risks to an
acceptable level. By assigning risk levels, the frequency of occurrence and the
severity of the risk, one can rank the risks and deal with them in the appropriate
manner. As a supplier Air Products is frequently called upon to assess and manage
these risks to the highest safety level practically possible.
The typical risk assessment checklist provided should be used by both the
manufacturer of the MGPS and the healthcare facility during design, installation,
commissioning and operation and on-going operation and monitoring of the MGPS.
Operational Management: When the MGPS is in use, the system needs to be
continuously maintained and repaired. Very often in healthcare facilities the MGPS
system is continuously modified, extended or simply upgraded for the growing
number of patients or new applications of medical gases and vacuum. These types of
changes on such a large system as the MGPS, which runs throughout the healthcare
facility’s buildings, requiring input from many different people, can only be safely
managed when all aspects of operational management are described in detail in an
Operational Management Document. Furthermore they should be led and supported
by the senior management of the facility.
The primary objective of this is to assign responsibilities to ensure the provision of
safe and reliable MGPS and its efficient operation and use and maintain patient safety
through continuity of supply. This objective will only be achieved if the medical and
nursing users and estates staff participate in the introduction of an operational policy
designed to minimizes the hazards likely to arise from misuse of the system. A plan
for upgrading existing systems should be prepared on the basis of risk management,
ensuring that patient safety is maintained throughout the process. Managers will need
to liaise with medical colleagues and take account of other published guidance in
order to assess the system for technical shortcomings.
9.9 STAFFING
The key personnel with specific responsibilities for the MGPS within the operational
policy are:
z executive manager;
z facilities engineering manager;
z authorised person;
z competent person;
(Supportive Services) z quality controller;
z designated medical officer;
z designated nursing officer; and
z designated person.
Check Your Progress
1. List down some Medical Gas Pipelines System Products?
……………………………………………………………………………….
……………………………………………………………………………….
2. List down the installation procedures of Medical Gas Pipelines?
……………………………………………………………………………….
……………………………………………………………………………….
9.10 OPERATIONAL MANAGEMENT DOCUMENT

The operational management requirements for operating the MGPS should be detailed
in an operational management document. It should include the following documented
procedures for:
z control of documents and records;
z training and communication;
z emergency;
z change of management;
z permit-to-work;
z preventative maintenance;
z repair;
z sources of supply management;
z cylinder storage and handling;
z medical equipment purchase; and
z managing contractors.
The document should state the procedures to be followed and the personnel who need
to be consulted before a new item of medical equipment is connected to the MGPS.
Special attention should be paid to the change of supply system or the introduction of
an oxygen concentrator system for supplying oxygen to the MGPS.
9.11 LET US SUM UP

The pipelines are the important and an essentials instruments in the hospitals, they
support various functions in the hospitals. In this lesson we discussed on the
significance of medical gas pipeline systems, its products, their installation procedures
operation and maintenance. We understood the safety issues, regulatory requirements
for medical gas pipelines and risk and operational management.

What are the factors to be considered in designing a Medical Gas Pipeline System in a
hospital?

9.13 KEYWORDS Medical Gas Pipelines
Medical Gas Pipeline System: A critical part of the medical installation and the
service in a hospital or special care center.
Single Fault Condition: A condition that the system must continue to provide
uninterrupted supply.

1. Discuss the significance of Medical Gas Pipeline Systems and its products.
2. Write the steps involved in installation procedures.
3. What are the safety issues in MGPS?
4. What are the regulatory requirements for Medical Gas Pipelines?
5. Briefly explain the risk and operational management.

1. Medical Gas Pipeline System Products:
Medical Air Compressors
Medical Vacuum Systems
Air Treatment Centers (ATC)
Medical Gas Pipeline Products
2. Installation Procedures:
Installation of Piping
Cleaning and Degreasing
Nitrogen Purge
Silver Brazing
Pressure Testing
Locating Leaks
Cross-connection Testing

Medical gas systems installer orientation notes-NFPA 99 page 1.
Orientation notes on recommended medical gas piping installation procedures for
installers - NFPA 99 2002 Edition, Health Care Facilities.
Medical Gas Pipeline Systems – Part 3: Pipelines for compressed medical gases and
vacuum 1998.
Medical Gas Pipeline Systems – Part 1: Pipelines for compressed medical gases and
vacuum. ISO 7396-1:2002.
92
LESSON
10
PLUMBING
CONTENTS
10.1 Design of Plumbing Systems
10.2 Principles of Effective Plumbing Systems
10.3 Standards for Materials used in Plumbing Systems
10.4 Codes of Practice for Plumbing
10.6 Risk Abatement
10.7 Risk Acceptance and Risk Transfer
10.8 Let us Sum up
10.10 Keywords

z Know the design of plumbing system
z Know the principles of effective plumbing system
z Understand the standards of materials used in the plumbing system
z Study the codes of practice for plumbing
z Get aware of the issues and challenges
10.1 DESIGN OF PLUMBING SYSTEMS

A plumbing system is a long-term investment and should be so designed that it does
not become outdated and need replacement while its major parts are still serviceable.
This requires careful estimation of current and future demand so that the correct
capacity can be specified. The capacity and dimensions of component parts in a
plumbing installation should be adequate to meet both immediate needs and
anticipated future use. However, perfection in design is frequently compromised by
cost, especially in poor and developing communities.
Good design of plumbing systems is an important step in ensuring that the
installations are efficient, safe and affordable. It should take into account the special
needs and limitations of developing countries and should also ensure that the
installations are appropriate for the different situations they serve. An understanding
of the technical requirements and regulatory restrictions is vital for the provision of
good plumbing services. Plumbing
This lesson includes design recommendations for plumbing installations. It deals with
special issues related to special purposes, hot water and other dual supply systems and
storm water drainage. It includes guidelines on capacities of plumbing systems,
plumbing materials and products, and the use of protective devices to prevent back-
siphonage and backflow.
1. Drinking-water supply pipes and specifications: In every case the actual values
will depend on local conditions, but no water service pipe should be of less than
20 millimetres (0.75 inch) diameter and all water service pipes should be laid so
as to avoid high points where air may become trapped.
The depth at which the service pipe should be laid will depend on climatic and
other circumstances. In areas subject to frost, the depth specified should be
sufficient to avoid damage from freezing, and a depth of 1 metre (3 feet) or even
more may be required. However, a maximum depth should be specified to
facilitate future maintenance and installation procedures and to enable the pipe to
be tracked if required. Distance requirements from other services such as electric,
telecommunications and gas pipes should be specified. Under no circumstances
should a service pipe be permitted to pass through a sewer, access chamber or
inspection chamber.
2. Drainpipes: Each separately occupied building should have its own drain
connection terminating at the public sewer. Such drains should be of adequate
size, and laid at a constant gradient that will permit their contents to discharge at a
self-cleansing velocity. Drains carrying human wastes need to have a diameter of
at least 100 millimetres (4 inches) for a single dwelling and at least 150
millimetres (6 inches) if more than one property is served. Where a number of
plumbing systems have a single connection to the sewer, the plumbing authority
may require a combined drainage agreement or other documentation to ensure that
disputes do not arise over the apportionment of maintenance responsibility.
Although internal and external drains are often referred to as “horizontal”, they
should never be laid level, but at a constant gradient that will ensure satisfactory
drainage. It may be necessary to use a pipe with a larger diameter if the relative
levels of the building and the sewer are such that the appropriate gradient is
inadequate to give a self-cleansing velocity for a particular size of pipe.
10.2 PRINCIPLES OF EFFECTIVE PLUMBING SYSTEMS

The system should be operating within a context of standards and codes, determined
and overseen by qualified public authorities, that specify the requirements for its
design, composition and management, and the training and practices of the plumbers
and operators who build and maintain it.
The three chief aims of a good plumbing system are to supply safe drinking-water in
adequate quantities, to remove liquid wastes efficiently, and to minimize risk of
failure through vigilance and quality assurance.
a) Water supply goals: The goal for every community or group of homes should be
for a piped central source of good-quality water for all domestic uses. In addition,
with a piped drinking-water supply, proper sanitary transport and waste treatment
and disposal facilities are important to ensure a safe domestic and community
environment. There are costs both in the initial construction and maintenance of
these facilities, and sustainability requires provisions for finance, operation and
maintenance.
9 The local drinking-water supply should be adequate in terms of quantity,
(Supportive Services) safety, continuity and reliability.
Water supplied for human consumption should be safe at all times.
Every building should have an internal drinking-water piped system.
Water should be conserved by minimizing leakage and wastage.
Water should be supplied from a suitable number of accessible and hygienic
fixtures.
Building contents should be protected from the effects of malfunctioning of
the plumbing system.
Adequate lighting and ventilation should be provided for toilet and washing
fixtures.
Hot water systems should be carefully designed to avoid health hazards.
b) Liquid waste disposal goals: Every fixture, including a wall-mounted tap, should
have drainage facilities to prevent the accumulation of wastewater and spillage,
even though this may be uncontaminated. Wastes should be removed rapidly from
each fixture by a system of drainpipes that will prevent any further human contact.
Liquid wastes should be disposed of promptly and hygienically
Drainage systems should be of adequate size and easily cleaned
Drainage systems should be equipped with liquid seal traps
All drains should be adequately ventilated
Deleterious substances should be excluded from sewers
Backflow of sewage should be prevented.
c) Plumbing goals:
Plumbing materials and workmanship should conform to accepted quality
standards
Plumbing installations should be tested and disinfected before being put into
service
Adequate training should be provided for plumbing professionals and the
public should be made aware of the dangers of poor plumbing
Plumbing systems should be properly maintained.
10.3 STANDARDS FOR MATERIALS USED IN PLUMBING

SYSTEMS
Standards
Standards are sets of rules that outline specification of dimensions, design of
operation, materials and performance, or describe quality of materials, products or
systems. These standards should cover the performance expectations of the product
for particular applications. The intent of standards is to provide at least minimum
quality, safety or performance specifications so as to ensure relatively uniform
products and performance. They reduce the risk of error by installers, and also provide
assurance to the plumbing system owners. Standards also provide direction to
manufacturers in respect to the expectations of the products that they produce.
The existence of a standard does not always ensure that all available products meet a
specific standard. In order to be confident of uniformity in a product there must be
checks and balances. This is accomplished by assessment conformity. Simply stated, 9
it means that a product, material or device has been tested and verified to meet the Plumbing
specification that has been developed.
Products and Materials used in Plumbing

1. Standards for plumbing products and materials: The durability of a plumbing
system is dependent on the quality of its component parts and the assembly skills
of those who install it. No plumbing system, however well designed, can be
expected to operate safely or hygienically if the products or materials used are
unsatisfactory. The inverse is also true if the best-quality products or materials are
used but are installed incorrectly, the system will be a failure.
Most industrialized countries have national standards or codes that set out the
minimum requirements for the material specifications, design and use of specific
plumbing products. However, plumbing codes of practice vary considerably
according to the extent to which they specify the detailed standards for plumbing
products and other matters. Some countries take the view that the level of detail
should be minimized, whereas others are very prescriptive. Countries that are
members of the International Organization for Standardization (ISO) may choose
to adopt the ISO framework as a minimum standard set for plumbing products and
materials.
The process of certification of quality of plumbing products may necessitate the
setting up of testing establishments where products can be assessed. In many
cases it will be more economical to simply adopt an existing qualified standards
and certification programme that already has international acceptance. This will
also avoid unnecessary proliferation of standards. Product certifiers and their
testing facilities must be of the highest standard and subject to external auditing.
2. Selecting suitable products: In judging a product or material, the regulating
authority must consider factors such as the following:
Is the product or material under consideration suitable for the application or
purpose?
Will it be harmful to the health of the community in its normal use?
Is there a risk of these materials being released into the environment in the
first instance or after the working life of the product or material has expired?
All pipes, valves, taps and other fittings used for the supply of drinking-water or
the removal of wastewater must not contain harmful substances above the
specified amount that could leach into the water. Lead, cadmium and arsenic are
examples of many possible contaminants that could be present. The pipes, valves,
taps and other fittings must be capable of conveying water at a nominated
pressure within a prescribed environment, and must be of sufficient strength to
contain anticipated internal pressures. They must also be able to withstand
external pressures if they are to be buried. The impact of environmental factors
such as heat, cold, expansion, contraction, corrosion, pH and bacteria levels also
need to be considered.
3. Metallic and non-metallic materials used in pipework: There are two families of
materials available for water pipework systems: metallic and non-metallic
materials. Of these the most commonly used materials for drinking-water supply
piping are galvanized steel or iron, copper, polybutylene, unplasticized
polyvinylchloride (PVC), chlorinated polyvinylchloride (CPVC) and polyethylene
(PE). Metal alloys, which far exceed the performance specifications of their
respective parent materials, are also widely used. New materials and construction
technologies are continually being developed for the building industry and the
plumbing industry.
9 a) Galvanized steel or iron: Galvanized steel or iron was the traditional piping
(Supportive Services) material in the plumbing industry for the conveyance of water and
wastewater. The term “galvanizing” once referred to hot dipped galvanizing,
in other words total immersion in molten zinc after pretreatment cleaning.
This technology afforded a reasonable level of internal and external protection
to the metal pipe. It is still being used extensively in the fire protection
industry, but overall there are increasing limitations on how and where
galvanized piping may be used. Internal and external corrosion is a particular
problem where galvanized steel or iron piping is connected to dissimilar
materials.
b) Copper tubing: Copper tubing is extremely flexible in the hands of a
competent installer and smaller in overall diameter. Copper tubing, due to its
thinner wall section, is relatively light to handle and is available in coil form
or straight lengths as required. When assembled and installed correctly it can
blend into building structures without difficulty.
Copper tube or pipe is also particularly useful for hot water supply systems.
However, heat loss can become an issue if adequate insulation is not
provided. System designers must be aware that water flows through copper
tube piping systems must not exceed 3 metres per second. When this occurs
there is a high risk that the internal bore of the piping system will be eroded
by high flow and velocity scouring. Due to its electrical conductivity there is a
need for care to ensure that grounding connections are separated from piping
systems and any electrical wiring.
c) Polybutylene: Polybutylene in non-metallic piping systems is becoming
accepted as a suitable material for the conveyance of drinking-water in
domestic dwellings in some industrialized countries. It is a light, flexible
material that is easy to handle and install. It can be used in domestic dwellings
for both hot and cold water supplies. Caution must be exercised as it can
suffer degradation if exposed to excessive pressure and temperature, and
exposure to ultraviolet light (sunlight) is also detrimental to the material.
d) Chlorinated polyvinylchloride (CPVC): CPVC is widely used in water and
sanitary systems for hot and cold water distribution. It is a thermoplastic
produced by polymerization of vinyl chloride, with additional chlorination.
CPVC piping is manufactured by extrusion methods in sizes of diameter
0.25 inch to 12 inch. It offers much better resistance to corrosion and has a
high tolerance to acids. It is fire resistant, though toxic fumes are emitted
when it is burned. CPVC is lightweight, non-toxic and odourless, and reduces
growth of fungi, algae and bacteria.
e) Unplasticized polyvinylchloride (PVC): PVC, when used with a solvent
cement jointing system, is comparable in bulk to galvanized steel or iron for
drinking-water piping, but much lighter. It does not suffer the same corrosion
problems internally or externally as does galvanized steel. However, it is
susceptible to physical damage if exposed above ground and it becomes brittle
when exposed to ultraviolet light. The pipe is light to handle, but it is too
bulky for aesthetically acceptable internal use in domestic buildings. It is used
extensively around the world for drainage (waste or soil and storm water)
applications.
f) Polyethylene (PE): PE pipes and fittings of numerous types and designs have
been available for over forty years. The market requirements today have been
refined to three general groupings, as follows:
High-density PE: It is available in a post-manufactured stress-relieved
state or as extruded product with no treatment. It is used mainly for
drainage applications where it can withstand higher temperature 9
discharges than PVC. Plumbing
Medium-density PE: It is more flexible, slightly thinner wall thickness

and is capable of withstanding higher internal pressure. It is the preferred
material for long-distance drinking-water piping.
Low-density PE: It is suitable for the irrigation industry, where operating
pressures are very low and a high degree of flexibility and low cost is
required.
4. Design of plumbing fixtures: Both the component materials and the design of
plumbing fixtures (baths, washbasins, sinks, tubs, toilet pans, etc.) should be
subject to standards and certification to ensure integrity and safety. Fixtures
should be free of sharp projections and sharp corners that may cause injury. In
order to prevent drainage sewer gases from entering the area where the fixture is
installed, a fixture trap should be incorporated into the fitting, or provision should
be made for fitting one at a later date. To protect the drinking-water supply, all
plumbing fixtures should be designed so as to ensure that incoming water is
delivered through an air gap. Tapware should be appropriately matched to the
fixture that it is intended to serve. When installed, all taps and water delivery
outlet fittings should have an adequate clearance between the water outlet and the
spill level or water overflow level of the fixture being served.
5. Sanitary fixtures: Sanitary fixtures should be durable, smooth and impermeable
to water. There should be no hidden surface that can become fouled or polluted.
Both internal and exposed outside surfaces should be accessible for cleaning. The
most common and most economical material for domestic fixtures such as toilet
bowls, urinals, and washbasins is vitreous china. For more durable day-to-day use
in kitchen sinks and laundry tubs, stainless steel is recommended, but enamelled
pressed steel and suitable plastic materials may be acceptable.
Plastics are commonly used for bathtubs, shower trays, laundry tubs, cisterns,
washbasins and toilets and are often reinforced with fibre glass for extra strength
and durability. Plastic materials, although generally durable in themselves, are
readily prone to surface damage such as scratches and cuts. Stainless steel is a
preferred material for plumbing fixtures where there is a risk of damage from
users, such as in institutions and public amenities.
10.4 CODES OF PRACTICE FOR PLUMBING

A code of practice is intended to ensure the quality and functionality of plumbing
systems and to protect the health of the occupants of the premises where a plumbing
system is to be installed, as well as the health of the public in general. National codes
of practice are often designed to cover all the states, territories or provinces in that
country, and their content applies to all plumbing proposals. Codes of practice attempt
to minimize risk by specifying technical standards of design, materials, workmanship
and maintenance for plumbing systems.
The primary aims of a plumbing code of practice are to ensure the following:
z that planners, administrators and plumbers develop the required competency so
these codes are respected and applied;
z that standards are set to ensure that plumbing assemblies, materials and
technologies are safe and effective;
z that plumbing installations meet these standards;
z that plumbing installations are maintained to ensure continuous safety and
effectiveness.
9 The responsibility for overseeing the implementation of the code of practice is
(Supportive Services) awarded to a designated authority such as a National or State Government department
or a local government organization. The designated authority must have the requisite
competence, and the power and responsibility to enforce compliance within its area of
jurisdiction.

Risk Assessment and Risk Management
The supply of safe water and the removal of human waste are vital for health and
well-being. The main aim of plumbing systems is to collect, transport and distribute
water to individuals in a community, and to remove liquid waste. Unfortunately, all of
these beneficial processes incur risks. These risks include contamination of water
sources with bacteria, accidental cross-connection of drinking-water supply and waste
removal systems, and chemical contamination from corrosion of pipes and other
fittings. Thus, the second aim of plumbing systems must therefore be to manage risk.
Risk management uses a variety of different strategies. First of all, risks must be
recognized, analysed and evaluated. Some risks cannot by eliminated and the resultant
financial risk must be either accepted by the plumber or transferred by means of
insurance.
1. Risk Recognition: Risk recognition is based on a comprehensive understanding of
all potential hazards that may arise in establishing and maintaining a plumbing
system. For example, the Romans recognized the undesirability of contamination
of water from soil and human and animal waste and they built aqueduct systems
to deliver clean upland water to their cities, and sometimes used lead pipes. The
Latin word for lead (plumbum) gave rise to the common name for the plumbing
profession. It has taken almost two thousand years to recognize the risks
associated with lead pipes and corrosive water, and lead use was discontinued in
drinking-water systems relatively recently. The history of lead use is an important
reminder that new technologies will often bring new and unexpected risks.
2. Risk Evaluation and Analysis: Once a risk has been identified, the nature of the
risk must be analysed and its relative importance needs to be evaluated. The
analysis of the risk should reveal what causes the risk; the evaluation of the risk in
its context will enable a judgment to be made about what action to take. In some
cases, a risk might be identified but assessed to be very low in importance and
costly to eliminate. In this case, the evaluation might lead a community to accept
the risk and simply monitor the problem. On the other hand, the evaluation of
another risk might demand urgent action to protect the community.
10.6 RISK ABATEMENT

Once a risk has been recognized and evaluated as being important, steps must be taken
to minimize the risk. Risk abatement is the main strategy for managing risk in the
domain of plumbing. Plumbing risks can be prevented and minimized by education
and training and by the adoption of quality assurance systems such as codes of best
practice. Many countries enforce these codes of best practice by establishing laws and
regulations that demand certain standards of practice. Risk abatement in plumbing
requires both the community and individuals to make a major continuing investment
in time and money to prevent risks, and to minimize risk once discovered.
10.7 RISK ACCEPTANCE AND RISK TRANSFER

Because it is impossible to identify and eliminate every possible risk, plumbers must
face the possibility that even with good standards of practice there will be occasions
when some problem with a plumbing installation will occur. In some of these
situations people may be made ill or injured and the plumber may be held responsible. 9
There are three possible ways to deal with these kinds of circumstances: Plumbing
z The first and normally the best ethical approach is to accept responsibility and
rectify the problem.
z The second is risk acceptance – the plumber is confident that the risk is very low
and makes an informed judgment not to correct it. In this case the impact of being
wrong would be financially catastrophic because of legal liability.
z In the third option, then, the plumber can transfer the financial risk to an insurer
by paying an annual fee. Although this practice is possible in developed countries
it might be less feasible in many developing countries.
Regulation of plumbing technology and practice is intended to minimize public as
well as private health risks. The main instrument of regulation is the development and
implementation of good practice guidelines, commonly called a code of practice.
There is no doubt that the implementation of a well-designed plumbing code of
practice will assist those who design plumbing systems and the plumbers themselves,
and help to protect the public.
Check Your Progress
Explain the following:
1. Plumbing system
……………………………………………………………………………….
……………………………………………………………………………….
2. Standards
……………………………………………………………………………….
……………………………………………………………………………….
3. Risk evaluation and analysis
……………………………………………………………………………….
……………………………………………………………………………….
10.8 LET US SUM UP

Plumbing is significant aspect in the field of health care as various activities are dealt
with the use of pipes. Thus the plumbing must be done with utmost care for the
effective usage. This lesson provides us with certain principles and the standards for
effective plumbing system.

Inspect the plumbing services in different health sectors and analyse the problems of
improper plumbing.
10.10 KEYWORDS
Standards: Sets of rules.
Galvanizing: Total immersion in molten zinc after pretreatment cleaning.
Copper tube: Pipe useful for hot water supply systems.

Hospital Operation-II 10.11 QUESTIONS FOR DISCUSSION
1. Give the design of plumbing systems.
2. What are the principles of effective plumbing systems?
3. Explain the standards for materials used in plumbing systems.
4. What are the codes of practice for plumbing?

1. A plumbing system is a long-term investment and should be so designed
that it does not become outdated and need replacement while its major
parts are still serviceable. This requires careful estimation of current and
future demand so that the correct capacity can be specified.
2. Standards are sets of rules that outline specification of dimensions, design
of operation, materials and performance, or describe quality of materials,
products or systems.
3. The analysis of the risk should reveal what causes the risk; the evaluation
of the risk in its context will enable a judgment to be made about what
action to take.

Department of Protection of the Human Environment Water, Sanitation and Health 20
Avenue Appia, CH-1211 Geneva 27, Switzerland.
Essential environmental health standards in health care Edited by John Adams, Jamie
Bartram, Chartier WHO Library Cataloguing-in-Publication Data World Health
Organization.
(1) Environmental health — standards. (2) Health-care facilities — standards.
(3) Health-care facilities — organization and administration. (4) Health policy.
(5) Sanitation — standards. Developing countries. I. Adams, John. II. Bartram, Jamie.
III. Chartier, © World Health Organization 2008.
101
LESSON Sanitation
11
SANITATION
CONTENTS
11.1 Introduction
11.2 Factors
11.3 Human Waste and Health
11.4 Disposal of Wastewater (Sullage)
11.5 Refuse Collection and Transport
11.6 Medical Wastes
11.7 Let us Sum up
11.9 Keywords

z Know the meaning and the factors affecting sanitation
z Make a comparative study on different waste
z Know the disposal methods of various waste
11.1 INTRODUCTION
Sanitation includes solid waste disposal, including medical wastes, wastewater
disposal, wastewater reuse, human excreta disposal, and drainage of surface (rain)
water.
Safe disposal of waste is crucial for preventing the spread of infectious diseases.
Communities and hospital facilities planners need to realize that safe human excreta
disposal brings about huge health benefits. The control and management of wastes are
an essential part of operation and maintenance. In rural areas, the users themselves are
largely involved in preventive maintenance activities for wastewater and solid waste
disposal. Awareness campaigns, involving the community in sanitation problems, can
help to change behaviour and improve the operation and maintenance of basic
sanitation systems in hospitals.
11.2 FACTORS
Factors to consider when choosing a sanitation system are as follows:
z the initial cost of the technology and the costs of operation and maintenance.
z demand and use - what is the population density, and will the system be used in
(Supportive Services) homes, schools, market places?
z climate - temperature, humidity and rainfall
z soil and topography - infiltration properties of the soil, and what is the direction of
the groundwater flow?
z water availability - for waterborne systems
z cultural beliefs, values and practices around sanitation
z the availability of technical skills
z agriculture - what are the characteristics of the local agriculture and home
gardening
11.3 HUMAN WASTE AND HEALTH

a) Faeces: Human faeces may contain a range of disease-causing organisms,
including viruses, bacteria and eggs or larvae of parasites. The microorganisms
contained in human faeces may enter the body through contaminated food, water,
eating and cooking utensils and by contact with contaminated objects. Diarrhoea,
cholera and typhoid are spread in this way and are major causes of sickness and
death in disasters and emergencies. Some fly species and cockroaches are
attracted to or breed in faeces, but while they theoretically can carry faecal
material on their bodies, there is no evidence that this contributes significantly to
the spread of disease. Children are especially vulnerable to all the above
infections, particularly when they are under the stress of disaster dislocation, high-
density camp living and malnutrition.
While specific measures can be taken to prevent the spread of infection through
contamination by human faeces for example chlorinating the water supply,
providing hand-washing facilities and soap, the first priority is to isolate and
contain faeces.
b) Urine: Urine is relatively harmless, except in areas where the urinary form of
schistosomiasis occurs. This parasitic infection, caused by Schistosoma
haematobium, is similar to the one described in the section above, except this
parasite species resides in the veins around the bladder and its eggs are excreted
with urine. In these areas, urinating in water courses should be prevented;
otherwise, indiscriminate urination is not a health hazard.
c) Sullage: Wastewater from kitchens, bathrooms and laundries is called sullage. It
can contain disease-causing organisms, particularly from soiled clothing, but its
main health hazard occurs when it collects in poorly drained places and causes
pools of organically polluted water that may serve as breeding places for
mosquitoes. This genus of mosquitoes transmits some viruses as well as the
parasitic diseases.
d) Solid waste: Rats, dogs, cats and other animals, which may be carriers of disease-
causing organisms are attracted to discarded food, cloth, medical dressings and
other components of solid waste. Small rainwater collections in solid waste may
serve as the breeding places for mosquitoes, vectors of the dengue virus. Deep,
compacted burial and, in particular, incineration of medical waste are essential to
eliminate the associated health risks. Inorganic waste, such as fuel ash, can be
hazardous to health. Items such as empty pesticide containers should be crushed
and buried to ensure that they are not accidentally recycled.
Technology Choice
Sanitation
a) Waterborne systems for excreta disposal: Wastewater coming from kitchens and
bathrooms is termed “sullage” (or grey water).“Sewage” (or black water),
includes sullage and human excreta from waterborne facilities. Sewage is called
“sludge” when it becomes a thick mud. In areas of high population density,
wastewater can pose a serious public-health threat, such as when it surfaces
during flooding, or when there is no proper drainage. Not only would it cause foul
odours, but it would also be a source of pathogens. If sewer pipes break, or if
wastewater stagnates because the soil absorbs poorly, the wastewater could seep
into the drinking-water supply and contaminate it.
The problems associated with waterborne waste disposal are:
the high water consumption;
the sewer system often becomes blocked; and the high capital and operation
and maintenance costs.
b) Dry sanitation systems for excreta disposal: One dry sanitation method is to
dehydrate the human faeces. Special collection devices, which divert urine into a
separate container for storage, allow faeces to be dehydrated fairly easily. The
urine can be used directly as a fertilizer, since urine contains most of the nutrients
and the risks from pathogens are relatively low.
A second dry sanitation method is to compost the human faeces. This involves a
biological process in which bacteria and worms break down the organic material
under controlled conditions (e.g. temperature, moisture, and airflow) and make
humus. If the composting conditions are properly controlled, the humus is free of
human pathogens and is an excellent soil conditioner.
A drawback of this method is that in many developing countries it is likely that
the composting conditions would not be controlled properly, which could lead to
humus contaminated with pathogens. The health aspects of dry sanitation systems,
either by dehydration or composting, are not well understood yet and these
technologies cannot be recommended without a clear understanding of how they
function. The most common problems with dry sanitation are:
The faeces become wet, and therefore smells persist, flies breed, and
pathogens survive. This could be caused by leaking urine conduits or blocked
vent pipes, or poor maintenance of the system.
Cleaning material is used inappropriately after defecation.
c) Simple pit latrines: Individual simple pit latrines, either hand-dug or drilled, may
be an option in lower density, longer-term emergency settlements. Initial, simple
screening to provide privacy can be improved to give protection from the weather
as needed. It is important for the control of flies, mosquitoes and odours that tight-
fitting lids for the squatting holes are provided and are always closed by users
after each visit to the latrine.
The latrine slab can be made of sawn timber, logs with or without an earth
covering, concrete, plastic, or a combination of two or more of these. The latrine
superstructure may be made of a wooden framework covered with plastic
sheeting, grass, or other local materials. Temporary superstructures may be
replaced by the users with more permanent materials after the emergency phase.
The choice of materials for slabs and superstructures will depend on
considerations such as cost, local availability, environmental impact, and ease of
use.
Normally the pit should be designed to last at least a year, and its volume should
be calculated on the basis of about 0.07 m3 per user per year. In unstable soils, the
10 top 50 centimetres of the pit, or the whole depth of the pit, may need to be lined to
(Supportive Services) prevent collapse. Pit linings may be made of many different materials, including
brick, concrete, old oil drums or bamboo. Pit linings should normally not be
watertight below 50 centimetres deep.
d) Other types of latrine: The simple pit latrine is the basis for the design of a
number of other types of latrine, described below. Some may be appropriate for
specific soil or site conditions. Most require more time, materials and specialist
knowledge for their construction.
1. Ventilated Improved Pit (VIP) latrines: The VIP latrine incorporates one-way
ventilation through the pit to reduce odours and insect breeding. While non
ventilated latrines should have lids to reduce these problems the VIP latrine
does not require a cover over the defecation hole if there is sufficient wind to
create an air flow up the pipe .The end of the ventilation pipe should be
covered with mosquito netting. Flies that breed in the pit and then fly up the
pipe towards the daylight cannot then leave the latrine, and flies on the
outside that are attracted by the smell coming from the top of the pipe are
unable to enter the latrine. Pit design is as for the simple pit latrine.
2. Double-pit latrines: Double-pit latrines are useful where there is limited room
for digging new pits. The filled side can be emptied via an access hatch while
the other side is being used. If the filling of one side takes sufficient time
emptying can be delayed until anaerobic decomposition has killed the
pathogens. Double-pit latrines may be ventilated or non ventilated. A
variation on this technique is the twin-pit latrine used with water-seal toilets.
Two separate pits are used, joined to a water-seal toilet with a pipe with a Y-
junction in an access chamber. Each separate pit is used in turn, as with the
double-pit system, switching between pits being achieved by blocking one
half of the Y-junction.
3. Composting latrines: The composting latrine can be used in lower-density,
longer-term settlements, where the compost produced can be used in food
production. It may take 12–24 months for the compost to become safe to
handle, depending on the climate.
4. Water-seal latrines: Water-seal (or pour-flush) latrines are similar to simple
pit latrines, but instead of having a squatting hole in the cover slab, they have
a shallow toilet pan with a water seal. In the simplest type, excreta falls
directly into the latrine pit when the pan is flushed with a small quantity of
water. Pour-flush latrines can be connected at a later stage with either a septic
tank, the effluent from which can be disposed of by means of subsurface-soil
absorption, or a small-bore sewer system. It may be possible to install such
latrines, depending on the lead time in setting up an emergency settlement; the
length of its life, its location and the availability of pour-flush pans.
e) Septic tank and aqua privy: Septic tanks and aqua privies have a water tight
settling tank with one or two compartments. Waste is flushed into the tank by
water from a pipe that is connected to the toilet. If the septic tank is under the
latrine, the excreta drop directly into the tank through a pipe submerged in the
liquid layer (aqua privy). If the tank is away from the latrine (septic tank), the
toilet usually has a U-trap. Neither system disposes of wastes: they only help to
separate the solid matter from the liquid. Some of the solids float on the surface,
where they are known as scum, while others sink to the bottom where they are
broken down by bacteria to form a deposit called sludge.
The liquid effluent flowing out of the tank is as dangerous to health as raw sewage
and should be disposed of, normally by soaking it into the ground through a soak
away, or by connecting the tank to sewer systems. The accumulated sludge in the
tank must be removed regularly, usually once every 1–5 years, depending on the 10
size of the tank, number of users, and kind of use. If sullage is also collected in the Sanitation
tank, the capacity of both the tank and the liquid effluent disposal system will
need to be larger. If the soil has a low permeability, or if the water table is high, it
may be necessary to connect the tank to a sewer system, if available. Every tank
must have a ventilation system to allow methane and malodorous gases to escape.
The gases are generated by bacteria during sewage decomposition, and methane in
particular is highly flammable and potentially explosive if confined in the tank.
Septic tanks are more expensive than other on-site sanitation systems and require
higher amounts
f) Vacuum tanker: A vacuum tanker is a motor vehicle, equipped with a vacuum
pump and tank, for emptying or desludging pit latrines, septic tanks or sewers, and
for hauling sludge to a disposal station. Conventional vacuum tankers have a
hauling capacity of 4-6 m3 of sludge, and mini tankers less than 2 m3.
All vacuum tanker systems use a pump to create a vacuum in the tank and suction
hose. The vacuum then lifts the sludge into the tanker. If the bottom layers of
sludge are compacted, they can be broken up with a long spade, or jetted with a
water hose, before being pumped out. Water hoses are often fitted to the tankers.
Some tankers have high-powered vacuum pumps and an air stream into the
suction hose that acts as a transport medium for the sludge. These tankers can deal
with heavy sludge in pit latrines. A small amount of sludge should always be left
in the pit to ensure that decomposition continues rapidly.
Site selection for latrines

Latrines should be sited at least 30 metres from any water source. If the abstraction
point is upstream of the latrine, the distance can be reduced provided that the
groundwater is not abstracted at such a rate that its flow direction is turned towards
the abstraction point. In heavily-fissured rock this distance may have to be increased
substantially. Because pollution tends to disperse downslope from its source, latrines
should be sited downhill from any groundwater source, particularly if the bottom of
the latrine is less than 2 metres above the water table.
Consideration should also be given to the pattern of usage of communal latrines. Such
usage will probably not be uniform, but concentrated along lines of common travel. It
may be necessary to close some latrines and open others at some stage, to adjust to
demand. Latrines should be sited no more than 50 metres from users’ shelters, to
encourage their use, but sufficiently far away, at least 6 metres to reduce problems
from odours and pests.
Management of excreta disposal facilities

One of the main reasons that sanitation facilities fail in emergencies is insufficient
management. There are several reasons for this, including insufficient consultation
with users at the design stage, leading to facilities that are not used as intended;
insufficient resources provided for maintaining and cleaning public facilities; and
inadequate supervision of self-build sanitation programmes, leading to incorrect siting
and construction of latrines. Excreta disposal programmes in emergencies demand
substantial resources and management support, from the assessment stage to
decommissioning facilities or handing them over. Some of the common methods of
disposal of sludge are as follows:
z Disposal into water: Sludge can be disposed into water, if it is left untouched for
about 2 years. However, untreated sludge poses very high risks to health and the
environment.
10 z Disposal onto Land: Sludge can be disposed onto land, if it is left untouched for
(Supportive Services) about 2 years. However, untreated sludge poses very high risks to health and the
environment.
z Composting: Mix the sludge with 2-3 times its volume of vegetable waste. Turn it
several times in the first few weeks, then heap it into a pile and leave it for several
weeks. After this, it can be used as fertilizer.
z Household bio-gas units: Add latrine or septic tank sludge to bio-gas units
(mainly used with animal waste).
z Drying beds: Sludge flows into a shallow tank that allows drainage, and is
covered with a layer of sand.
The sludge is then lifted after about one week.
z Solid-liquid separation: Solids are separated from the liquid wastes by
sedimentation or rough filtering. The solids are then lifted.
z Anaerobic digestion: Sludge from the latrine is added to wastewater sludge, and
separated by sedimentation at wastewater treatment plants.
z Extended aeration: The sludge is aerated.
z Sewerage system: Sludge is discharged into wastewater treatment plants. The rate
of discharge is important for this method to work properly.
z Waste stabilization Ponds: The sludge is treated in waste stabilization ponds,
either with municipal wastewater, or separately addition, appropriate anal
cleansing materials should be available in or near the latrine.
z Ash or sawdust can be sprinkled into the pit to reduce the smell and insect
breeding. Non biodegradable materials, such as stones, glass, plastic, rags, etc.,
should not be thrown into the pit, as they reduce the effective volume of the pit
and hinder mechanical emptying.
11.4 DISPOSAL OF WASTEWATER (SULLAGE)

In many emergency situations, it may be judged that the quantity and nature of the
wastewater produced do not present a health risk sufficient to justify control activity.
In others, efforts to limit the production of wastewater may be sufficient to keep the
problem under control. In many situations, however, specific measures are needed to
dispose of wastewater, and these are described below:
Wastewater disposal techniques: The main options for disposing of wastewater are to
discharge it into water courses, with or without treatment, to infiltrate it into the soil,
or to use it for irrigation in which case most of the water is disposed of by infiltration,
evaporation and evapotranspiration.
Disposal into water courses: If nearby water courses suitable for accepting the type
and quantity of wastewater produced are available, the best disposal method may be to
direct the wastewater to them through pipes or open channels. It may be possible to
make a connection to an existing drainage network and thereby to treatment and
discharge installations. It is important for staff to investigate the drainage system as
far as the final discharge point, to avoid creating or contributing to environmental
pollution and contamination of water supplies:
a) Infiltration techniques: Infiltration into the soil should be facilitated where large
quantities of spilled or used water will accumulate, e.g. under water-distribution
tanks and taps, outside bath houses and laundries, and near communal kitchen
areas. The simplest technique is to construct a soakaway (or soakage pit). This is
an excavation at least 1.25 metres deep and 1.25 metres wide, filled with stones,
that allows water to seep into the surrounding ground. It is sealed from above by
an impermeable layer, oiled sacking, plastic or metal to discourage insect 10
breeding. Wastewater is fed by pipe into the center of the pit. Sanitation
As long as the level of the water in the pit does not rise above the top of the
ground, insect breeding is minimal. Soakaways can only dispose of a limited
amount of water because they provide a relatively small area of soil surface for
infiltration. Infiltration trenches, which are commonly used for disposing of the
effluent from septic tanks, overcome this problem through a series of parallel
trenches in which perforated pipes are laid in a bed of gravel.
b) Evaporation and evapotranspiration techniques: Where infiltration methods do
not work effectively because of low soil permeability, wastewater may be
disposed of by using it for irrigation. Even when infiltration methods are possible,
it may be appropriate to use wastewater for vegetable gardening if irrigation water
is scarce. Water is applied to garden plots by simple flood irrigation, or by
allowing it to collect in basins from where water is carried to plots. Care must be
taken to allow flood irrigated beds and storage basins to dry out regularly to avoid
mosquito breeding.
A simpler system that does not involve irrigation, is to allow water to flow into
shallow pans, where it simply evaporates. Alternatively, soap-free wastewater
from spillage at water collection points may be used for watering livestock, but
care should be taken not to create muddy and contaminated areas near water
points.
c) Grease traps: Whatever the disposal method chosen, wastewater from the kitchen
and laundry area should first be put through a grease trap . If hot water containing
fat is run into an adequate supply of cold water, the fat solidifies and rises to the
surface, where it can be skimmed off. A strainer is fitted to the inlet to catch any
large particles which might pass through the trap and choke the inlet to the
soakage pit. The first baffle prevents the entering water from disturbing the layer
of grease, the second keeps the effluent from carrying it off. Grease traps are also
effective at reducing the amount of sand and soap in wastewater.
11.5 REFUSE COLLECTION AND TRANSPORT

Before starting the collection service, it is necessary to determine: the quantity of solid
waste to be collected; how much waste will be generated; the frequency of the service;
the quantity and size of collector trucks; the number of workers required; the final
disposal method; and the disposal site.
Their tasks include cleaning streets and open spaces; collecting waste containers;
cleaning facilities, markets, and the like; and transferring waste to the treatment or
final disposal site. Daily refuse collection is best, especially from kitchens, but
collection not less than once a week is essential to minimize insect breeding One 5-ton
truck will probably be sufficient for 10,000 people, but this depends on the quantity
and density of refuse collected, the ease of collection, and the time required to
transport refuse to the disposal site. Although any kind of truck may be used for
emergency responses, compactor trucks are always preferable if these can be afforded.
11.6 MEDICAL WASTES

Special care must be taken with refuse from a field hospital or health centre. The main
categories of waste of concern are: infectious waste; pathological waste; sharps;
pharmaceutical waste; genotoxic waste; chemical waste; waste with high heavy metal
content; pressurized containers; and radioactive waste. Each type of waste requires
specific measures for handling, storage, collection and destruction. In the case of
simple health centers, particularly in rural areas, well-managed onsite burial may be
appropriate. In larger centres producing a significant quantity of sharps and infected
10 waste, incineration may also be required. When health facilities operate diagnostic
(Supportive Services) laboratory services, radiological diagnosis and treatment facilities, pharmacies, etc.,
waste management is a specialized activity requiring trained and well equipped staff,
and the subject is beyond the scope of this book.
Since this is a rapid-response activity, it is highly recommended that all wastes
generated during this stage, without exception, are stored in containers, preferably in
red bags, that are properly labelled as “biocontaminated waste”. Direct contact with
such wastes must be avoided.
Waste Management during Routine Medical Activities

Management will be similar for permanent and provisional health facilities. Wastes
should be segregated at the point of generation according to their type:
z biocontaminated wastes (including sharp materials);
z chemical wastes (drugs, chemical solutions, etc.);
z common wastes (paper, cardboard, glass, or the like; chemical product containers
should be treated as chemical wastes).
For each hospital room, washable and easily disinfected PVC containers with a
capacity of 40–50 litres should be used. Waste should be disposed of in colored bags
according to the following codification:
z red bags for biocontaminated wastes;
z yellow bags for chemical wastes;
z black bags for common wastes.
Hermetic plastic containers of 2–5 litre capacity or opaque glass bottles may be used
to store sharp objects. These wastes should then be collected separately every 12–24
hours. Small carts, preferably with lids, should be adapted to this end and the
personnel assigned should be protected with aprons, masks, boots and gloves.
Treatment should be done according to the type of waste. Sharp materials should be
disinfected with a 0.5% total chlorine solution before incineration or burial in a sharps
pit. Biocontaminated wastes should be incinerated. Burned biocontaminated wastes,
disinfected sharp materials, and chemical wastes should be disposed of by burial on-
site if possible. The burial area should be isolated and protected to avoid illegal
recycling. However, this may not be possible in permanent health facilities, due to
lack of space. In such cases, protected areas should be used at landfill sites to receive
treated wastes. Common wastes may be managed by the municipal waste-collection
service, as long as they do not contain hazardous material.
Check Your Progress
1. Sanitation
……………………………………………………………………………….
……………………………………………………………………………….
2. Medical waste
……………………………………………………………………………….
……………………………………………………………………………….
10
11.7 LET US SUM UP Sanitation
The sanitation is the common phenomenon which is essential in determining the level
of hospital in its sanitary aspects. This lesson reveals the aspects regarding various
factors affecting sanitation facilities, various types of waste and its disposal methods.

Think that in a health care sector sanitation facilities are lacking. What essential
guidelines would you provide for building a new system?
11.9 KEYWORDS
Sullage: Wastewater from kitchens, bathrooms and laundries.
Sewage: When sludge becomes a thick mud.
Vacuum Tanker: A motor vehicle, equipped with a vacuum pump and tank, for
emptying or dislodging pit latrines, septic tanks or sewers.

1. Explain the factors affecting sanitation.
2. Discuss on human waste and health system in hospitals.
3. Write on disposal of wastewater.
4. What are medical wastes? Explain.

1. Sanitation includes solid waste disposal, including medical wastes,
wastewater disposal, wastewater reuse, human excreta disposal, and
drainage of surface (rain) water.
2. Medical waste is refuse from a field hospital or health centre. The main
categories of waste of concern are: infectious waste; pathological waste;
sharps; pharmaceutical waste; genotoxic waste; chemical waste; waste
with high heavy metal content; pressurized containers; and radioactive
waste.

Davis Lambert (2002), Harvey, Baghri & Reed (2002);.Intermediate and communal
models for drinking-water supply and sanitation, sanitation assessment and
programme design, see: Sphere Project (2000).
Feachem & Cairncross (1978), Winblad & Kilama (1985), Franceys, Pickford & Reed
(1992), Cairncross & Feachem (1993), Pickford (1995), Davis & Lambert (2002),
Latrine designs.
Solid waste management, United Nations Centre for Human Settlements (1989).
Davis & Lambert, Surface water and wastewater drainage, World Health Organization
(2002).
Reed & Dean, Management of medical wastes, World Health Organization, (1994).
110
LESSON
12
AIR-CONDITIONING SYSTEM
CONTENTS
12.1 Introduction
12.2 Air-conditioning Applications in Hospitals
12.3 Benefits of Air-conditioning Systems in Hospitals
12.4 Types of Air-conditioning Equipment
12.5 Associated System Equipment
12.6 Issues and Problems
12.7 Let us Sum up
12.9 Keywords

z Know the meaning and applications of air conditioning system
z Understand the benefits and types of air conditioning system
z Know about the associated air conditioning equipments
z Get aware of issues and problems
12.1 INTRODUCTION
The term “air conditioning” refers to the cooling and dehumidification of indoor air
for thermal comfort. In a broader sense, the term can refer to any form of cooling,
heating, ventilation or disinfection that modifies the condition of air. An air
conditioner is an appliance, system, or mechanism designed to stabilise the air
temperature and humidity within an area used for cooling as well as heating
depending on the air properties at a given time, typically using a refrigeration cycle
but sometimes using evaporation, most commonly for comfort cooling in buildings
and motor vehicles.
The term “Air Conditioning Systems” refers to an assembly of components for the
treatment of air, controlling its temperature, humidity, cleanliness, and distribution
within an air-conditioned space. Types of systems differ, but the basic components
may include: outside-air intake, preheater, return-air intake, filters, dehumidifier,
heating coil, humidifier, fans, ductwork, air outlets, air terminals, refrigeration
machine, piping, pumps, and water or brine.
1
12.2 AIR-CONDITIONING APPLICATIONS IN HOSPITALS Air-Conditioning System
Air-conditioning engineers broadly divide air conditioning applications into: comfort

and process.
a) Comfort applications: It aims to provide a building indoor environment that
remains relatively constant in a range preferred by humans despite changes in
external weather conditions or in internal heat loads. The highest performance for
tasks performed by people seated in an office is expected to occur at 72°F (22°C)
Performance is expected to degrade about 1% for every 2°F change in room
temperature.
b) Process applications: It aims to provide a suitable environment for a process
being carried out, regardless of internal heat and humidity loads and external
weather conditions. Although often in the comfort range, it is the needs of the
process that determine conditions, not human preference. Process applications
include these:
Hospital operating theatres, in which air is filtered to high levels to reduce
infection risk and the humidity controlled to limit patient dehydration.
Although temperatures are often in the comfort range, some specialist
procedures such as open heart surgery require low temperatures (about 18°C,
64°F) and others such as neonatal relatively high temperatures (about 28°C,
82°F).
Clean rooms for the production of integrated circuits, pharmaceuticals, and
the like, in which very high levels of air cleanliness and control of
temperature and humidity are required for the success of the process.
Facilities for breeding laboratory animals. Since many animals normally only
reproduce in spring, holding them in rooms at which conditions mirror spring
all year can cause them to reproduce year round.
Physical testing facilities, Chemical and biological laboratories and
processing areas whether there is need not only to control temperature, but
also humidity, air quality, air motion, and air movement from space to space.
12.3 BENEFITS OF AIR-CONDITIONING SYSTEMS IN

HOSPITALS
Health Consideration
z The need to restrict air movement in and between the various departments.
z The specific requirements for ventilation and filtration to dilute and reduce
contamination in the form of odour, airborne micro organisms and viruses, and
hazardous chemical and radioactive substances.
z The different temperature and humidity requirements for various areas.
z Hospitals must maintain the highest level of hygiene and indoor air quality in
order to combat the growth of bacteria. The air conditioning is essential in this
process. While intended to control humidity, temperature, CO2 and other indoor
climate parameters, air conditioning systems can also be the cause of transmission
of diseases within a hospital. Special preventative measures can ensure optimal
performance of the air conditioning and a reduced risk of microbiological
outbreaks.
z Indoor Air Quality (IAQ) is more critical in healthcare facilities due to the
hazardous microbial and chemical agents present and the increased susceptibility
of the patients.
1 z Studies show that patient in controlled environments generally has more rapid
(Supportive Services) physical improvement than do those in uncontrolled environments.
Environmental Control
Temperature and Relative Humidity Control Codes and guidelines specify
temperature range criteria in some hospital areas as a measure for infection control.
Local temperature distributions greatly affect occupant comfort and perception of the
environment. If the ambient indoor air temperature is too warm, people perceive the
environment to be stuffy with little airflow. This condition can often result in fatigue
and lethargy.
Relative humidity affects human comfort directly and indirectly. It is a thermal
sensation, skin moisture, discomfort, and tactile sensation of fabrics, health and
perception of air quality. Low humidity affects comfort and health. Comfort
complaints about dry nose, throat, eyes and skin occur in low humidity conditions
always persist.
The laminar airflow concept developed for industrial clean room use has attracted the
interest of some medical authorities. Laminar airflow in surgical operating theatres is
airflow that is predominantly unidirectional when not obstructed. Laminar airflow has
shown promising results in rooms used for the treatment of patients who are highly
susceptible to infection.
12.4 TYPES OF AIR-CONDITIONING EQUIPMENT

a) Window and through-wall units: Many traditional air conditioners in homes or
other buildings are single rectangular units used to cool an apartment, a house or
part of it, or part of a building. Air conditioner units need to have access to the
space they are cooling and a heat sink, normally outside air is used to cool the
condenser section. For this reason, single unit air conditioners are placed in
windows or through openings in a wall made for the air conditioner; the latter type
includes portable air conditioners.
Window and through-wall units have vents on both the inside and outside, so
inside air to be cooled can be blown in and out by a fan in the unit, and outside air
can also be blown in and out by another fan to act as the heat sink. The controls
are on the inside.
b) Evaporative coolers: In very dry climates, evaporative coolers or "swamp
coolers" are popular for improving comfort during hot weather. An evaporative
cooler is a device that draws outside air through a wet pad, such as a large sponge
soaked with water. The sensible heat of the incoming air, as measured by a dry
bulb thermometer, is reduced. Some of the sensible heat of the entering air is
converted to latent heat by the evaporation of water in the wet cooler pads. If the
entering air is dry enough, the results can be quite comfortable. These coolers cost
less and are mechanically simple to understand and maintain.
c) Absorptive chillers: Some buildings use gas turbines to generate electricity. The
exhausts of these are hot enough to drive an absorptive chiller that produces cold
water. The cold water is then run through radiators in air ducts for hydronic
cooling. The dual use of the energy, both to generate electricity and cooling,
makes this technology attractive when regional utility and fuel prices are right.
d) Central air-conditioning: Central air conditioning, commonly referred to as
central air or air-con, is an air conditioning system which uses ducts to distribute
cooled and/or dehumidified air to more than one room, or uses pipes to distribute
chilled water to heat exchangers in more than one room, and which is not plugged
into a standard electrical outlet.
With a typical split system, the condenser and compressor are located in an 1
outdoor unit; the evaporator is mounted in the air handling unit. With a package Air-Conditioning System
system, all components are located in a single outdoor unit that may be located on
the ground or roof.
Central air conditioning performs like a regular air conditioner but has several added
benefits:
z When the air handling unit turns on, room air is drawn in from various parts of the
building through return-air ducts. This air is pulled through a filter where airborne
particles such as dust and lint are removed.
z The filtered air is routed to air supply ductwork that carries it back to rooms.
Whenever the air conditioner is running, this cycle repeats continually.
z Because the central air conditioning unit is located outside the home, it offers a
lower level of noise indoors than a free-standing air conditioning unit.
Check Your Progress
1. Air-conditioning system
……………………………………………………………………………….
……………………………………………………………………………….
2. Evaporative coolers
……………………………………………………………………………….
……………………………………………………………………………….
3. Central air-conditioning
……………………………………………………………………………….
……………………………………………………………………………….
12.5 ASSOCIATED SYSTEM EQUIPMENT

a) Portable air conditioners: A portable air conditioner or portable A/C is an air
conditioner on wheels that can be easily transported inside a home or office. They
are currently available with capacities of about 1,800 to 18,000 watts output and
with and without electric resistance heaters. Portable air conditioners come in
three forms, split, hose and evaporative:
i) A split system has an indoor unit on wheels connected to an outdoor unit via
flexible pipes, similar to a permanently fixed installed unit.
ii) Hose systems Air-to-Air and Monoblock are vented to the outside through air
ducts. A function of all cooling that use a compressor, is to create water as it
cools the air. The "monoblock" version collects the water in a bucket or tray
and stops when full. The Air-to-Air version, re-evaporates the water and
discharges it through the ducted hose and can hence run continuously.
iii) Evaporative air conditioners do not have a compressor or condenser. Instead,
liquid water is poured in and released as vapour. Because they do not have a
condenser which needs cooling, they do not need hoses or pipes, allowing
them to be truly portable.
b) Heat pumps: Heat pump is a term for a type of air conditioner in which the
refrigeration cycle is able to be reversed, producing heat instead of cold in the
11 indoor environment. Using an air conditioner in this way to produce heat is
(Supportive Services) significantly more efficient than electric resistance heating. Some home-owners
elect to have a heat pump system installed, which is actually simply a central air
conditioner with heat pump functionality. When the heat pump is enabled, the
indoor evaporator coil switches roles and becomes the condensor coil, producing
heat. The outdoor condensor unit also switches roles to serve as the evaporator,
and produces cold air.
c) Thermostats: Thermostats control the operation of HVAC systems, turning on the
heating or cooling systems to bring the building to the set temperature. Typically
the heating and cooling systems have separate control systems so that the
temperature is only controlled "one-way". Thermostats may also be incorporated
into facility energy management systems in which the power utility customer may
control the overall energy expenditure.
d) Insulation: Insulation reduces the required power of the air conditioning system.
e) Air filter: An air filter is a device which removes solid particulates such as dust,
pollen, mold, and bacteria from air. Air filters are used in applications where air
quality is important, notably in building ventilation systems and in engines, such
as internal combustion engines, gas compressors, diving air compressors, gas
turbines and others.
Some buildings, use foam, pleated paper, or spun fiberglass filter elements. Another
method uses fibers or elements with a static electric charge, which attract dust
particles. The air intakes of internal combustion engines and compressors tend to use
either paper, foam, or cotton filters.
12.6 ISSUES AND PROBLEMS

A number of questions have to be answered in this regard. They are as follows:
z What types of air-filtration and air-cleaning systems are effective for various
Chemical Biological Radiology agents?
z What types of air-filtration and air-cleaning systems can be implemented in an
existing heating, ventilation, air-conditioning system?
z What types of air-filtration and air-cleaning systems can be incorporated into
existing buildings when they undergo comprehensive renovation?
z How to properly maintain the air-filtration and air-cleaning systems installed in
your building?
z How are the filters in each system held in place and how are they sealed?
z Are the filters simply held in place by the negative pressure generated from
downstream fans?
z Do the filter frames provide for an airtight, leak-proof seal with the filter rack
system?
z What types of air contaminants are of concern?
z Consider checking with your local emergency or disaster planning body to
determine if there are large quantities of TICs or TIMs near your location or if
there are specific concerns about military, chemical, or biologic agents.
z How might the agents enter your building?
z Are they likely to be released internally or externally to the building envelope, and
how can various release scenarios best be addressed?
z What is needed? Are they to improve current indoor air quality, provide 11
protection in an accidental or intentional release of a nearby chemical processing Air-Conditioning System
plant, or provide protection from a potential terrorist attack using CBR agents?
z How clean does the air need to be for the occupants, and how much can be spent
to achieve that desired level of air cleanliness?
z What are the total costs and benefits associated with the various levels of
filtration?
z What are the current system capacities (fans, space for filters, etc.) and what is
desired?
z What are the minimum airflow needs for the building?
z Who will maintain these systems and what are their capabilities?
Total life-cycle cost (i.e., energy costs, maintenance, disposal, replacement, etc.) is
another consideration, which includes more than just the initial purchase price.
Attempts to minimize total cost by selecting the optimum change-out schedule, based
on equipment life and power requirements has to be undertaken.
In addition there also arise the need to conduct periodic quantitative performance
evaluations and should use a quantitative evaluation to determine the total system
efficiency. The evaluation for various particle sizes and at the appropriate system flow
rate has to be analyzed.
Establish effective maintenance schedules based on predicted service life.Ensure
maintenance personnel are well trained. Choosing the most suitable equipment with
the highest possible efficiency is the first problem on this system.
Proper periodic maintenance of parts and equipment associated with the air-
conditioning systems, including cleaning of heat exchangers, cleaning air outlets,
repair of ducts, periodic substitution of filters and proper heat isolation of conditioned
sites are some of the many functions that could improve efficiency and reduce
consumption hence has to be properly monitored.
Campaigns focusing on proper use by hospital personnel and automation of the
system, by applying sensors and better controls, are actions that reduce the workload
of the system and hence utmost importance.
12.7 LET US SUM UP

Air-conditioning is a system which is helpful in treatment of air, avoidance or to keep
temperature at control in the hospitals, to help the patience to get cured. In this lesson
we discussed the type and system of air conditioning equipments used and their
importance.

Make a study on the various air-conditioning system existing in hospitals.
12.9 KEYWORDS
Air-conditioning: The cooling and dehumidification of indoor air for thermal comfort.
Air Filter: A device which removes solid particulates from air.

1. Explain the air-conditioning applications in hospitals.
2. What are the benefits of air-conditioning systems in hospitals?
11 3. Discuss the issues and problems in installing the air-conditioning system.
(Supportive Services) 4. Write on air-conditioning equipments and its types of air-conditioning equipment.

1. An assembly of components for the treatment of air, controlling its
temperature, humidity, cleanliness, and distribution within an air-
conditioned space.
2. An evaporative cooler is a device that draws outside air through a wet
pad, such as a large sponge soaked with water. The sensible heat of the
incoming air, as measured by a dry bulb thermometer, is reduced.
3. Central air conditioning is an air conditioning system which uses ducts to
pipes to distribute chilled water to heat exchangers in more than one
room, and which is not plugged into a standard electrical outlet.

Guidance for Filtration and Air-Cleaning Systems to Protect Building Environments
from Airborne Chemical, Biological, or Radiological Attacks Department of Health
and Human Services Centers for Disease Control and Prevention National Institute for
Occupational Safety and Health, April 2003.
117
LESSON Hot Water and Steam Supply
13
HOT WATER AND STEAM SUPPLY
CONTENTS
13.1 Introduction
13.2 Benefits of Hot Water and Steam Supply
13.3 Sources of Hot Water and Steam Supply
13.4 Let us Sum up
13.6 Keywords

z Know the benefits of hot and steam water
z Know the various sources of hot and steam water
13.1 INTRODUCTION
Reliable and effective building services are needed to create comfortable, well-
maintained environment that is vital in helping patients get better. For decades,
healthcare industry is supplying hot water and steam control systems services, for
sterilization and other vital medical tests and processes as apart of patient care.
Hospital Engineering Systems would be incomplete without proper components and
equipments supplying hot water and steam. It includes systems like:
a) Boiler House Engineered Systems: providing full control and heat recovery for
the boiler house.
b) Hot Water Engineered Systems: providing instantaneous and efficient hot water
supplies, from domestic (DHW) to high temperature (HTHW).
c) Clean Steam Generators: providing clean steam on demand for sterilisation
applications.
d) Flow metering Stations: providing accurate steam metering for fiscal control.
13.2 BENEFITS OF HOT WATER AND STEAM SUPPLY

z Improving patient care and the welfare of surgery patients.
z Targeting a healthy focus.
z Providing true value for money to the patients.
11 z Lower administrative and commercial costs -single supplier sourcing eliminates
(Supportive Services) the need to deal with multiple suppliers.
z Reduced design costs – today’s suppliers, designs and engineers each system to
meet the application’s demands, substantially cutting the specialist design
workload.
z Less project management - off-site construction simplifies site management and
cuts the cost of skilled labour on site.
z Less civil engineering - Engineered Systems are compact and can be built to fit
small and awkward site spaces, which often eliminates the need to build or extend
plant rooms.
z No risk of cost or time overruns – responsibility for correct operation of the
system rests with suppliers, eliminating the risk of performance shortfalls that are
costly and time consuming to fix.
z Low operational costs - matched components and factory-quality construction
increase plant reliability, efficiency and lifespan.
z Low maintenance costs - factory-built systems tend to be more reliable than site
built plant which, with lifetime support, reduces maintenance costs.
z All services, including installation, commissioning, service contracts and steam
plant surveys are all fully supported by dedicated and experienced Service
Engineers.
z These systems offers a wide range of services dedicated to helping to identify,
improve and sustain the hospital’s efficiency. Using technical support and
services the system works to design and implement improvements to the hospital
and help to maintain the resulting performance gains.
13.3 SOURCES OF HOT WATER AND STEAM SUPPLY

I) Boilers: Boilers are fuel-burning appliances that produce either hot water or steam
that gets circulated through piping for heating or process uses. Proper
maintenance and operation of boilers systems is important with regard to
efficiency and reliability. Without this attention, boilers can be very dangerous.
A) Types of Boilers: Boiler designs can be classified in three main divisions –
fire-tube boiler, water-tube boiler, and electric boilers.
a) Fire-Tube Boilers: Fire-tube boilers rely on hot gases circulating through
the boiler inside tubes that are submerged in water. These gases usually
make several passes through these tubes, thereby transferring their heat
through the tube walls causing the water to boil on the other side. Fire-
tube boilers are generally available in the range 20 through 800 boiler
horsepower (bhp).
b) Water-Tube Boilers: Most high-pressure and large boilers are of this type.
It is important to note that the small tubes in the water-tube boiler can
withstand high pressure better than the large vessels of a fire-tube boiler.
In the water-tube boiler, gases flow over water-filled tubes. These water-
filled tubes are in turn connected to large containers called drums. Water-
tube boilers are available in sizes ranging from smaller residential type to
very large utility class boilers.
c) Electric Boilers: Electric boilers are very efficient sources of hot water or
steam, which are available in ratings from 5 to over 50,000 kW. They can
provide sufficient heat for any HVAC requirement in applications ranging
from humidification to primary heat sources.
B) Critical Components: In general, the critical components are those whose 11
failure will directly affect the reliability of the boiler. The critical components Hot Water and Steam Supply
can be prioritized by the impact they have on safety, reliability, and

performance. These critical pressure parts include:
Drums
Headers
Tubing
Piping
Main Steam
Feedwater
Air openings
Flue gas vent system
Pilot and main burner flames
Boiler heating surfaces
Burners and base
C) Safety Issues: Boiler safety is a key objective of the National Board of Boiler
and Pressure Vessel Inspectors. The figure below details the 1999 boiler
incidents by major category. It is important to note that the number one
incident category resulting in injury was poor maintenance/operator error.
Furthermore, statistics tracking loss-of-life incidents reported that in 1999,
three of seven boiler-related deaths were attributed to poor
maintenance/operator error. The point of relaying this information is to
suggest that through proper maintenance and operator training these incidents
may be reduced.
Boiler inspections should be performed at regular intervals by certified boiler
inspectors. Inspections should include verification and function of all safety
systems and procedures as well as operator certification review.
D) Results Best Practices: In a study conducted by the Boiler Efficiency Institute
researchers have developed eleven ways to improve boiler efficiency with
important reasons behind each action.
Reduce excess air: Excess air means there is more air for combustion than
is required. The extra air is heated up and thrown away. The most
important parameter affecting combustion efficiency is the air/fuel ratio.
Install waste heat recovery: A major problem with heat recovery in flue
gas is corrosion. If flue gas is cooled, drops of acid condense at the acid
dew temperature. As the temperature of the flue gas is dropped further,
the water dew point is reached at which water condenses. The water
mixes with the acid and reduces the severity of the corrosion problem.
Reduce scale and soot deposits: Scale or deposits serve as an insulator,
resulting in more heat from the flame going up the stack rather than to the
water due to these deposits. Any scale formation has a tremendous
potential to decrease the heat transfer.
Reduce blowdown: Blowdown results in the energy in the hot water being
lost to the sewer unless energy recovery equipment is used. There are two
types of blowdowns. Mud blow is designed to remove the heavy sludge
that accumulates at the bottom of the boiler. Continuous or skimming
blow is designed to remove light solids that are dissolved in the water.
1 Recover waste heat from blowdown: Blowdown contains energy, which
(Supportive Services) can be captured by a waste heat recovery system.
Stop dynamic operation on applicable boilers: Any boiler which either
stays off a significant amount of time or continuously varies in firing rate
can be changed to improve efficiency.
Reduce line pressure: Line pressure sets the steam temperature for
saturated steam.
Cogenerate: This refers to correct utilization of steam pressure. A boiler
provides steam to a turbine, which in turn, is coupled to an electric
generator. In this process, all steam exhaust from the turbine must be fully
utilized in a process requirement.
Operate boilers at peak efficiency: Plants having two or more boilers can
save energy by load management such that each boiler is operated to
obtain combined peak efficiency.
Preheat combustion air: Since the boiler and stack release heat, which
rises to the top of the boiler room, the air ducts can be arranged so the
boiler is able to draw the hot air down back to the boiler.
Switch from steam to air atomization: The energy to produce the air is a
tiny fraction of the energy in the fuel, while the energy in the steam is
usually 1% or more of the energy in the fuel.
E) Maintenance of Boilers: A boiler efficiency improvement program must
include two aspects:
1. action to bring the boiler to peak efficiency, and
2. action to maintain the efficiency at the maximum level.
Good maintenance and efficiency start with having a working knowledge of
the components associated with the boiler, keeping records, etc., and end with
cleaning heat transfer surfaces, adjusting the air-to-fuel ratio, etc.
F) General Requirements for a Safe and Efficient Boiler Room:
1. Keep the boiler room clean and clear of all unnecessary items. The boiler
room should not be considered an all-purpose storage area. The burner
requires proper air circulation in order to prevent incomplete fuel
combustion.
2. Ensure that all personnel who operate or maintain the boiler room are
properly trained on all equipment, controls, safety devices, and up-to-date
operating procedures.
3. Before start-up, ensure that the boiler room is free of all potentially
dangerous situations, like flammable materials, mechanical, or physical
damage to the boiler or related equipment.
4. Ensure a thorough inspection by a properly qualified inspector.
5. After any extensive repair or new installation of equipment, make sure a
qualified boiler inspector re-inspects the entire system.
6. Monitor all new equipment closely until safety and efficiency are
demonstrated.
7. Use boiler operating log sheets, maintenance records, and manufacturer’s
recommendations to establish a preventive maintenance schedule based
on operating conditions, past maintenance, repair, and replacement that
were performed on the equipment.
8. Establish a checklist for proper startup and shutdown of boilers and all 1
related equipment according to manufacturer’s recommendations. Hot Water and Steam Supply
9. Observe equipment extensively before allowing an automating operation

system to be used with minimal supervision.
10. Establish a periodic preventive maintenance and safety program that
follows manufacturer’s recommendations.
II) Steam Traps: Steam traps are automatic valves that release condensed steam from
a steam space while preventing the loss of live steam. They also remove non-
condensable gases from the steam space. Steam traps are designed to maintain
steam energy efficiency for performing specific tasks such as heating a building or
maintaining heat for process.
Once steam has transferred heat through a process and becomes hot water, it is
removed by the trap from the steam side as condensate and either returned to the
boiler.
A) Types of Steam Traps: Steam traps are commonly classified by the physical
process causing them to open and close. The three major categories of steam
traps are:
1. mechanical,
2. thermostatic, and
3. thermodynamic.
In addition, some steam traps combine characteristics of more than one of
these basic categories.
a) Mechanical Steam Trap: The operation of a mechanical steam trap is
driven by the difference in density between condensate and steam. The
denser condensate rests on the bottom of any vessel containing the two
fluids. As additional condensate is generated, its level in the vessel will
rise. This action is transmitted to a valve via either a “free float” or a float
and connecting levers in a mechanical steam trap.
b) Thermostatic Steam Trap: As the name implies, the operation of a
thermostatic steam trap is driven by the difference in temperature between
steam and sub-cooled condensate. Valve actuation is achieved via
expansion and contraction of a bimetallic element or a liquid-filled
bellows.. Although both types of thermostatic traps close when exposure
to steam expands the bimetallic element or bellows, there are important
differences in design and operating characteristics. Upstream pressure
works to open the valve in a bimetallic trap, while expansion of the
bimetallic element works in the opposite direction.
c) Thermodynamic Steam Traps: Thermodynamic trap valves are driven by
differences in the pressure applied by steam and condensate, with the
presence of steam or condensate within the trap being affected by the
design of the trap and its impact on local flow velocity and pressure.
B) Maintenance of Steam Traps: Considering that many federal sites have
hundreds if not thousands of traps, and that one malfunctioning steam trap can
cost thousands of dollars in wasted steam per year, steam trap maintenance
should receive a constant and dedicated effort. Excluding design problems,
two of the most common causes of trap failure are oversizing and dirt.
Oversizing causes traps to work too hard. In some cases, this can result in
blowing of live steam.
1 Dirt is always being created in a steam system. Excessive build-up can
(Supportive Services) cause plugging or prevent a valve from closing. Dirt is generally produced
from pipe scale or from over-treating of chemicals in a boiler.
C) Checklist Indicating Possible Steam Trap Failure
Abnormally warm boiler room.
Condensate received venting steam.
Condensate pump water seal failing prematurely.
Overheating or underheating in conditioned space.
Boiler operating pressure difficult to maintain.
Vacuum in return lines difficult to maintain.
Water hammer in steam lines.
Steam in condensate return lines.
Higher than normal energy bill.
Inlet and outlet lines to trap nearly the same temperature.
D) General Requirements for Safe and Efficient Operation of Steam Traps:
1. Every operating area should have a program to routinely check steam
traps for proper operation. Testing frequency depends on local
experiences but should at least occur yearly.
2. All traps should be numbered and locations mapped for easier testing and
record-keeping. Trap supply and return lines should be noted to simplify
isolation and repair.
3. Maintenance and operational personnel should be adequately trained in
trap testing techniques. Where ultrasonic testing is needed, specially
trained personnel should be used.
4. High maintenance priority should be given to the repair or maintenance of
failed traps.
5. All traps in closed systems should have atmospheric vents so that trap
operation can be visually checked. If trap headers are not equipped with
these, they should be modified.
6. Proper trap design should be selected for each specific application.
Inverted bucket traps may be preferred over thermostatic and
thermodynamic-type traps for certain applications.
7. It is important to be able to observe the discharge from traps through the
header. Although several different techniques can be used, the most
foolproof method for testing traps is observation.
8. Traps should be properly sized for the expected condensate load.
Improper sizing can cause steam losses, freezing, and mechanical failures.
9. Condensate collection systems should be properly designed to minimize
frozen and/or premature trap failures. Condensate piping should be sized
to accommodate 10% of the traps failing to open.
1
Check Your Progress Hot Water and Steam Supply
1. List down the sources of hot water supply in hospitals.
………………………………………………………………………………..
………………………………………………………………………………..
2. Mention the types of steam traps.
………………………………………………………………………………..
………………………………………………………………………………..
13.4 LET US SUM UP

Hospitals require large quantities of water to be heated, stored and distributed.
Heating is usually carried out by a separate boiler, a steam coil or a heat exchange
from a central heating or other system, and the temperature is normally controlled to
within fairly narrow limits. Heating and storage vessels should be clearly marked with
their safe working pressure limits, and gauges should be fitted to enable a regular
check to be made that those limits are being observed.

Make a study on the hot water supply systems in various hospitals and List down their
sources of Hot Water and Steam Supply.
13.6 KEYWORDS
Boilers: fuel-burning appliances that produce either hot water or steam.
Steam Traps: automatic valves that release condensed steam from a steam space.

1. What are the benefits of hot and steam water?
2. Give the different sources of hot and steam water.

1. Sources of Hot water Supply in Hospital:
A. Boilers are fuel-burning appliances that produce either hot water or
steam that gets circulated through piping for heating or process uses.
B. Steam traps are automatic valves that release condensed steam from a
steam space while preventing the loss of live steam.
2. Types of Steam Traps Steam traps are commonly classified by the
physical process causing them to open and close. The three major
categories of steam traps are:
1. mechanical,
2. thermostatic, and
3. thermodynamic.
12
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economy in a squatter area of Maila, Social Science and Medicine, 55(4): 627-641.
Al-Ali F M, Hossain M M and Pugh R N H, 1997, The associations between feeding
modes and diarrhea among urban children in a newly developed country, Public
Health, 111: 239-243.
Bartram J, 1999. Effective Monitoring of Small Drinking-water Supplies in Providing
Safe.
Drinking-water in Small Systems, Cotruvo A, Craun G and Hearne N (Eds). CRC
Press, Boca Raton, USA, pp: 353-365.
Birmingham M E, Lee L A, Ntakibirora M, Bizimana F and Deming M S, 1997, A
household survey of dysentery in Burundi: implications for the current pandemic in
sub-Saharan Africa, Bulletin of the World Health Organization, 75(1): 45-53.
Buttle M and Smith M,1996, Out in the cold: emergency water supply and sanitation
in cold climates. WEDC, Loughborough University.
Cairncross S, 1987, The benefits of water supply, In Pickford, J (ed) Developing
World Water. Grosvenor Press, London.
Cairncross S, 1993, Control of enteric pathogens in developing countries, In Mitchell
R (ed).
Cairncross S and Feachem R, 1993, Environmental health engineering in the tropics:
an introductory text (2nd edition). John Wiley and Sons, Chichester, UK.
Curtis V, Cairncross S and Yonli R, 2000, Domestic hygiene and diarrhea -
pinpointing the problem, Tropical Medicine and International Health, 5(1): 22-32.
Emerson P M, Cairncross S, Bailey R L and Mabey D C W, 2000, Review of the
evidence base for the ‘F’ and ‘E’ components of the SAFE strategy for trachoma
control, Tropical Medicine and International Health, 5(8): 515-527.
Esrey SA, Potash JB, Roberts L and Shiff C, 1991, Effects of improved water supply
and sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection,
schistosomiasis, and trachoma, Bulletin of the World Health Organization, 609-621.
Esrey S, 1996, Water, waste and well-being: a multi-country study, American Journal
of Epidemiology, 143(6): 608-623.
Fass S M, 1993, Water and poverty: implications for water planning, Water Resources
Research, 29(7): 1975-1981.
Food and Nutrition Board, 1989, Recommended dietary allowances 10th edition,
National Academy Press, Washington, DC.
website:
http://www.who.int/water sanitation health
125
LESSON Communication System
14
COMMUNICATION SYSTEM
CONTENTS
14.1 Introduction
14.2 Definitions
14.3 Scope of Hospital Communication System
14.4 Benefits of Hospital Communication System
14.5 Components of Basic Communication System
14.6 Components of Hospital Communication System
14.7 Modern Operation and Associated Equipments
14.8 Challenges in Communication Systems
14.9 Let us Sum up
14.11 Keywords

z Understand the meaning and definition of communication system
z Understand the flow/direction of communication in hospitals
z Study the comparison between the components of basic and hospital
communication system
z Analyze the various challenges in the communication
14.1 INTRODUCTION
Patients typically have a difficult time judging the quality of medical care they
receive. But they have no difficulty in judging whether the picture on their television
was clear, if the nurse could hear them when they called for help or the sleep they lost
when an intruder ran down the hall at 3:00 am. Helping you increase patient
satisfaction in these non-clinical areas is the mission of Hospital Communications
Systems.
Many hospitals, because of communication problems, do not use their personnel
(primarily nurses) in the most efficient manner. The present preferred way of best
utilizing a nurse's time is for one or more nurses to be stationed at a central nurses
station. From this station, the nurse services a floor, a wing, or a plurality of rooms of
a hospital, depending upon the size and layout of the hospital by continuously rotating
12 through the rooms assigned to her to check on "her" patient's condition. This method
(Supportive Services) of operation has several disadvantages. It requires that the nurse be constantly moving
and, thus, is physically exhausting. In addition, a nurse may be checking on one
patient when an emergency occurs to another patient, and, thus, she may not be alerted
in time to assist the patient with the emergency. To alleviate this undesirable situation,
most hospitals have installed what is commonly known as a Communication System.
Such a system provides a means of signal communication between a patient and a
nurse located at a central station. In addition, such a system usually provides two-way
audio communication between the nurse and the patient. While these systems
somewhat improve the communication between a nurse and her patients.
A quality communications system plays a vital role in any hospital or other health care
facility. Hospital Communications Systems provides not only the latest, most reliable
equipment, but goes further with unparalleled installation and service.
14.2 DEFINITIONS
Communication: It is the process of generation, transmission, or reception of
messages to oneself or another entity, usually via a mutually understood set of signs.
There is much discussion in the academic world of communication as to what actually
constitutes communication. Currently, many definitions of communication are used in
order to conceptualize the processes by which people navigate and assign meaning.
Communication is also understood as the exchanging of understanding.
We might say that communication consists of transmitting information from one
person to another. In fact, many scholars of communication take this as a working
definition, and use Lasswell's maxim, "who says what to whom in what channel with
what effect”.
A communication system is provided with multiple purpose personal communication
devices. Each communication device includes a touch-sensitive visual display to
communicate text and graphic information to and from the user and for operating the
communication device. Voice activation and voice control capabilities are included
within communication devices to perform the same functions as the touch-sensitive
visual display. The communication device includes a built-in modem, audio input and
output, telephone jacks, and wireless communication.
Hospital Communication Systems: It is defined as, “The transmission of messages to
staff and patients within a hospital”. This invention relates to communication systems
and more particularly to a communication system for communicating between
hospital room patients and a central nurses' station
14.3 SCOPE OF HOSPITAL COMMUNICATION SYSTEM

Hospital Communication Systems ...offers tailored turnkey solutions to help our
clients meet their television, nurse call, security and other communication needs
regardless of the job size or specifications:
a) Communication Solution: A quality communications system plays a vital role in
any hospital or other health care facility. Hospital Communications Systems
provides not only the latest, most reliable equipment, but goes further with
unparalleled installation and service.
b) Security Solution: Hospital Communications Systems provide you with the latest
security technology that will allow your staff to concentrate on what matters most:
Caring for your patients in a safe secure environment.
c) Nurse Call Solution: A nurse call system plays a critical role in the delivery of
quality patient care. In a hospital or other health care setting, a reliable high-
functioning system is the next best thing to face to face communication between a 12
patient and nurse. Communication System
d) Television Solution: A part of Hospital Communications Systems' mission is to

ensure that your patients are educated and entertained while they are cared for.
Hospital Communication System offers a number of television and video system
solutions which offer the convenience and safety required in a health care setting.
14.4 BENEFITS OF HOSPITAL COMMUNICATION

SYSTEM
Hospital Communications Systems does much more than providing equipments for
transmitting information. The system’s approach begins with a thorough analysis of
the client's needs. These needs are used as the basis for designing a system where
equipment and engineering integrates with other communication systems in the
facility. This is supported by employee technicians rather than subcontractors who
install and service the systems.
Hospital Communications Systems has a wide variety of equipment for television,
video on-demand, nurse call, wireless phone, security and other communication
systems from well-known manufacturers such as Zettler, Versus, DGA Technologies,
Ascom, Visiplex, Curbel, Galaxy Control Systems, Xmark Systems, Pelco, Loronix,
Blonder Tongue, Lucasey, RCA, Zenith, PDI Communications, and Sumitomo. With
technology advancing so rapidly, the system always seeking and evaluating the latest
products from leading manufacturers.
The emphasis is on providing a more comprehensive approach to client relationships
and thereby increasing equipment value. Following are some of the notable benefits
from Hospital communication systems:
z Fast, easy, accurate notification
z Activate automated or live dispatcher notifications through Personal Computer ,
web, or phone clients
z Establish message priorities for various alarms and events
z Alerts a mass number of people in seconds
z Dispatch messages to a variety of pagers, mobile phones, hard-wired phones,
e-mail, instant messages, dome lights, and pocket PC’s
z Aids in business continuity, disaster planning and recovery processes
z Escalate messages from one person to another until the message is acknowledged,
up to five levels
z Device sequencing for failover to alternate wireless networks and devices
z Provides configurable alerts aimed at reducing patient falls and improving patient
safety based on real-time bed status information.
z Eliminates noisy disruptive paging and keeps the hospital environment quiet and
confidential improving patient satisfaction and increasing staff productivity
z Alerts admissions and housekeeping of room clean status automatically
z Delivers alerts immediately through multiple wireless communication options,
z Communicates room-to-room directly and hands-free instantly connecting
patients and caregivers
z Installs services easily with industry standard
12 z Configure care alerts increase patient safety a powerful communications tool
(Supportive Services) providing instant, hands-free communication among caregivers, patients,
dispatchers, and staff.
z offers configurable fall risk alerts and other patient safety and operational alerts
based on real-time bed information.
z enables improved staff efficiency and patient flow by automatically alerting
admissions and housekeeping of room status.
z Better communications, better information – all in one system
z Improving caregiver-patient communication – helps satisfy patient needs and
improve patient satisfaction.
z The optimization of resource utilization, improving efficiency in the care
environment by integrating real-time connections between products and solutions,
and delivering actionable information to the right people at the right time helps all
hospital staff care for patients more safely, efficiently and effectively.
z Information at the fingertips of patients & Easy Installation Service. A caregiver
responds to the patient. Quiet confidential environment eliminates the need for
duplicate data entry, thereby saving valuable staff time. Patient information and
room/bed assignments are updated automatically
Administrative Client is a valuable tool for hospital administrators responsible for
compiling data on patient care activities and staff efficiency.
In short it provides wide range of services covering:

Patient Satisfaction: The room to room hospital communications and wireless
interface capabilities keep the patient environment quiet and free from overhead
paging.
Housekeeping Efficiency: This nurse call system enables improved efficiency and
patient flow by automatically alerting admissions and housekeeping of room status.
Operational Efficiency: The display of staff location information can result in
valuable time savings for caregivers. The hospital communication system seamlessly
integrates infrared staff locating with room to room hospital communications to
provide caregivers the ability to locate and answer calls from any room equipped with
an audio station with digital display.
Enhanced Reporting: the hospitals patient satisfaction goals can be monitored using
enhanced reports for patient call response times. Staff management can be better
addressed using staff activity reports designed for nursing management.
Easy to install and maintain: The system uses standard cabling with connectors to
simplify installation and maintenance of the system. Home run cables enhance the
overall reliability of the system
14.5 COMPONENTS OF BASIC COMMUNICATION

SYSTEM
A communication system consists of three basic elements:
z a transmitter- that takes information and converts it to a signal;
z a transmission medium - that carries the signal; and
z a receiver - that receives the signal and converts it back into usable information.
For example, in a radio broadcast the broadcast tower is the transmitter, free space is
the transmission medium and the radio is the receiver. Often telecommunication
systems are two-way with a single device acting as both a transmitter and receiver or 12
transceiver. Communication over a phone line is called point-to-point communication Communication System
because it is between one transmitter and one receiver. Telecommunication through

radio broadcasts is called broadcast communication because it is between one
powerful transmitter and numerous receivers.
Analogue or digital: Signals can be either analogue or digital. In an analogue signal,
the signal is varied continuously with respect to the information. In a digital signal,
the information is encoded as a set of discrete values for example ones and zeros.
During transmission the information contained in analogue signals will be degraded
by noise. Conversely, unless the noise exceeds a certain threshold, the information
contained in digital signals will remain intact. This noise resistance represents a key
advantage of digital signals over analogue signals.
Networks: A collection of transmitters, receivers or transceivers that communicate
with each other is known as a network. Digital networks may consist of one or more
routers that route information to the correct user. An analogue network may consist of
one or more switches that establish a connection between two or more users. For both
types of network, repeaters may be necessary to amplify or recreate the signal when it
is being transmitted over long distances.
Channels: A channel is a division in a transmission medium so that it can be used to
send multiple streams of information. For example, a radio station may broadcast at
96.1 MHz while another radio station may broadcast at 94.5 MHz. In this case, the
medium has been divided by frequency and each channel has received a separate
frequency to broadcast on. Alternatively, one could allocate each channel a recurring
segment of time over which to broadcast — this is known as time-division
multiplexing and is sometimes used in digital communication.
Modulation: The shaping of a signal to convey information is known as modulation.
Modulation can be used to represent a digital message as an analogue waveform. This
is known as keying and several keying techniques exist (these include phase-shift
keying, frequency-shift keying and amplitude-shift keying). Modulation can also be
used to transmit the information of analogue signals at higher frequencies. This is
helpful because low-frequency analogue signals cannot be effectively transmitted over
free space. There are several different modulation schemes available to achieve this
two of the most basic being amplitude modulation and frequency modulation.
14.6 COMPONENTS OF HOSPITAL COMMUNICATION

SYSTEM
Hospital Communication Systems offers turnkey solutions to help our clients meet
their television, nurse call, security, and other communications needs:
z Hospital televisions - MATV & RF Distribution
z On-demand education/information systems
z Satellite systems - entertainment, teleconferences, and programming packages
z Nurse call systems, intercom and overhead paging
z Infant abduction and patient wandering
z Access control systems
z CCTV surveillance/security systems
z In-building wireless phone systems
z Service and maintenance contracts
1
Hospital Operation-II 14.7 MODERN OPERATION AND ASSOCIATED
EQUIPMENTS
Telephone
a) Optical fibre: provides cheaper bandwidth for long distance communication. In an
analogue telephone network, the caller is connected to the person he wants to talk
to by switches at various telephone exchanges. The switches form an electrical
connection between the two users and the setting of these switches is determined
electronically when the caller dials the number. Once the connection is made, the
caller's voice is transformed to an electrical signal using a small microphone in the
caller's handset. This electrical signal is then sent through the network to the user
at the other end where it transformed back into sound by a small speaker in that
person's handset. There is a separate electrical connection that works in reverse,
allowing the users to converse.
b) Fixed-line telephones: in most nursing homes are analogue — that is, the
speaker's voice directly determines the signal's voltage. Although short-distance
calls may be handled from end-to-end as analogue signals, increasingly telephone
service providers are transparently converting the signals to digital for
transmission before converting them back to analogue for reception. The
advantage of this is that digitized voice data can travel side-by-side with data from
the Internet and can be perfectly reproduced in long distance communication.
c) Mobile phones: had a significant impact on telephone networks. Increasingly
these phones are being serviced by systems where the voice content is transmitted
digitally such as GSM or W-CDMA with many markets choosing to depreciate
analogue systems such as AMPS.
Radio and Television

In a broadcast system, a central high-powered broadcast tower transmits a high-
frequency electromagnetic wave to numerous low-powered receivers. The high-
frequency wave sent by the tower is modulated with a signal containing visual or
audio information.
The antenna of the receiver is then tuned so as to pick up the high-frequency wave and
a demodulator is used to retrieve the signal containing the visual or audio information.
The broadcast signal can be either analogue, signal is varied continuously with respect
to the information or digital, information is encoded as a set of discrete values.
The broadcast media industry is at a critical turning point in its development, with
many countries moving from analogue to digital broadcasts. This move is made
possible by the production of cheaper, faster and more capable integrated circuits. The
chief advantage of digital broadcasts is that they prevent a number of complaints with
traditional analogue broadcasts. For television, this includes the elimination of
problems such as snowy pictures, ghosting and other distortion.
Internet
The Internet is a worldwide network of computers and computer networks that can
communicate with each other using the Internet Protocol. Any computer on the
Internet has a unique IP address that can be used by other computers to route
information to it. Hence, any computer on the Internet can send a message to any
other computer using its IP address. These messages carry with them the originating
computer's IP address allowing for two-way communication. In this way, the Internet
can be seen as an exchange of messages between computers.
The Internet works in part because of protocols that govern how the computers and
routers communicate with each other. The nature of computer network
communication lends itself to a layered approach where individual protocols in the 1
protocol stack run more-or-less independently of other protocols. This allows lower- Communication System
level protocols to be customized for the network situation while not changing the way
higher-level protocols operate.
Local Area Networks

Despite the growth of the Internet, the characteristics of local area networks, computer
networks that run at most a few kilometres, remain distinct. This is because networks
on this scale do not require all the features associated with larger networks and are
often more cost-effective and efficient without them.
It is at the data link layer though that most modern local area networks diverge from
the Internet. Whereas Asynchronous Transfer Mode (ATM) or Multiprotocol Label
Switching (MPLS) are typical data link protocols for larger networks, Ethernet and
Token Ring are typical data link protocols for local area networks. These protocols
differ from the former protocols in that they are simpler (e.g. they omit features such
as Quality of Service guarantees) and offer collision prevention. Both of these
differences allow for more economic set-ups.
Check Your Progress
Define communication, communication systems and hospital communication
systems.
…………………………………………………………………………….........
…………………………………………………………………………….........
14.8 CHALLENGES IN COMMUNICATION SYSTEMS

a) Managing multiple communication networks: It can often be challenging for a
communications department to manage the various combinations of local and
wide area communication systems. And even more difficult is managing the
ongoing departmental requests to interface applications with limited
communication ports.
This needs most advanced, flexible communication gateway that can interface
with up to 100 communication systems. In addition, user modules, application
adapters and developer toolkits are needed to interface users and applications into
an existing and future communication infrastructure.
b) Mass communication for the entire healthcare enterprise: Today there arise a
need to healthcare organizations to make use of interface applications with any
communication network and device. And only by implementing a redundant
communication gateway, information flow and reliability can be maintained at a
rate of 99.9% and higher. Communication is critical in healthcare, and only
advanced technology provides a proven, reliable communication platform that
meets the needs of the most demanding healthcare enterprises.
c) Cost-containment efforts: Hospitals have been largely affected by payment and
other reforms than have community hospitals. As a result, further reductions in
use of hospitals will likely to occur as they strive to shift more of its care to
outpatient and other more cost-effective settings.
d) Adapting to Changes: Changes include the hospitals’ basic structure and
management; reinvention of basic work, procurement, and supply processes;
development of new marketing strategies; and methods and procedures for
monitoring and delivering patient care. Now a days hospitals has focused attention
on such areas as materials management and development of clinical guidelines
1 and outcome measures. Another challenge is to have focused attention on other
(Supportive Services) areas such as transforming basic work processes, contracting for patient and non-
patient care services, and marketing. Teaching hospitals face additional
challenges.
e) Advancing technology: In the first three-quarters of the century, advancing
technology increased demand for hospital care however, recent innovations have
had the opposite effect. Until the last few years, demand for inpatient medical and
non medical services was not affected by such medical advances as much as was
demand for care in community hospitals. Because its methods for allocating
resources to its facilities favored inpatient hospital care. But now it was slowing
down unable to cope up with upcoming technological advancements.
f) Changing Hospital Structure and Management: As they struggle to survive,
hospitals are increasingly forming alliances and networks with other hospitals and
adding other types of health care services, hiring outside management; and
improving accounting and information systems to enable managers to better
identify and eliminate inefficiencies. With the exception of hiring outside
management, is similarly changing its health care system, and it faces many
challenges in this regard.
g) Transforming Work Processes:
contracting for both patient care and non-patient care services when it is less
expensive than providing the care directly,
using more part-time and temporary nurses and other health care professionals
to increase flexibility in meeting changing workloads and patient mix,
cross-training personnel to perform many jobs to more efficiently use
available staff,
developing nurse extender and other new auxiliary positions to allow nurses
to devote more time to direct patient care, and
restructuring the delivery of care to emphasize patient-centered care to
increase efficiency and patient satisfaction.
14.9 LET US SUM UP

Communication is an essential tool which plays a major role in conversation of certain
messages. In this lesson we discussed the techniques, components and the problems in
the communication of messages.

Design a communication system flow chart for a hospital.
14.11 KEYWORDS
Modulation: Shaping of a signal to convey information.
Networks: A collection of transmitters, receivers or transceivers that communicate
with each other.
Channel: A division in a transmission medium.

1. What are the scope of hospital communication system?
2. Explain the benefits of hospital communication system.
3. Compare the components of basic communication system and components of 1
hospital communication system. Communication System
4. What are the modern operation and associated equipments?

5. Explain the challenges in communication systems.

Communication: It is the process of generation, transmission, or reception of
messages to oneself or another entity, usually via a mutually understood set of
signs.
Communication systems: It is provided with multiple purpose personal
communication devices. Each communication device includes a touch-
sensitive visual display to communicate text and graphic information to and
from the user and for operating the communication device.
Hospital communication systems: It is the transmission of messages to staff
and patients within a hospital. This invention relates to communication
systems and more particularly to a communication system for communicating
between hospital room patients and a central nurses' station.

VA Health Care: Status of Efforts to Improve Efficiency and Access , 98-48, Feb. 6,
1998.
VA Medical Care: Increasing Recovering From Private Health Insurers Will Prove
Difficult -98-4, Oct. 17, 1997.
The Results Act: Observations on VA’s August 1997 Draft Strategic Plan -97-215,
Sept. 18, 1997.
VA Health Care: Resource Allocation Has Improved, but Better Oversight Is Needed
– 97-178, Sept. 17, 1997.
VA Health Care: Lessons Learned From Medical Facility Integrations - 97-184, July
24, 1997.
VA Health Care: VA Is Adopting Managed Care Practices to Better Manage
Physician Resources -97-87, July 17, 1997.
Veterans’ Affairs: Veterans Benefits Administration’s Progress and Challenges in
Implementing GPRA -97-131, May 14, 1997.
VA Health Care: Assessment of VA’s Fiscal Year 1998 Budget Proposal -97-121,
May 1, 1997.
Department of Veterans Affairs: Programmatic and Management Challenges Facing
the Department -97-97, Mar. 18, 1997.
Substance Abuse Treatment: VA Programs Serve Psychologically and Economically
Disadvantaged Veterans -97-6, Nov. 5, 1996.
134
LESSON
15
BIOMEDICAL ENGINEERING DEPARTMENT
CONTENTS
15.1 Introduction
15.2 Definition
15.3 Scope
15.4 Role of Biomedical Engineering
15.5 Disciplines in Biomedical Engineering
15.6 Functions of Biomedical Engineering Department
15.7 Responsibilities of Biomedical Engineering Department
15.8 Biomedical Engineering Personnel
15.9 Biomedical Engineering Operation and Maintenance Program
15.9.1 General Operation
15.9.2 Maintenance
15.9.3 Equipment Procurement
15.10 Biomedical Engineering Training
15.11 Safety Requirements
15.12 Let us Sum up
15.14 Keywords

z Understand the meaning, scope and role of biomedical engineering department
z Get to know the disciplines and functions of biomedical engineering department
z Study the responsibilities and safety requirements
z Know the training methods in biomedical engineering
15.1 INTRODUCTION
Quality in health services is a main objective for health care institutions. This means
not just to correct adverse events but preventing them, as the concept of total quality
approach establish. In this sense, the objective of a Biomedical Engineering
Department (BED) in a hospital, is to maintain the medical equipment in optimal
conditions of functionality as well as the hospital facilities, because of these elements 13
has an important impact in the health services quality. The objective of this work was Biomedical Engineering Department
to develop and to apply some control forms, in order to provide information about the
performance of the technical personnel of the BED, as well as maintenance processes
done by the BED from the Child’s Hospital of Sonora State, improving the
performance level of the personnel and helping in health services quality.
15.2 DEFINITION
Biomedical Engineering (BME) is the application of engineering principles and
techniques to the medical field. It combines the design and problem solving skills of
engineering with medical and biological sciences to help improve patient health care
and the quality of life of individuals.
As a discipline biomedical engineering consists of research and development,
covering an array of fields: bioinformatics, medical imaging, image processing,
physiological signal processing, biomechanics, biomaterials and bioengineering,
systems analysis, 3-D modeling, etc. Examples of concrete applications of biomedical
engineering are the development and manufacture of biocompatible prostheses,
medical devices, diagnostic devices and imaging equipment such as MRIs and EEGs,
and pharmaceutical drugs
15.3 SCOPE
Biomedical engineering can be divided into four sub-areas:
z Bioengineering focuses on pure research; with the aid of mathematical models
and simulations;
z Medical Engineering is directed to the study, design and construction of
instrumentation (mainly electronic), sensors, and prosthesis for the medical field;
z Clinical or Hospital Engineering focuses in certification and testing of medical
equipments and hospital activities, such as design, adequacy and execution of
installations, consulting for acquisition of equipments, training of maintenance
teams;
z Rehabilitation Engineering aims the development of electronic and mechanical
systems for the improvement of the quality of life of physically challenged
people.
15.4 ROLE OF BIOMEDICAL ENGINEERING

Biomedical engineering developed with an early large emphasis on the maintenance,
electrical safety, and electronics aspects of medical equipment. This encouraged the
consideration of broader safety aspects in health care.
Biomedical engineer must provide education for nursing, medical, and paramedical
staff to facilitate their understanding of present technology and future trends. In
consultation with medical and administrative staff, he or she must ensure that
equipment purchases and hospital designs and systems are optimal and that
technology acquisitions are appropriate; he or she must engage in applied research and
development at all levels to improve patient care and make provisions for the safe and
effective use of technology.
15.5 DISCIPLINES IN BIOMEDICAL ENGINEERING

Biomedical engineering is widely considered an interdisciplinary field, resulting in a
broad spectrum of disciplines that draw influence from various fields and sources.
1 Due to the extreme diversity, it is not atypical for a biomedical engineer to focus on a
(Supportive Services) particular aspect. There are many different taxonomic breakdowns of BME, one such
listing defines the aspects of the field as such:
z Bioelectrical and neural engineering
z Biomedical imaging and biomedical optics
z Biomaterials
z Biomechanics and biotransport
z Biomedical devices and instrumentation
z Molecular, cellular and tissue engineering
z Systems and integrative engineering
In other cases, disciplines within BME are broken down based on the closest
association to another, more established engineering field, which typically include:
z Chemical engineering - often associated with biochemical, cellular, molecular and
tissue engineering, biomaterials, and biotransport.
z Electrical engineering - often associated with bioelectrical and neural engineering,
bioinstrumentation, biomedical imaging, and medical devices.
z Mechanical engineering - often associated with biomechanics, biotransport,
medical devices, and modeling of biological systems.
z Optics and Optical engineering - biomedical optics, imaging and medical devices.
a) Clinical engineering: Clinical engineering is a branch of biomedical engineering
for professionals responsible for the management of medical equipment in a
hospital. The tasks of a clinical engineer are typically the acquisition and
management of medical device inventory, supervising Biomedical Engineering
Technicians (BMETs), ensuring that safety and regulatory issues are taken into
consideration and serving as a technological consultant for any issues in a hospital
where medical devices are concerned. Clinical engineers work closely with the IT
department and medical physicists.
b) Medical devices: A medical device is intended for use in:
the diagnosis of disease or other conditions, or
in the cure, mitigation, treatment, or prevention of disease,
intended to affect the structure or any function of the body of man or other
animals, and which does not achieve any of its primary intended purposes
through chemical action and which is not dependent upon being metabolized
for the achievement of any of its primary intended purposes.
A pump for continuous subcutaneous insulin infusion, an example of a
biomedical engineering application of electrical engineering to medical
equipment.
Some examples include pacemakers, infusion pumps, the heart-lung machine,
dialysis machines, artificial organs, implants, artificial limbs, corrective lenses,
cochlear implants, ocular prosthetics, facial prosthetics, somato prosthetics, and
dental implants.
Stereolithography is a practical example on how medical modeling can be used to
create physical objects. Beyond modeling organs and the human body, emerging
engineering techniques are also currently used in the research and development of
new devices for innovative therapies, treatments, patient monitoring, and early
diagnosis of complex diseases.
c) Medical imaging: An MRI scan of a human head, an example of a biomedical 13
engineering application of electrical engineering to diagnostic imaging. Imaging Biomedical Engineering Department
technologies are often essential to medical diagnosis, and are typically the most
complex equipment found in a hospital including:
Fluoroscopy
Magnetic Resonance Imaging (MRI)
Nuclear Medicine
Positron Emission Tomography (PET) PET scansPET-CT scans
Projection Radiography such as X-rays and CT scans
Tomography
Ultrasound
Electron Microscopy
d) Tissue engineering: One of the goals of tissue engineering is to create artificial
organs for patients that need organ transplants. Biomedical engineers are currently
researching methods of creating such organs. In one case bladders have been
grown in lab and transplanted successfully into patients. Bioartificial organs,
which utilize both synthetic and biological components, are also a focus area in
research, such as with hepatic assist devices that utilize liver cells within an
artificial bioreactor construct.
e) Regulatory issues: Regulatory issues are never far from the mind of a biomedical
engineer. To satisfy safety regulations, most biomedical systems must have
documentation to show that they were managed, designed, built, tested, delivered,
and used according to a planned, approved process. This is thought to increase the
quality and safety of diagnostics and therapies by reducing the likelihood that
needed steps can be accidentally omitted again.
15.6 FUNCTIONS OF BIOMEDICAL ENGINEERING

DEPARTMENT
Biomedical/Clinical Engineering Departments with expertise in engineering and
technology management have a vital role to play in determining the potential for
implementation and cost effectiveness of new medical technologies through
technology assessment. Technology assessment offers the essential bridge between
basic research and development and the prudent practical applications of medical
technology. Because of the recent explosion of healthcare technologies, it is almost
impossible for any single individual to stay abreast of these new technologies, much
less provide an adequate assessment.
A typical biomedical engineering department does the corrective and preventive
maintenance on the medical devices used by the hospital, except for those covered by
a warranty or maintenance agreement with an external company. All newly acquired
equipment is also fully tested. That is, every line of software is executed, or every
possible setting is exercised and verified. Most devices are intentionally simplified in
some way to make the testing process less expensive, yet accurate. Many biomedical
devices need to be sterilized. This creates a unique set of problems, since most
sterilization techniques can cause damage to machinery and materials. Most medical
devices are either inherently safe, or have added devices and systems so that they can
sense their failure and shut down into an unusable, thus very safe state.
To conclude it performs wide range of functions such as:
z Equipment Inventory
1 z Preventive Maintenance (PM)
(Supportive Services) z Corrective Maintenance (CM)
z Pre-purchase Consultation
z Acceptance Testing (Incoming Inspections)
z Management of Service Contracts
z Risk Management
z Quality Control
z Education and Training
z Research and Development
15.7 RESPONSIBILITIES OF BIOMEDICAL

ENGINEERING DEPARTMENT
The major responsibilities for the biomedical engineering department are:
a) Education: Prime responsibility for making provisions for training and education
associated with technology and instrumentation used in the hospital are education
of Biomedical engineering staff and education of health care facility staff
b) Clinical Research and Development: These include design of new equipment,
patient aids, and techniques to aid in patient care and assistive devices.
c) Computing Applications: On of the most important function of Biomedical
engineering is development and management of hospital and patient information
and data-acquisition systems.
d) Facility Planning: The application and proper use of technology entail the
appropriate management of all resources, including equipment, personnel,
supplies, and space. It must also be reflected at a very early stage in the planning
process in the planning and design of the facility itself.
e) Systems Management: This includes systems analysis, design and evaluation of
health care systems, and quality management.
f) Equipment Management: This includes consultation with other health care staff
in the planning and purchase of equipment and doing for maintenance and
modification of equipment.
15.8 BIOMEDICAL ENGINEERING PERSONNEL

Biomedical Engineering Professionals divides into two main categories:
z The Clinical Engineers (CE) or Biomedical Engineers, and
z The Biomedical Engineering (Equipment) Technicians (BMET)
Some organization add another professional called “Biomedical Instrumentation
Technology (BMIT)”.
15.9 BIOMEDICAL ENGINEERING OPERATION AND

MAINTENANCE PROGRAM
15.9.1 General Operation
An equipment management program must be based upon risk assessment that
considers the equipment function, physical risks to the patient, maintenance
requirements, equipment incident history, age and any unique local requirements.
Properly established, coordinated, and administered, it will keep equipment repair 1
costs to a minimum, ensure the inherent reliability of the equipment, and provide Biomedical Engineering Department
valuable information to the activity for systematic planning, technology management

and budgeting of equipment replacement. Within each program, procedures must be
developed to ensure the optimum performance of the following tasks:
1. Scheduled Maintenance: A scheduled maintenance program will be conducted to
determine and monitor the effectiveness of the entire maintenance program and
the performance of equipment users.
2. Administrative Procedures: Adequate administrative procedures will be
established for the control and documentation of all work performed.
3. Repairs: Equipment will be repaired in a timely manner with consideration. When
equipment repair requests are presented, the customers will be consulted to
determine the urgency of the repair, delays anticipated, existing logistical
problems, and estimated date of completion.
4. Modifications: Equipment modifications will be performed when directed by
equipment manufacturers or higher authority.
5. Condition Code Update: The condition code will be updated whenever an item of
equipment receives servicing that modifies the current condition code.
6. Equipment Evaluation: Equipment will be evaluated with each occurrence of
unscheduled maintenance and during the performance of preventive maintenance
to provide budgetary recommendations for overhaul, lifecycle extension or
possible replacement.
7. Equipment Installation: The installation of newly procured equipment items will
be conducted or monitored when installation is not included in the purchase price
of the equipment. A determination must be made of whether or not installation by
Government personnel will void manufacturer's warranties.
8. Receiving Inspections: Receiving inspections will be performed on all transferred
or newly acquired equipment. BIOFACS control numbers should be established
for each maintenance significant item and remain unchanged unless transferred to
another BIOFACS system and facility.
9. Procurement Planning Guidance: Technical management guidance and
assistance will be provided to equipment custodians, heads of service, and/or
department heads, as applicable, in planning for new equipment procurement.
10. Technical Library: A technical library of operating and service manuals,
miscellaneous technical reference manuals, parts and price listings, schematics,
and wiring diagrams will be maintained for all items of equipment that are to be
maintained.
11. Training: A technical training program for continuing education will be
established and maintained within the BMED/DED. Training should be directed
towards theory of operation, maintenance, and repair of equipment currently
installed within the command, or being procured.
12. Technical Guidance: Technical guidance and assistance will be provided in the
training of equipment operators in user maintenance procedures and proper
operation of equipment when necessary. Trained operators will establish training
within their department/division ensuring their personnel are sufficiently
qualified.
13. Repair Parts Management Program: A viable and economical repair parts
management program will be established.
1 15.9.2 Maintenance
Types of Maintenance Requirements (MR)
There are three types of MR:
1. Preventive Maintenance (PM): often called scheduled maintenance, serves to
ensure inherent reliability, increase operational availability, and prevents
excessive wear of moving parts.
2. Unscheduled Maintenance (UM): often referred to as corrective maintenance,
repairs equipment breakage or malfunctions.
3. No Maintenance Required (NMR): applies to equipment that normally requires
no scheduled maintenance based upon Risk Assessment, but is included in the
equipment files to document.
Maintenance Levels
There are three maintenance levels:
1. Level I (Performance testing): organizational maintenance consists of operator
maintenance that is performed before, during, and after equipment usage. It is the
basic maintenance required to keep equipment operating on a daily basis.
Procedures usually consist of maintaining fluid levels, simple lubrication, daily
inspections, cleaning, and/or operator calibration checks and adjustments.
2. Level II (Preventive Maintenance): intermediate maintenance relates to
scheduled periodic (planned) technical inspection, lubrications requiring
disassembly, replacement of worn or deteriorated parts, interior cleaning,
calibration verification and/or adjustment, and verification of Level I
performance. Level II maintenance is to be performed by a BMET, DET, or
contracted service.
3. Level III: maintenance consists of maintenance requiring complete overhaul of
the item of equipment and is considered depot level maintenance or equipment
manufacturer service center level maintenance. At command discretion,
performance of Level III maintenance by the local maintenance shop is permitted
if required parts, personnel with technical expertise, tools and test equipment, and
man hours are available. Level III maintenance will usually result in extension of
service life and should be documented in appropriate service history.
15.9.3 Equipment Procurement

A comprehensive approach to the procurement of medical and dental equipment is
essential. The department in conjunction with the safety manager, equipment
manager, department head, and facilities manager, should recommend procurement
specifications necessary for the safe and efficient installation and operation of
equipment.
1. Documentation: All requisitioning documents for new medical or dental
equipment will specify that contractors furnish two complete sets of manuals,
handbooks, and/or brochures. Literature furnished should contain the following
minimum information as applicable to equipment being procured:
Step-by-step, illustrated procedures for proper use and care of equipment.
Safety considerations in the application and servicing of the equipment.
Utility requirements with technical performance specifications (specifications
to include design levels of leakage current).
Schematics, wiring diagrams, plumbing diagrams, mechanical layouts, 1
complete parts lists, and other pertinent data for the item of equipment as Biomedical Engineering Department
shipped.
Preventive maintenance, trouble-shooting guides, and repair procedures
(service instructions should be the same as those furnished to the equipment
manufacturer's service engineers or technicians).
Diagnostic software for proper operation and servicing of the equipment.
2. Inspection: All newly acquired medical or dental equipment will be inspected by
a BMET to ensure that it will meet safety standards, manufacturer's specifications,
and contract requirements. Failure of inspection criteria will be reported to the
contracting officer for disposition. Minimum inspection requirements will consist
of the following:
Confirm that the item is free of physical or functional damage caused by
improper shipment and/or faulty manufacture.
Confirm that two copies of the operator's and service manuals have been
provided as per contract.
Confirm that the item of equipment meets all safety requirements (i.e., ground
resistance, leakage current, etc).
Conduct a complete safety and operational check of all systems to ensure that
the equipment performs according to the manufacturer's specifications.
3. Equipment History: Upon receipt and completion of inspection, all new medical
and/or dental equipment found to be acceptable will have an equipment history
record prepared and results of inspection, manufacturer's warranty information,
and initial condition code recorded. One copy of the operator's manual will
accompany the item of equipment when it is delivered to the requisitioning
department. Information concerning any idiosyncrasies of the equipment or its
operation should be brought to the attention of the personnel (operator) of the
requisitioning department.
4. Installation: The maintenance shop will ensure that installation, if provided by
contract, is complete.
15.10 BIOMEDICAL ENGINEERING TRAINING

1. Education: Biomedical engineers combine sound knowledge of engineering and
biological science, and therefore tend to have a bachelors of science and advanced
degrees from major universities. Many colleges of engineering now have a
biomedical engineering program or department from the undergraduate to the
doctoral level. Traditionally, biomedical engineering has been an interdisciplinary
field to specialize in after completing an undergraduate degree in a more
traditional discipline of engineering or science, the reason for this being the
requirement for biomedical engineers to be equally knowledgeable in engineering
and the biological sciences. However, undergraduate programs of study
combining these two fields of knowledge are becoming more widespread,
including programs for a Bachelor of Science in Biomedical Engineering.
Graduate education is also an important aspect in BME. Although many
engineering professions do not require graduate level training, BME professions
often recommend or require them. Since many BME professions often involve
scientific research, such as in the pharmaceutical and medical device industries,
graduate education may be highly desirable as undergraduate degrees typically do
not provide substantial research training and experience.
1 2. Specialized Technical Training: Specialized technical training required for the
(Supportive Services) maintenance and repair of a specific item of equipment that is to be procured
should be programmed into the purchase price of that item of equipment.
Additionally, training should be coordinated to occur in conjunction with the
receipt and installation of that item.
3. Professional certification: Engineers typically require a type of professional
certification, such as satisfying certain education requirements and passing an
examination to become a professional engineer. These certifications are usually
nationally regulated and registered, but there are also cases of self-governing
bodies, such as the Canadian Association of Professional Engineers. In many
cases, carrying the title of "Professional Engineer" is legally protected.As BME is
an emerging field, professional certifications are not as standard and uniform as
they are for other engineering fields.
Check Your Progress
1. Define biomedical engineering.
……………………………………………………………………………….
……………………………………………………………………………….
2. List down the various disciplines of biomedical engineering.
……………………………………………………………………………….
……………………………………………………………………………….
15.11 SAFETY REQUIREMENTS

The facility must include sufficient quantities of properly designed tools and
equipment, machine guards where mechanical hazards exist, high standards of
working environment including adequate lighting and ventilation; ample and orderly
working surfaces, storage areas for tools and materials; and systematic removal and
disposal of waste. The safety procedures and precautions outlined in Safety
Precautions for Shore Activities must be followed.
15.12 LET US SUM UP

The biomedical engineering is used for the purpose of problem solving in the field of
medical sciences inorder to improve patience health. In this lesson we discussed on
the roles, disciplines, functions, responsibilities of biomedical engineering and the
maintenance and training program in biomedical engineering department.

Explain a real life situation of biomedical engineering in a hospital. Explain its
workings.
15.14 KEYWORDS
Biomedical Engineering: Application of engineering principles and techniques to the
medical field.
Clinical Engineering: The management of medical equipment in a hospital.

1. What are the roles of biomedical engineering in a hospital?
2. What are the functions and responsibilities of biomedical engineering department? 1
Biomedical Engineering Department
3. Discuss on biomedical engineering personnel department.
4. Explain biomedical engineering operation and maintenance program.
5. Explain biomedical engineering training.
6. Write a note on safety requirements in biomedical engineering.

1. Biomedical Engineering: BME is the application of engineering principles
and techniques to the medical field. It combines the design and problem
solving skills of engineering with medical and biological sciences to help
improve patient health care and the quality of life of individuals.
2. Disciplines of Biomedical Engineering:
Bioelectrical and neural engineering
Biomedical imaging and biomedical optics
Biomaterials
Biomechanics and biotransport
Biomedical devices and instrumentation
Molecular, cellular and tissue engineering
Systems and integrative engineering

Biomedical Engineering, Navmed P-5132, 22 Oct 98, 1-10.
Paul McCown, Smith Seckman Reid. McCown, Creating an Energy Efficient Building
Jan/Feb 2005.
146
LESSON UNIT III 147
Laundry Services
16
LAUNDRY SERVICES
CONTENTS
16.1 Introduction
16.2 Definition and Meaning
16.3 Scope and Significance of Laundry Services
16.4 Functions
16.6 Role and Responsibilities of the Department
16.7 Duties and Responsibilities for the Department Head/Incharge Staff
16.8 Staffing Requirements
16.9 Selection of Equipment
16.11 Let us Sum up
16.13 Keywords

z Understand the meaning and scope of laundry services in hospitals
z Study the importance, role and responsibilities of laundry services
z Study the staffing function of laundry services in hospitals
z Analyze the equipments needed and the issues and challenges
16.1 INTRODUCTION
The importance of a clean environment and linen for optimal patient care has been
stressed upon since the very inception of hospitals. It goes without saying that
“supportive” services are indispensable for a hospital to perform in the true
perspective and deliver good patient care; besides going a long way in developing
good public relation of the hospital. A sick person coming to the alien environment of
the hospital gets tremendously influenced and soothed by the aesthetics or cleanliness
of the surroundings and the linen. On the contrary, dirty linen tends to result in
psychological dissatisfaction like a chain reaction, which creates a negative image of
the entire hospital. Studies have proved beyond doubt, that hospital acquired
infections show an increase whenever laundry and linen services are inadequate.
14 A reliable laundry service is of utmost importance to the hospital. In today’s medical
(Supportive Services) care facilities, patients expect linen to be changed daily. An adequate supply of clean
linen is sufficient for the comfort and safety of the patient thus becomes essential. The
hospital can either purchase washing machine or engage a washer man (dhobi) to
manually wash the clothes. The main purpose of this department is to provide clean
material to the patients and ensure that hygienic conditions are maintained in the
process.
16.2 DEFINITION AND MEANING

Laundry service is responsible for providing an adequate, clean and constant supply of
linen to all users. The basic tasks include: sorting, washing, extracting, drying,
ironing, folding, mending and delivery.
The term ‘hospital linen’ includes all textiles used in the hospital including mattress,
pillow covers, blankets, bed sheets, towels, screens, curtains, doctors coats, theatre
cloth and table cloths. Cotton is the most preferred and frequently used material. The
hospital receives all these materials from different areas like Operation Theatre,
wards, outpatient departments and office areas.
16.3 SCOPE AND SIGNIFICANCE OF LAUNDRY

SERVICES
The importance of running a laundry service at a reasonable cost to the patient by the
hospital needs greater emphasis. The importance of a clean environment and linen for
optimal patient care has been stressed upon since the very inception of hospitals. A
sick person coming to the alien environment of the hospital gets tremendously
influenced and soothed by the aesthetics or cleanliness of the surroundings and the
linen. Clean linen is an aid to reduction of hospital acquired infections. The main
objective of the laundry service will be to provide better patient care through properly
planned and cleaned linen supplies.
Laundry is an essential function for all institutional housekeeping departments, but in
health care facilities, laundry plays an even more important role not only contributing
to comfort and aesthetics, but also assisting with infection control. Because of its high
level of energy, chemical and water consumption, laundry processing also has a
significant impact on hospitals’ environmental and financial bottom line.
Like any department, laundry services must continuously find ways to increase
efficiency and decrease costs. Purchasing and Materials managers may be involved
with decision-making about purchasing new laundry chemicals and technologies, so it
makes sense to be informed about laundry innovations. Several developments in
laundry technologies and products have enabled laundry managers to cut energy and
water use significantly and to reduce the impact of laundry chemicals on the
environment.
Many healthcare facilities have decided, for reasons of space, or economies of scale,
to outsource laundry functions, yet a significant proportion of facilities still manage
laundry on-site, or through a central laundry owned and operated by their health
system. When analyzing the financial viability of in-house laundry facilities, it is
important to consider facility upgrades as a possible means to saving money and
improving environmental performance while maintaining control over laundry
processing. Assessing the comparative environmental and cost impacts of
transportation for pickup and delivery of linens is also important. But whether laundry
services are outsourced or handled in house, implementation of innovative programs
and technologies can reduce environmental impact and should be promoted through
service agreements or purchasing specifications.
Any hospital has the requirement to laundry or dry-clean the hospital linen, which 14
comprises of big or small linen items both white and coloured, blankets, plastic Laundry Services
curtains or tapestry etc. The laundry is to be operated on all days in one or more shifts
depending on workload. The washed linen has to be delivered within 24 hours of
receipt for processing. The quantity of linen items to be washed at present in any
ordinary hospital is approximately 15,000 pieces per day. This quantity is likely to
increase with the addition of new centers or patient care facilities.
16.4 FUNCTIONS
Laundry can either be done in-house or contracted to an outside enterprise. Hence the
functions may also be divided into two heads as:
Functions of the In-house Laundry Services

1. Collecting soiled linen from various places.
2. Sorting the linen and processing them.
3. Inspecting and repairing or replacing damaged materials.
4. Distributing clean linen to the respective user departments.
5. Maintaining different types of registers.
Functions of the Contracted Laundry Services

1. The laundry services shall be meant for the whole institute (Main Hospital and
Centres including IPD, OPD, different Diagnostic blocks, Emergency services,
Maternity services, Minor and Major OT’s, Administrative block etc.), or as per
the directions of institute authorities from time to time.
2. The provision of appropriate manpower, material supplies, required for
performing the tasks processes of the laundry services, shall be borne by the
contractor.
3. The complete job of collecting of dirty linens from earmarked place/places to
supply of cleaned linens to earmarked place/places of the hospitals shall be carried
out by the contractor, i.e. sluicing, washing, hydro-extraction, drying, repairing of
the linens, ironing/calendaring, storing and issue or distribution of cleaned linen.
4. The tenderer will be wholly responsible for providing laundry services in the
institute. The linen must be washed and ironed properly up to the satisfaction of
institute authorities.
5. The equipment provided by the hospital authorities shall be used by the contractor
solely for the laundry services of the hospital. The contractor, as per the operating
manual of the equipment shall strictly adhere to appropriate handling of the
equipment. The contractor shall ensure the routine repair for the all minor/normal
wear and tear due to use and breakdown in the laundry system.
6. Every worker engaged in laundry services shall wear the prescribed neat and clean
uniform according to season affixing thereon the badge mentioning on the same,
the name and designation of the worker provided by the contractor at his own
cost.
7. If any complaint of misbehavior and misconduct comes into the knowledge of the
institute authorities then all such responsibility shall be of the contractor and any
loss owing to negligence or mishandling by the laundry staff, the contractor shall
himself be responsible to make good for the losses so suffered by the institute.
8. The contractor shall not, at any stage, cause or permit any sort of nuisance in the
premises of institute or do anything which may cause unnecessary disturbance or
inconvenience to other working there as well as to the general public in the
institute premises and near to it.
1 9. The contractor shall not engage any sub-contractor or sublet/transfer the contract
(Supportive Services) to any other agency/person in any manner.
10. The contractor shall, for providing proper and hygienically laundry services,
ensure the following:
i) That a daily report of its staff on duty and about their performance is
furnished and maintained.
ii) That its staff does not smoke at the place of work.
iii) That any specific laundry work assigned to it by the Principal Employer or
any officer authorized by him is carried out by him diligently and well in
time.
iv) That before using any equipment/appliances or material and products of
laundry, it is having the approval of the Principal Employer as no sub
standard material being used.
v) The Principal Employer may also furnish that the salary wages shall be
distributed in full as per Minimum Wages Act by the contractor to the laundry
worker(s) in the presence of a representative of the institute and a certificate
to this effect is provided.

The laundry should be located in an area that has ample daylight and natural
ventilation. Ideally, it should be on the ground floor of an isolated building connected
or adjacent to the water and power plant. The following are the space requirements for
the laundry services:
1. Space for heavy equipments like washing machine, squeezer etc.
2. Provision for supply of water and power.
3. Storage place for cleaning agents.
4. Space is also needed for sorting the soiled linen
5. Facilities to manually wash doctor’s uniform and clean other soiled linen.
6. Clothes lined to dry in the sun.
7. Lines of cards to dry clothes in the sun.
8. Place for sewing, and mending area.
9. Place for ironing.
10. Desk to have registers and files.
11. Space in every ward for storing clean linen.
16.6 ROLE AND RESPONSIBILITIES OF THE

DEPARTMENT
Processes to be undertaken
1. Collection and transport of dirty linen: the department is responsible for collection
of dirty linen from the different user areas and transport the same to laundry
department.
2. Sorting, processing of used linen with standard laundering processes including
repairing (if required), finishing and packing. Transportation and delivery of
washed clothes in a covered trolley to the user area daily.
3. The staff will identify torn linen at the time of collection, process and wash them.
Only torn linen will be replaced by the institute.
4. The department is responsible for safe disposal of left chemicals and other 15
washing materials and other garbage produced in laundry, as per the norms. Laundry Services
5. Separate trolleys for transport and storage of dirty and washed linen will be used.
The hampers or carts to transport soiled textiles should be appropriately cleaned
after every use and should be kept away from those to be used in transporting
clean textiles.
6. The department will process linen as per approved washing procedure and
approved washing formulae.
7. Standard universal precautions to be followed while collecting and handling
Infected/soiled linen.
8. Bio-Medical Waste management rules, wherever applicable will be followed by
the department.
Manpower
1. Adequacy and training: The department shall employ adequate number of well
trained staff. Firm will provide uniforms, aprons and other protective gear to
ensure proper protection to all workers. All workers will be immunized by the
firm before employment and during the course of employment as and when
needed. All personnel involved in collection, transport, sorting, and washing of
soiled textiles should be consistently and appropriately trained at frequent
intervals specially for the use of, appropriate Personal Protective Equipment
(PPE), and be supervised to assure compliance with protective procedures.
2. Medical examination of staff: The department shall employ only those persons in
the laundry who are found to be medically fit. Hospital reserves its rights to
examine any of the employees for medical fitness without prior notice. Expenses,
if any incurred on medical examination of such employees, shall be borne and
paid by the hospital.
3. Wages to employees and Insurance: The department shall comply with the laws
applicable to employees working in the laundry regarding working hours,
minimum wages, safety, cleanliness, leave, over time allowances, provident fund,
retrenchment benefit, medical benefit like ESI etc. If on account of non-
compliance with the provisions of any such laws, hospital is called upon to make
any payment to or in respect of his employees.
Equipments and Maintenance

All machines provided will be maintained before expiry of warranty period by the
department by coordinating with the supplier. In addition to machines, Trolleys for
carrying the linen to be provided to the firm by the institute, the maintenance of which
will be responsibility of the firm. Institute authorities will provide administrative
support during this period. After expiry of warranty period, preventive in-house
maintenance will be the responsibility of the department. The department will also be
responsible for maintaining the laundry equipment in working condition through out
the contract period. The department shall not damage the said premises and the
equipments provided to them by the Institute or allow the above mentioned to be
damaged.
Washing Chemicals/Detergents
The department shall be responsible for procurement of all the detergents/washing
chemicals of the specification as per approved washing formula. The institute
authorities can make surprise check to verify that the items used are as per approved
formula and right quantity of these are being used.
1 Cleanliness
(Supportive Services) It shall be the responsibility of the vendor to employ adequate number of cleaners and
sweepers and provide them with adequate and necessary equipments/materials for
keeping the laundry scrupulously clean and in a sanitary condition to the satisfaction
of the institute authorities. Anti rodent and pest control measures will also be strictly
followed and it will be the responsibility of the department to ensure that premises are
free of these.
Security and Safety

The Hospital shall not be held responsible for any loss or damage due to any reasons
whatsoever to any type of inventory, that may be kept in the said Laundry store by the
department, especially under contract services. The premises provided to the vendor
should only be used for the purpose as mentioned in the contract i.e. Laundry services
only. Under no circumstances, the premises are to be used for any other purpose, than
what has been mentioned in the contract. The general safety & ensuring fire safety of
the premises is the responsibility of the department head or the contractor
whomsoever it may concern.
Work Schedule
To maintain and manage the laundry department effectively, the housekeeper should
follow the planned work schedule:
Daily work
z Clean all equipments in laundry
z Follow Daily Work procedure
z Check the equipment’s working condition
Weekly work
z Indent the washing agents from the stores on every Saturday
z Wash doctors coat on every Sunday and replace
Monthly work
z Check linen stock in the wards
z Calculate Monthly expenses
z Check the contaminated and faded, damaged fabrics and enter in the register
Control Desk
The control desk is the nerve centre of the entire department and its efficiency
determines the smooth operation and effectiveness of the department. It is the focal
point for the dissemination of information and communication to various points in the
department. List of files and registers:
1. Linen stock register
2. Daily transaction register for wards
3. Daily transaction register for other areas
4. Dhobi pay register
5. Camp register
16.7 DUTIES AND RESPONSIBILITIES FOR

THE DEPARTMENT HEAD/INCHARGE STAFF
1. All registers in the linen services to be maintained. Maintain a separate Indent for
the cleaning agents used in laundry and the Indent should be signed by the
housekeeping manager.
2. Daily use of cleaning agents are to be recorded and the records to be put up for 1
housekeeping managers signature monthly. Laundry Services
3. Linen and curtains are to be checked for wear and tear quarterly.
4. Torn or faded linen is to be segregated and to be shown to the manager quarterly.
If any item is found unserviceable the same should be written off the ledger after
getting the approval of manager.
5. Torn or faded linen can be used for cleaning purposes.
6. Purchase date of linen should be noted in the register to check the lifetime of the
fabric.
7. Periodical maintenance of washing machine, Ironing machine, Iron box and
Sewing machine to be carried out and the record to be maintained.
8. Washing charges for various lines are to be fixed. For any change in the charges,
prior approval should be taken from the authority.
9. Tailoring rates for various items of stitched materials are to be maintained.
10. Plan and schedule of the standard procedure for cleaning all types of linen should
be displayed in laundry room.
11. Time schedule to be prepared for collection of clean/soiled linen and to be
followed strictly.
12. Ensure proper discipline among Housekeepers, Sweepers, Dhobi, and Tailor
working in linen department.
13. Budget salary for dhobi can be based on the size and number of linen materials
washed per day. The payment can be on daily basis and it can be calculated and
given once in 15 days.
14. Training classes should be conducted for trainees when required.
16.8 STAFFING REQUIREMENTS

Human resources requirement for inside laundry services are as follows: This is
applicable to 50 and above bedded hospital.
S. Human resources Required Assigned task Report to
No. no.
1. Senior housekeeper 1 Controlling & Managing all Housekeeping
activities in laundry manager
2. Dhobi (according to 1 Sorting, Washing, drying folding Housekeeper
the mix of washing and ironing of all linen materials incharge of
by hand and laundry
machine)
3. Sweeper (Part time) 1 Receiving & delivering the linen Housekeeper
materials. incharge of
laundry
4. Tailor (part time 1 Mending the damaged materials and Housekeeper
Optional) stitching curtain pillow covers etc. incharge of
laundry
Note: If the hospital doesn’t have the tailor they can approach outside tailoring unit. If the hospital does
not provide machineries then they have to recruit more than one dhobi.
1
Hospital Operation-II Check Your Progress
1. Define laundry services.
……………………………………………………………………………….
……………………………………………………………………………….
2. List down the functions of in-house laundry services in hospitals.
……………………………………………………………………………….
……………………………………………………………………………….
16.9 SELECTION OF EQUIPMENT

The selection of equipment of a proper size is most important for economical
production. The laundry equipment should be carefully selected. The following
factors should be kept in mind:
z Reasonable capital cost
z Availability of spare parts and ease of maintenance
z Efficiency in working under normal conditions
z Economy in consumption of utilities like water and power etc.
z Continuity of workflow and reduction of manual effort
List of Equipments
The following is a list of commonly used equipment in a laundry.
z Washing machine (non-automatic) capacity
30 bed sheets/load
60 Pillow covers/load
z Water extractor capacity
8 Bed sheets/load
30 pillow covers/load
z Flat work iron (calendaring) capacity
5 Bed sheets/load
6 pillow covers
z Hand iron box
z Sewing machine
z Tumble dryer
z Air compressor
Others
z A cart to receive and distribute linen
z A tub to soak the contaminated or heavily soiled linen
z Ironing table 1
Laundry Services
z Iron buckets
z Cleaning brush
z Hangers
z Clips
Note: the hospital can go in for different types/capacity of machines according to their
needs and benefits.

a) Hospital management shall have the right to terminate the contract of the services
rendered by the laundry service provider/vendor, which are not of the requisite
standard.
b) Management shall demand and be supplied with a sample of any washing
chemical or detergent for inspection and analysis and if required to be sent for
testing by the approved laboratory.
c) Hospital authorities will have unfettered right to inspect the premise, process of
laundry, finished product at anytime and the department will cooperate with the
authorities.
d) Designated officials of hospital will have unfettered right to enter the Laundry
premise at any time in order to inspect and execute, any Structural additions and
alterations or repairs to the said laundry premises, repairs to electric, water and
sanitary installations, which may be found necessary from time to time. The time
and date for this purpose will be fixed with the mutual convenience of both the
parties, as far as possible.
16.11 LET US SUM UP

Thus, laundry and linen service plays a very important role in maintaining and
safeguarding the health and hygiene of both the inpatient and medical staff. The
quality and standard of this service determines in large measure, the quality of any
health care system.

List down the essentials of laundry services in any hospital of your choice.
16.13 KEYWORDS
Laundry: To provide clean material to the patients.
Control Desk: The nerve centre of the entire department.

1. Define laundry services, its meaning and significance in detail.
2. List down the functions of laundry services in hospitals.
3. What are the facilities needed for the laundry services in hospitals?
4. Explain the role and responsibilities of laundry services in hospitals.
5. How the staffing function of laundry services is done in a hospital?
15
1. Laundry service is responsible for providing an adequate, clean and
constant supply of linen to all users. The basic tasks include: sorting,
washing, extracting, drying, ironing, folding, mending and delivery.
2. Functions of the In-house Laundry Services:
a) Collecting soiled linen from various places.
b) Sorting the linen and processing them.
c) Inspecting and repairing or replacing damaged materials.
d) Distributing clean linen to the respective user departments.
e) Maintaining different types of registers.

Sidharth Sathpathy, R.K. Sharma, D.K. S, Indmedica - Conditions of Usage -2006
Mrs. Krishna Veni, Laundry and Linen Services in Hospitals.
AHRMM Newsletter, February 2006, Environmental Improvements in Laundry
Equipment and Products.
Sarah O’Brien, Hospitals for a Healthy Environment.
Energy Star Commercial Clothes Washers listings.
http://www.energystar.gov/index.cfm?
fuseaction=clotheswash.display_commercial_cw
DFE Industrial and Institutional Cleaners Project Information
http://www.epa.gov/opptintr/dfe/pubs/projects/formulat/index.htm
Lists of formulator chemicals and their environmental effects
http://www.epa.gov/dfe/pubs/projects/iil/findings.htm
Partners and recognized products:
http://www.epa.gov/opptintr/dfe/pubs/projects/formulat/formpart.htm#iil
Terrachoice Ecolabel Criteria for laundry products
Nursing Homes, February 2003 article “Does Ozone Laundry Really Work? A User’s
Report”
http://www.findarticles.com/p/articles/mi_m3830/is_2_52/ai_98033895
157
LESSON Housekeeping Services
17
HOUSEKEEPING SERVICES
CONTENTS
17.1 Introduction
17.2 Present Scenario
17.3 Definition
17.4 Objectives of Housekeeping Department
17.5 Functions
17.6 Operation
17.7 Role of Housekeeping Department
17.8 Location and Space Requirements
17.9 Organization
17.11 Let us Sum up
17.13 Keywords

z Understand the meaning and definition of house keeping services in hospitals
z Know the role of house keeping services in hospitals
z Study the aspects of location, organization of house keeping services in hospitals
z Analyze the issues and challenges
17.1 INTRODUCTION
The housekeeping services had its origin in the hotel industry. Later the concept of
housekeeping got incorporated as a hospital service. There are, however, differences
in concept and practice of housekeeping activities in hospital and hotels. Control and
prevention of hospital infection is one of the most vital functions of hospital
housekeeping.
The hospital housekeeping services comprise of activities related to cleanliness,
maintenance of hospital environment and good sanitation services for keeping the
premises free from pollution. Inadequate cleaning and disinfection will result in health
care institutions becoming reservoirs of large number of microorganisms. Cleaning
15 must not only be effective in removing dirt but also in maintaining low levels of
(Supportive Services) micro-organisms. Cleaning materials and disinfectants are essential components in
ensuring quality assurance in housekeeping services. Materials of the right quality,
quantity and used in the appropriate specified frequency will not only augment the
quality of housekeeping services but also ensure optimum utilization of resources. It
will also enhance patient satisfaction.
The housekeeping departments work has advanced rapidly in recent years and requires
not only knowledge of technical skills but also an understanding of the ‘Tools’ of
management. The hospital has to plan, organize, coordinate, control and monitor all
the housekeeping activities in hand for effective utilization of all their resources .The
concept of housekeeping is simplistic but when one considers maintaining a ‘house’
of several hundreds of rooms and numerous public areas, the task becomes gigantic.
17.2 PRESENT SCENARIO

In India cleanliness and disinfection practices vary drastically in different health care
institutions, corporate/public sector, primary/secondary/tertiary care hospitals. Even in
the same category of health care institutions practices and end results of housekeeping
may significantly differ.
In India majority of the health care institutions activities related to the housekeeping
services including use of cleaning materials and disinfectants are done by personnel
with little or no formal education. They carry on their jobs without much training,
scientific supervision or direction, they seem to learn everything on the job. In a
number of instances housekeeping activity is a purposeless ritual. Inappropriate
dilution and ad hoc formulation is generally resorted to in housekeeping activities.
Generally there is indiscriminate mixing of detergents with disinfectants and the
efficacy of it is determined by the odour and colour of the cleaning mixture. The
outdated mob and one bucket-system of cleaning is the most prevalent in Indian health
care institutions.
Disinfectants are often misused and rationalization of their use in hospitals in
desirable for control both of infection and costs. Surprisingly infection maybe caused
by microorganisms which contaminate disinfectants during use specially when objects
such as mops are stored in disinfectants. Unnecessary use of disinfectants is not only
wasteful but may increase the microbiological hazard to the hospital environment and
subsequently to patients, visitors, and staff.
17.3 DEFINITION
The Hospital Housekeeping function is defined to include “all labor, transportation,
equipment, materials, supplies, management, coordination, and supervision required
to perform hospital housekeeping services. Included are: service calls, intensive care
cleaning, nursery cleaning, emergency room cleaning, patient room cleaning, clinic
cleaning, general office cleaning, entrance/platform area cleaning, stairwell/stairway
cleaning, patient unit checkout cleaning, executive housekeeper administration, floor
stripping, waxing, and sealing, carpet shampooing, wall cleaning, ceiling cleaning,
light fixture cleaning, exterior window cleaning, interior A/C cover cleaning, drape
and curtain cleaning, and blind cleaning”.
In short “Housekeeping is defined as the provision of a clean, comfortable and safe
environment for the patients and public in a hospital setup”.
17.4 OBJECTIVES OF HOUSEKEEPING DEPARTMENT

z Achieve the maximum efficiency possible in the care and comfort of the patients
and in the smooth running of the hospital.
z Establish a welcoming atmosphere and a courteous, reliable service from staff of 15
all departments. Housekeeping Services
z Ensure a high standard of cleanliness and general upkeep in all areas.

z Train, control and supervise the staff of housekeeping department.
z Establish a good working relationship with other department.
z Ensure that safety and security regulations are made known to all staff of the
hospital.
17.5 FUNCTIONS
The hospital takes responsibility for the total upkeep and maintenance of the hospital
and to provide safe, pleasant and pollution free environment in the client
organizations.
z Desk/Control room: Proper maintenance and operation of communication.
z Floors/Lobby/Corridors/suites/administrative offices/back areas/outer areas
Proper Upkeep and cleanliness.
z Linen: Issue of proper uniforms to the staff and linen as required.
z Gardening: Maintenance of the total landscaping and all other horticultural
activities.
z Pollution Control: Waste management and proper poll control as required.
In brief the routine functions of House Keeping Department include:
z Daily cleaning
z Periodic cleaning
z Trash and garbage removal including proper hospital waste disposal
z Discharge cleaning
z Exterminating bugs and pests
z Preventing spread of infection
z Safety and security of the hospital
z Creating healing environment
z Gardening
z Interior decoration
17.6 OPERATION
The operation of the housekeeping services to conform to norms by inputting high
quality trained staffs, combined with standard, cleaning materials and equipments
including functions like:
z Guaranteed annual cost
z Employee recruiting, hiring, initial training
z Ongoing employee training
z Guaranteed performance
z Consistent staffing levels
z Inventory management
1 z Proprietary cleaning systems
(Supportive Services) z Low administrative requirements
z Maintenance of the service equipments on a regular basis.
z Setting up predetermined rooms of high quality.
z Supervision of the activities at every stage by trained supervisors and the
managerial staff, to effect spot corrections and future avoidance of errors.
17.7 ROLE OF HOUSEKEEPING DEPARTMENT

a) Housekeeping Manager: Under administrative direction, plans, organizes,
coordinates, staffs and directs assigned housekeeping and related operations
within the Department of Health Care Services; and does related or other duties as
required in accordance with Rule 3, Section 3 of the Civil Service Rules.
b) Duties of Housekeeping Department:
1. Plans, organizes, coordinates, staffs and directs various housekeeping delivery
systems appropriate to the needs of the operations; through subordinate
supervisors, provides guidance and technical expertise to staff performing
housekeeping and related activities.
2. Evaluates work methods and systems; develops and utilizes quality control
and quality improvement methods; conducts environmental rounds to ensure
that infection control and cleanliness standards are maintained; assures
compliance with state and other standards/regulations; reviews call logs and
service requests to monitor customer service; recommends process and
procedural changes to meet existing needs.
3. Develops, interprets and applies goals, policies and procedures for effective
and efficient management of housekeeping operations; establishes and directs
the preparation/maintenance of policy and procedure manuals and
instructions; provides liaison to and confers with other managers, supervisors
and staff to seek feedback and coordinate housekeeping activities with other
service areas.
4. Prepares and administers the housekeeping budget; establishes, implements
and maintains fiscal control standards for all housekeeping activities including
purchasing, inventory, storage, preparation and service; requisitions supplies
and equipment; evaluates and recommends suppliers and prepares contracts
for outside service agreements as needed; maintains financial records and
prepares reports.
5. Assures appropriate staffing; selects, assigns, trains and evaluates the
performance of subordinate personnel; takes appropriate action on
disciplinary matters; verifies and monitors staff proficiency; identifies staff
development needs and oversees training activities as required.
6. Monitors equipment to assure proper function as well as the need for timely
maintenance, repairs and/or replacement; assures that staff have up-to-date
supplies and tools; assures the proper use of chemicals and personal safety
equipment; develops accident prevention, emergency and disaster plans,
recommend facility and/or grounds improvements to improve housekeeping
functions.
7. Collects and maintains accurate operations and other data; produces timely
reports.
8. Investigates complaints regarding housekeeping activities; determines and
implements corrective actions.
1
17.8 LOCATION AND SPACE REQUIREMENTS Housekeeping Services
The Housekeeping serves all corners of the hospital and hence should be placed at the
centre, close to the transport system. This would help in facilitating easy movement of
housekeeping materials and equipments.
The following facilities and space are required for house keeping:
z Office for executive housekeeper
z Clerical work area
z Office for assistant executive housekeeper and supervisor
z Storage room for equipments
z Storage for housekeeping supplies
17.9 ORGANIZATION
a) Staffing: In general the head of the housekeeping department is called the
Executive Housekeeper, who is assisted by an Assistant housekeeper and Floor
supervisors. In smaller hospitals, the executive housekeeper usually reports to the
director of nursing or nursing superintendent, but in larger hospitals, he reports to
the Associate Administrator.
While sourcing the personnel for this department the following principles has to
be kept in mind:
Tapping the right source
Interview process
Selection process
Grooming
Personal Hygiene
Honesty
Courtesy tact and diplomacy
b) Qualities of the Housekeeper:
Basic knowledge of health care sanitation
Ability to plan, administer, and develop all phases of a comprehensive
housekeeping program
Ability to assign, supervises, and evaluates the work of subordinates
A pleasant personality
An interest in people and tact in handling them
Housekeeping employees are largely unskilled at the lower salary level hence they
should receive an orientation, in-service education and necessary trainings.
c) Orientation: Following guidelines has to be kept in mind while imparting
orientation training:
The organization and brief outline of the hospital
Information regarding condition of service, pay, etc.
Information regarding grooming, hygiene, courtesy, safety, security, etc.
Rules like dress code, hours of work, leave policies and procedure, lunch
hours, etc.
1 Hospital tour
(Supportive Services) Observing Equipments and supplies used in the housekeeping department
Observing cleaning procedures done
d) Training: Necessary training has to be given in the following areas:
Methods of supervision
Housekeeping procedures like sweeping, mopping, dusting work
Equipments and supplies, when to use and how to use, amount to use and care
of the equipment
Refresher training
During lean periods
Newer techniques/methods
Practical training under supervision for quality improvement
e) Managing Housekeeper Employees: Workers under housekeeper’s head has to
be necessarily managed and includes activities like:
work distribution for male and female workers
Recruitment and selection procedure
Nearby areas
Different areas and families
Physical appearance
Age mix
Effective supervision
Handling the difficult worker
Effective communication
Performance evaluation

However there are some issues even in case of effective management like:
z Maintaining Effective interdepartmental relationship(Maintenance department
(electricity, plumbing, carpentry, civil, Stores, Laundry, Security, Nursing etc)
z Effective communication
z Absent of responsible person
z Work Allocation
z Conflicts Management
z Time Management
z Routines need to be planned so that they do not inconvenience doctors, nurses,
visitors
z Cleaning has to be consistent, suitable in conjecture with nursing procedures, e.g.
bed making before vacuum cleaning
z A greater need for flexibility and the ability to adjust to interruptions
z Methods and equipment require special attention so as to prevent cross – infection
z The noise is of more importance than elsewhere 1
Housekeeping Services
z Greater variation in different work methods and standards in different areas,
example - operating theatres, wards and visitor’s lounge
z The need for check cleaning, that is the frequent re-doing of cleaning tasks, in
heavy use areas e.g. mopping of floors, cleaning of toilets and wash basins
z Issues in retaining sanitary workers and helpers in a tough job hence proper
consideration has to be given in areas of:
Nutritious snacks
Providing free lunch
Free uniform
Free medical facilities
Recreation (tours, movies etc.)
Sick leave
Change their shifts if they have any acceptable reason
Help them if they require money for emergency
Help them to educate their children
Bonus for 100% attendance.
Check Your Progress
1. Define housekeeping.
……………………………………………………………………………….
……………………………………………………………………………….
2. State the objectives of housekeeping.
……………………………………………………………………………….
……………………………………………………………………………….
3. Explain the location of housekeeping department in a hospital.
……………………………………………………………………………….
……………………………………………………………………………….
17.11 LET US SUM UP

The housekeeping department is a non-revenue-producing service department in the
hospital. A poorly run department results in money needlessly spent and creates a
negative impression on patients, visitors and staff, which will adversely affect their
perception of the quality of care provided by the hospital.

“Is house keeping function so essential in a hospital”. Analyze the housekeeping
function of a hospital of your own choice.
17.13 KEYWORDS
Housekeeping Function all labor, transportation, equipment, materials, supplies,
management, coordination, and supervision.
1 Housekeeping manager person who plans, organizes, coordinates, staffs and directs
(Supportive Services) assigned housekeeping.

1. Define housekeeping and state its objectives.
2. List down the functions of housekeeping in a hospital.
3. Explain the role of housekeeping function in hospital.
4. State and explain the aspects of location, pace requirements of housekeeping
department in a hospital.
5. Explain how the department is organized in the hospital.

1. The hospital housekeeping services comprise of activities related to
cleanliness, maintenance of hospital environment and good sanitation
services for keeping the premises free from pollution.
2. Objectives of Housekeeping Department:
Achieve the maximum efficiency possible in the care and comfort of
the patients.
Establish a welcoming atmosphere and a courteous, reliable service
Ensure a high standard of cleanliness and general upkeep in all areas
Train, control and supervise the staff of housekeeping department
Establish a good working relationship with other department
Ensure that safety and security regulations are made known to all staff
of the hospital.
3. The Housekeeping serves all corners of the hospital and hence should be
placed at the centre, close to the transport system.

Cambridge memorial hospital Manager, Housekeeping Services, Journal of the
Academy of Hospital Administration.
Aarti Vij, Sunil Kant, Shakti Gupta, All Medical Journals Issues Contents Editorial
board & Information, Analytical Evaluation of Cleaning Agents and Disinfectants in
use for Housekeeping Practices at a Tertiary Care Hospital, Vol. 13, No. 1 (2001-01-
2001-06).
Draft naval facilities engineering command Guide Performance Work Statement
(GPWS) for hospital housekeeping services.
Housekeeping Management in Hospitals G. Krishna Veni, Aravind Eye Hospital,
CBE.
165
LESSON Energy Conservation
Methods
18
ENERGY CONSERVATION METHODS
CONTENTS
18.1 Introduction
18.2 Benefits of Energy Conservation
18.3 Approaches to Energy Conservation
18.4 Organizing an Effective Energy Management Program
18.5 Measures for Conservation of Different Energy Sources
18.5.1 Heat Generation
18.5.2 Energy Conservation – HVAC System
18.5.3 Electrical Energy Conservation
18.5.4 Hospital Medical Equipment
18.5.5 Building Envelopes
18.6 Let us Sum up
18.8 Keywords

z Understand the benefits of energy conservation methods
z Analyze the different approaches of the energy conservation methods
z Study the steps in organizing the effective energy management program
z Study the different measures of conservation of energy sources
18.1 INTRODUCTION
Hospitals have high energy use per unit of floor area and high energy bills, but a
number of technologies can be employed to lower them significantly. Hospitals have
office spaces and a number of facilities that are open 24 hours per day. Because of the
risk of microbial contamination, high ventilation rates with 100 percent fresh air are
required. Accordingly, hospitals are dominated by Heating Ventilation
Air-Conditioning energy use (45%), but they also consume a lot of electricity to light
24-hour areas (25%). Most also have significant process loads for sterilization,
laundering, and cooking. With plug loads, these total 30% in typical facilities.
Alternative energy projects begin with a review of the proposed system which will
utilize solar or other energy alternatives to ensure the load be it electrical equipment,
1 heating or cooling of space, water or processes is as energy efficient as possible.
(Supportive Services) Conservation is the first step in all alternative energy applications.
18.2 BENEFITS OF ENERGY CONSERVATION

a) Saves Money: The more we can constrain demand, the less supply capability we
will need - which means reduced initial investment and lower maintenance costs
of our generation facilities. It also reduces our need to import power from other
regions, when our own generation resources can't keep up with demand.
Conservation also reduces the need for transmission investments and the securing
of rights of way - both of which require lengthy and complex project
management.
b) Creates Employment: Energy-saving technologies and products create new
business opportunities - as the marketplace retires old, energy-inefficient products
and techniques. The emerging market for energy conservation creates jobs:
in design, production and sales of new products and technologies
in construction and installation of energy efficient products
in training and consulting for new projects - and the monitoring and
evaluation of results to comply with new standards .
c) Environmental Benefits: All energy generating and transmission facilities have
some environmental impacts – on air or water quality, land use or resource
depletion. More than 80 percent of all human-generated carbon dioxide (CO2)
emissions come from energy production. Elevated levels of greenhouse gases,
especially CO2, are a major contributor to global climate change. Gas-fired
generators, while cleaner than coal, are a source of greenhouse gas emissions.
Successful conservation programs that reduce peak demand will have a direct
impact on our CO2 emissions.
d) Improved system reliability: There is no doubt that all energy is vital to our way
of life - to our standard of living, our economic prosperity and our social well-
being. So helping to ensure reliability of supply in the future is one compelling
reason for stepping up our conservation efforts. Hospitals working and conserving
together can make a significant contribution towards a safe, reliable and
sustainable system.
18.3 APPROACHES TO ENERGY CONSERVATION

Here are five approaches to energy conservation:
1. Conservation of Use: It means using less energy - purely and simply. It doesn’t
mean making major lifestyle changes, but it does mean changing our consuming
behaviour.
2. Energy Efficiency: It means investing in lower energy-consuming appliances,
light bulbs, office and industrial equipment and buildings.
3. Demand Management: It means modifying the time when you consume energy -
so that you are using electricity at times when the demand is the lowest.
4. Fuel Switching: It means switching from electricity to alternate energy sources
wherever possible.
5. Self-Generation: It means reducing the load on the power grid by generating
electricity on-site using renewable sources, or through co-generation facilities
1
18.4 ORGANIZING AN EFFECTIVE ENERGY Energy Conservation
MANAGEMENT PROGRAM Methods
A. An effective Energy Management Program includes the following points:

Having a good knowledge of each space conditioning and system and all of its
components.
Identifying the real needs associated with space conditioning required.
Estimating as accurately as possible the costs of production and distribution of
space conditioning.
Reducing the unnecessary consumption, i.e., proper system operation.
Organizing the maintenance of each system with cost in mind.
Repairing and replacing those components which perform poorly.
Recording the energy consumption on a regular basis.
B. Organizing as a process includes the following steps:
Step 1: Knowing the system: This task begins with updating the drawings of each
system, working with those individuals who understand what is actually in place
in the hospital. Especially important to understand is just how each system is
controlled. On site inspection of critical components can prove very rewarding.
Step 2: Evaluating the needs: Whether it is the space conditioning, specific needs
in the hospital must be met. Are the needs being met is often most quickly
determined by interviewing those familiar with that particular room or zone. Is the
temperature well controlled? Is the ventilation adequate? Is the resources to the
room meeting the needs? Measurements such as temperature and flow at these
locations will prove very helpful in the evaluation.
Step 3: Estimating cost: This item is often best achieved by reviewing hospital
energy consumption, and associated costs, and then trying to allocate those costs
associated with space conditioning. Sub metering of systems may be necessary to
make the energy/cost breakdown. Comparison with similar facilities and/or target
values is very worthwhile.
Step 4: Reducing unnecessary consumption: proper system operation: Over
conditioned space (too much heating, cooling, or ventilation) or the wasting of
resources are indicators that energy consumption can be reduced. Improved
guidance to the hospital staff and making certain that the controls are adequately
marked, and functioning properly, are first steps in reducing consumption.
Step 5: Organizing the maintenance of each system: Each system must be
maintained properly, filters changed, valves lubricated and serviced, etc.
Maintenance must be performed religiously and is vital to an energy management
program.
Step 6: Repair and replacement of system components: Beyond maintenance is
the continual upgrading of the system; replacement of valves that are more
reliable, improved filters, more efficient subsystems, etc. The systems must be
considered as fully functional.
Step 7: Recording the energy consumption regularly: Continuous review of the
hospital energy use is key to avoiding energy waste and therefore costly surprises.
This recording should continue on an indefinite basis, and the information
reviewed by responsible staff. Often complex systems are required to handle the
heating, ventilating and air conditioning needs within the hospital. Additional
factors of relative humidity and zone pressure become part of that equipment plan.
1 C. Energy Management Policy:
(Supportive Services) Promote energy saving and conservation of resource
Use of non-conventional sources of energy
Comply with the energy legislation and other regulations
Promote use of energy efficient alternatives
Communicate energy management policy to all employees and encourage
their involvement through training and participation
Create awareness amongst all employees for innovative ideas towards
conservation of energy
To make an effort to reduce the cost continuously every year by adopting an
effective “Energy Management System”.
Check Your Progress
1. List down the benefits of energy conservation in a hospital?
………………………………………………………………………………
………………………………………………………………………………
2. What are the different approaches of energy conservation?
………………………………………………………………………………
………………………………………………………………………………
3. Explain the steps in organizing an effective energy conservation system.
………………………………………………………………………………
………………………………………………………………………………
18.5 MEASURES FOR CONSERVATION OF DIFFERENT

ENERGY SOURCES
This could be focused both on short-term and long-term basis:
Short-term Measures
1. Energy Conservation: Operationalise complete pilot phase of programme for
energy efficiency in hospital buildings and prepare action plan for wider
dissemination and implementation.
2. Energy audit of buildings: Energy audit has to be undertaken to all the
departments and Monitoring and verification of energy savings to be done.
3. Capacity building amongst departments to take up energy efficiency
programmes: Train core group members to implement energy efficiency in
buildings.
Long-term Measures
Some measures focusing on long term include:
1. Hospital industry specific task forces.
2. Notifying more hospitals as designated consumers.
3. Conduct of energy audit amongst notified designated consumers hospitals.
4. Recording and publication of best practices (sectorwise).
5. Development of energy consumption norms. 1
Energy Conservation
6. Monitoring of compliance with mandated provision by designated hospital Methods
consumers.
18.5.1 Heat Generation

The heat generation plant and the distribution network are the heart of the energy
network in the hospital. More than 2/3 of the energy consumed in a hospital flows
through them. It is therefore most important to improve the heat generation and
distribution efficiencies because any gain in the building system results in large
amounts of energy saved.
For example, if the boiler of a 400 beds hospital consumes 1,400,000 kg of oil per
year, a gain of 5% in the heat generation efficiency would save 96,000 kg of oil per
year, without any change in the heating demand.
Different Types of Heating Systems

1. Cogeneration systems: Cogeneration, or CHP (Combined Heat and Power)
production, may be described as a method by which electricity and heat are
simultaneously produced in more efficient manner than if, each were produced
separately. In a CHP plant, in fact, the heat released in power production is
recovered and sent to the users through a suitable carrier medium.
2. Air heating systems: Air heating systems, in which the air is heated centrally and
then is ducted to the individual rooms. With any system that tends to mix air from
individual rooms concerns must be raised as to the spread of infection. Therefore,
the system may be suitable to only limited areas of the hospital. If ventilation
requirements are such that there is no return flow, e.g., patient room air exhausts
from attached toilet rooms, then concerns for contamination are minimized. Use
of such direct air heating systems allows control of relative humidity at the same
time.
3. Heat generators: The different kinds of heat generators are designed for different
temperature levels, apart from direct electrical heating, where the plant efficiency
is practically independent of the temperature level. The temperature is an
important factor for the energy production efficiency of all the heat generators.
4. Warm water systems: Warm water systems are another heating approach that has
been proven effective and widely used in hospitals. In these systems, water is
heated, up to a maximum temperature of about 90°C (190°F) in a central boiler
and is distributed to the individual heating terminals or heating surfaces using the
supply water pipe network. After heat extraction from the terminals, the water is
returned to the boiler at a lower temperature level.
5. Steam heating systems: Steam heating systems can still be found in older
hospitals. From a central steam generation boiler, that may also supply laundry
and kitchen facilities, steam is led to the individual heating terminals mainly
radiators, through either one or two pipe systems. From there, the condensate is
returned to the steam generator. Steam as an energy carrier for the purpose of
space heating can prove to be especially uneconomical because of the high system
temperatures. Steam-supplied radiators are difficult to regulate and they tend to
have high surface temperatures.
6. Individual room heaters: Individual room heaters are another option for hospital
heating. These may take the form of electrical heaters such as: baseboard units,
wall panel units, ceiling/floor electric heating cable, or approaches such as
through-the wall heat pumps.
1 7. Control: Room thermostats can be installed in combination with all the systems
(Supportive Services) mentioned above, and they can take into account individual heating demands or
heat sources in particular room. In addition to room thermostats, other control
systems are often installed. These system are subdivided for the variety of
individual demands of hospital zones, e.g., zones with different solar orientations.
Often, in newer facilities, individual terminals are equipped with thermostatic
valves to regulate the heat release. The influence on the space temperature due to
solar radiation or internal heat sources (e.g., lighting and other hospital
equipment) can be compensated by the regulation methods just described.
Examples of supply temperature regulation are as follows: manual adjustment
depending on the season, temperature control as a linear function of the outside
temperature and room thermostatic control of individual terminals.
8. Strategy at plant level: The goal of this section is to provide guidelines to reduce
the energy consumption (fuels and electricity) of the heat generation plant. The
energy consumed, by the heat generation plant is equal to the sum of heat
furnished and of the heat generation losses. To reduce the fuel energy
consumption, one has to reduce the losses occurring during the heat production
and/or to reduce the heat demand. Emphasis is put on the reduction of the heat
generation losses.
9. Efficiency, measurement, target values: In the heat generation plant, before
taking action, one has to determine its overall efficiency in order to be able to
gratify its performance and compare it with target values.
In order to be able to analyze the plant quality one must proceed to some
measurements. There are different levels of measurements:
Short duration measurements like, stack gases temperature, unburnt gas
content, liters of feed water consumed per fuel unit delivered.
These measurements will allow to find out the efficiency in steady state, and its
quality.
10. Levels of actions to be taken: To be able to assess the heat production efficiency
and compare it with target values, one must begin by maintenance and tune-up of
the heating plant and then compare the steady-state values of the efficiency of the
heat generators with the target values. This comparison gives a first indication of
the extent of the losses due to the heat generation plant. Once the efficiency has
been determined, the next step is to take some measurements of the operating
conditions, which will also provide a basis for a change in the operating
conditions.
18.5.2 Energy Conservation – HVAC System

The following are a list of possible actions that can be taken to save energy in the
HVAC systems in the hospital. These are maintenance and operational items in which
little or no cost other than the time of hospital staff would be involved. or items with
minor expenditure.
z Check to be sure that outside air ventilation quantities are consistent with current
code requirements. In some cases, outside air requirements will have decreased,
while air filtration efficiencies requirements will have increased. Outside air
quantities should be measured for each air handling unit.
z Check air balancing and correct if required. Maintain proper space set points by
checking settings and calibration proper space set point by checking settings and
calibration of all space thermostats 'and humidistats. Adjusting the anticipator
setting where appropriate.
z Operate shades, drapes and shutters for proper balance of daylighting; consider 1
Energy Conservation
heating and cooling needs. Methods
z Inspect air heating, cooling and dehumidification coils for cleanliness. Coils can
be kept clean by using a mixture of detergent and water in a high pressure
portable cleaning unit.
z Post signs next to all operable windows, instructing occupants not to open them
while the building is being heated or cooled.
z Indicate the months included in heating and cooling seasons.
z Clean or replace air filters on a regular basis. Consider installing manometers
across the filters so that replacement is based on performance (pressure drop), not
on appearance.
z Check and calibrate all temperature controls and temperature readout devices at
least every two years. Proper set points for each control and acceptable ranges for
each readout should be clearly marked next to, or directly on, each item.
z Check the accuracy of all recording instruments used to monitor pressure,
temperature, steam flow, etc. Obtain maintenance and calibration data from
manufacturers.
z Develop guidelines for the operation of laboratory exhaust hoods, and post them
in the vicinity of the switches that operate the fans. Hoods should be run only as
long as is necessary to implement a particular procedure.
z Sliding doors on the fronts of enclosed hoods should be closed as far as possible.
Consider installing timers on the fan switches.
z Check to see whether exhaust air from various areas is used to ventilate storage
area, equipment rooms, etc. This is basically free space conditioning. for these
areas which have low ventilation requirements.
z Check all accessible air ducts for leakage. Tape and caulk joints as needed. Use
materials that ensure long life.
18.5.3 Electrical Energy Conservation

The objective of the project is to save energy costs without impairing the everyday
operation and proper functioning of the hospital. Two approaches are conceivable,
either separately or jointly:
z energy saving,
z taking advantage of the rate structure.
Taking advantage of the tariff structure means:
z increase of the load factor
z reduction of the peak load
z shift consumption to times of low rates
For carrying out saving measures it is necessary, that the hospital technician in charge
has a copy of the tariff contract in his hands. Costs can be cut in many cases simply by
updating the parameters to the practical operation of the hospital. The contracted
power for instance, in the beginning, is often determined on the basis of the installed
power of the machinery under consideration of an estimated operating schedule.
An adjustment to practical requirements is often overlooked. Therefore, the technician
must also have the electricity bill at hand in order to have an overview over the
situation. After studying the contract as well as the electricity bill, the person in
charge should know the actual procedure of the cost calculation. When preset values,
1 fixed in the contract; count towards the billing, it should be checked whether the
(Supportive Services) contract conditions can be changed. If actual values of peak loads and power
consumption are taken as a basis, the next step is to get a deeper understanding of the
situation by measuring load cycles of the complete hospital and of single departments
or consumer sections. This gives information about the major energy users and the
consumers responsible for peak loads.
How to save energy with minor changes

1. Updating of tariff parameters: If the contract is based on fixed values of
contracted power and minimum consumption it must be checked to see whether
these values can be changed to the advantage of the hospital. The result should be
a lower electricity bill without even changing the consumption level. Electricity
companies usually offer consulting services for this topic.
2. Avoiding of coincident peak loads: Cost can be cut mainly by avoiding extreme
peak loads, peaks occurring with intermittently operating users are hard to
anticipate, anyway. It would therefore seem obvious that ventilation drives, for
instance, are slowed down at critical times and refrigeration or electrical boilers
are switched off temporarily.
3. Judging suitable users for power reduction: during times of peak loads depends
very much on the organization of the particular hospital. For the technician,
however, who knows his hospital it is usually possible to find consumers that can
be influenced for these purposes. If possible, especially energy intensive operation
of equipment should be shifted to times of low power consumption or low tariff
times.
How to save energy by modifyinq installations

Maximum load control system: The installation of an automatic control system or the
including of this function in a computerized building control system demands the
consulting and planning by an engineering company. Nevertheless, some possibilities
should be shown in this context to give the technician background information,
because his feedback of knowledge is needed for the engineer.
For short term actions, not considering a longer load leveling, three different ways of
handling can be distinguished:
Switching off
z without requiring compensation
z with a limited (in power) compensation (space cooling)
z with full compensation (refrigeration)
18.5.4 Hospital Medical Equipment

Hospital medical equipment as referred to consists of all the technical power aids in
the hands of the medical staff for proper diagnosis and therapy. Medical equipment is
connected to other hospital systems, mainly the electrical system from which it draws
20-95 % of its power. But other systems are involved, such medical gases, in order of
consumption compressed air vacuum, nitrogen, oxygen, cool air, to cool equipment
and/or rooms heated operating equipment cold water, for equipment cooling
demineralised water.
z How to save energy in the purchasing phase: Great attention should be paid in
the specification and purchasing phase so as not to over specify the medical and
energy requirements. The energy manager should assist the doctor in selecting the
medical equipment that will satisfy the doctor's requirements and his own. When
specifications are prepared for purchasing equipment which have a high energy
use, a specific section should be included on energy. Thus, when bids are being 1
Energy Conservation
analyzed, a comparison of long term energy consumption of, such tenders can be Methods
prepared and should form part of the purchasing decision. Often some equipment
can be purchased to operate on different power values or pressures. If this is not
taken into account, a major system change might be needed to make the
equipment usable.
z How to save energy in the installation phase: Conditions can exist in some
hospitals where large volumes of air and/or water are required to cool medical
equipment. Due consideration should be given in such cases to whether some
energy can be recovered by heat pumps or other systems.
z Maintenance: Equipment should be maintained in top working order. This is
important for the efficiency of medical use but also for energy consumption. A list
of management and operation items are as follows:
Laboratory Equipment:
z Check equipment periodically for efficiency.
z Do not leave faucets running.
z Turn off burners, ventilation hoods, or any other energy consuming equipment
when not being used.
z Turn off lights when rooms are not occupied.
z Sterilizers and glassware washers should be used at full load rather than two part
load.
z Use proper temperature.
z Keep walls, ceilings and light fixtures clean to reflect maximum light.
z Place frequently used items in front of unit to reduce length of time doors are
open.
Technical staff- Maintenance Measures:

z Develop and practice a preventive maintenance program.
z Check for proper working of control valves, etc. on washers.
z Check refrigerators and freezers for: cold spots, compressor leaks, low refrigerant
level, tight gaskets, dirt or other obstruction of coils, fans, etc.
z Defrost fryers frequently to prevent frost build up.
z Check timers on equipment to ensure they are working correctly on refrigerators
and freezers.
18.5.5 Building Envelopes

1. Air filtration: Maintenance can be done by under taking the following actions:
Systematic visual inspections of air tightness of windows, doors, etc. are of
prime importance because a leak which is large enough to be seen by eye
causes a significant energy waste, and these systematic inspections also allow
one to discover broken windows; doors or windows which are kept open or
semi-open in spite of orders or regulations.
Smaller leaks can be documented by smoke tests: these should be made
wherever a leak is suspected.
1 Measurement of air velocities in the vicinity of closed windows and doors
(Supportive Services) could also be made with a hot-wire anemometer. Air velocity above 0.20 m/s
is too much, and indicates a repair should be made.
Immediate repair of the failures or defects detected by visual inspections or
smoke tests is of prime importance: - replacing broken windows - readjusting
the fastenings of windows and doors - filling up the cracks and fissures
between windows or doors frames and walls with cement or silicon sealant -
etc.
If simple readjusting of windows and doors fastenings is not possible because
of their age or poor quality, their complete replacement must be considered.
Repairing the cracks and fissures in walls and their external and internal
coating to restore their tightness.
Especially in clean zones must the leaks be repaired.
Operational Changes
To reduce the thermal losses due to air infiltration, some Operational changes
could be made:
closing doors and windows when their opening is not required for duty,
comfort or exploitation purposes (check to see if overheating is not
responsible for window opening).
if possible, systems to close doors automatically could be added to inside
doors as well as for outside doors.
2. Windows: In terms of energy savings/sq meter, replacing old single glazed
windows by modern double glazing windows is more profitable than increasing
the insulating properties of walls, roofs and floors. In terms of costs savings, it is
exactly the opposite. The strategy in this buildings envelope component is to look
at modification of windows only if they have to be replaced for other reasons.
Saving energy with minor changes: It is necessary to emphasize the need to
clean the glazing and to maintain the mechanism of closing and opening the
windows, the curtains and the shutters. Although considered routine
maintenance these items are required if window systems are to function as
designed.
Saving energy through modification: The possible modifications often
involve:
Costly retrofits to buildings, and the profitability must be studied before
deciding upon any action.
Nevertheless, if some radiators are placed in front of glazed surfaces, it is
highly profitable to place an insulation material in place of glazing behind
the radiators.
For windows not facing south, and if it doesn't impair natural lighting, it
may also be useful to reduce glazed area by replacing some of it by
opaque and insulating material.
Replacing simple glazing by double or triple glazing must be evaluated to
determine if there is simultaneously a window replacement necessity for
other reasons.
When replacement of old windows is reviewed, it is sometimes profitable
to make certain the new windows have higher air tightness and thermal
brakes.
Overgrazing, the addition of storm windows, requires less work inside the 1
Energy Conservation
room than the complete replacement of the window. Methods
Properties of existing glazing can be improved by low-cost films
coverings. Two types of films are available: summer solar reflective,
which reduce room overheating, thus preventing excess window opening,
and winter heat retaining, which reduces the radiative loss from the room
to the outside.
18.6 LET US SUM UP

Energy conservation programs can save money for medical centers. The necessary
engineering capability to evaluate these methods can be provided by clinical
engineering staffs since the analytical ability of the clinical engineer is directly
transferable to energy conservation programs. Several conservation methods are
applicable to hospitals and deserve consideration.

Device your own plan to conserve energy in a hospital and list down the how the
hospital is benefited out of it.
18.8 KEYWORDS
Energy Efficiency: It means investing in lower energy-consuming appliances, light
bulbs, office and industrial equipment and buildings.
Demand Management: It means modifying the time when you consume energy - so
that you are using electricity at times when the demand is the lowest.
Fuel Switching: It means switching from electricity to alternate energy sources
wherever possible.
Self-Generation: It means reducing the load on the power grid by generating
electricity on-site using renewable sources, or through co-generation facilities.

1. List down the benefits of energy conservation in a hospital.
2. What are the different approaches of energy conservation?
3. Explain the steps in organizing an effective energy conservation system.
4. Explain the different measures for energy conservation in a hospital.

1. Benefits of Energy Conservation
a) Saves Money
b) Creates Employment
c) Environmental Benefits
d) Improved System Reliability
Contd…
17
Hospital Operation-II 2. Five Approaches to Energy Conservation
1. Conservation of Use
2. Energy Efficiency
3. Demand Management
4. Fuel Switching
5. Self-Generation
3. Organizing an Effective Energy Management Program
Step 1: Knowing the system.
Step 2: Evaluating the needs.
Step 3: Estimating cost.
Step 4: Reducing unnecessary consumption: proper system operation.
Step 5: Organizing the maintenance of each system.
Step 6: Repair and replacement of system components.
Step 7: Recording the energy consumption regularly.

“Energy Management in hospitals”- A guide for Energy Management in Hospitals,
Annex XIII.
Hospital Energy Conservation & Efficiency Tips.
International energy agency – energy conservation in buildings and community
systems programme, Dec 1989.
177
LESSON Cost Containment
Measures
19
COST CONTAINMENT MEASURES
CONTENTS
19.1 Introduction
19.2 Factors Contributing to Cost Containment
19.3 Conditions for Effective Cost Control
19.4 Management of Cost Containment Measures
19.5 Cost Containment Strategies
19.6 Cost Containment Measures
19.6.1 Human Resource Interventions
19.6.2 Material Management Interventions
19.6.3 Energy Saving Interventions
19.7 Specific Measures to Save Energy and Cut Down Cost
19.9 Let us Sum up
19.11 Keywords

z Understand the factors contributing to cost containment in hospitals
z Know the conditions essentials for effective cost control
z Know management of cost containment measures
z Understand cost containment strategies and cost containment measures
z Understand specific measures to save energy and cut down cost
z Understand the issues and challenges of cost containment measures in hospitals
19.1 INTRODUCTION
The commonest complaint voiced by a patient when he avails the services of a
hospital is towards the cost to be paid for such services. The expression has been
taken quite seriously in various countries and efforts are being made to control the
cost of healthcare delivery by implementation of cost containment measures or
17 standardisation of price through the interventions of TPAs, HMOs and health
(Supportive Services) insurance companies.
In our country, the interest of corporate players in the private healthcare delivery
model is on the surge and more and more private spend on the healthcare
infrastructure has been projected. The increase in spend has resulted in better hospitals
in terms of infrastructure, technology and treatment of tertiary and quaternary
ailments in the country. Even if the corporate don't look forward to the returns on the
investment, they want their hospitals to be financially self-sustainable models.
Due to rapid changes in the technology and pressure to acquire these technologies,
hospitals need patients and patients in turn want a very cost-effective hospital. For a
hospital to increase the throughput, it is very important that it provides quality
healthcare at a very affordable price and that is possible, only if the cost containment
mechanism is in place and the strict compliance with the cost containment protocols is
practiced.
19.2 FACTORS CONTRIBUTING TO COST

CONTAINMENT
Following are the factors that have to be duly considered while under taking Cost
Containment measures.
Parameters Factors Affecting Cost Containment

1. Leadership and Attitude z Concerned about cost
z Instituting a culture of cost consciousness
z Being available for timely decisions
z Viewing the patient as a partner in the healing process
z Forecasting and planning for expected workout
z Utilisation of community resources
2. Human resources z Job description

z Workload versus manpower planning
z Recruitment and selection
z Employee retention
3. Building and Infrastructure z Appropriate size and design

z Appropriate building technology and material
z Flexible and functional building design
z Durability and ease of maintenance
4. Supplies, Instruments and Equipment z Group purchasing
z Inventory management
z Models easy to repair and service
z Appropriate technology
z Preventive maintenance
5. Systems and Procedures z Standardisation
z Periodic review to eliminate unnecessary systems
19.3 CONDITIONS FOR EFFECTIVE COST CONTROL

Though cost containment is influenced by the health care systems that exist, certain
organisational conditions have to be in place for them to be effective. The leadership
has a strong role in this. The organisational leadership must be within the system and
be available to the organisation whenever required. Delayed or inappropriate decisions
tend to increase costs and inefficiency. It is also important that the leadership 17
Cost Containment
promotes a culture of cost consciousness. Measures
Standard clinical and administrative protocols are necessary to institute and review
cost containment measures without affecting quality, productivity or patient
satisfaction. The first table lists the various factors that influence costs.
a) Variable Costs: Variable costs are mostly made up of clinical consumables,
stationary, etc. Cost savings in this area require good inventory management and
group purchasing for better prices. Good materials management, to reduce
wastage through storage and pilferage, will again reduce the variable costs.
However, reviewing the clinical protocols and eliminating investigations,
procedures and medications that do not contribute to quality, productivity, good
outcome or patient comfort can result in greater reductions in variable costs.
Setting up a good clinical information system is necessary for making such
evidence based decisions.
b) Fixed Costs: In health care organisations, the fixed cost could account for as
much as 70% of the total recurring expenditure and hence deserves the most
attention. Investment in infrastructure, size of the facility and staffing are the
major determinants of fixed costs. While leasing out a part of the building,
reducing staff or better negotiations of maintenance or salary contracts could be
some of the options to reduce fixed costs, the focus in cost containment must be
more on reducing the 'fixed cost component within the overall unit cost' of service
through optimum utilisation of the infrastructure. This focus will lead to
continuous efficiency improvements resulting in sustained cost containment.
Seasonal variations in patient load affect capacity utilisation and thereby affect the
costs. Salaries constitute the major proportion of fixed costs. Thus, the staff
utilisation pattern, especially that of the ophthalmologists, has a direct impact on
costs.
19.4 MANAGEMENT OF COST CONTAINMENT

MEASURES
Any hospital's cost containment protocol can be evolved in the under mentioned:
a) Formation of the cost containment team: The cost containment team should be
very carefully constituted. The chairman of the team should be Chief Executive
Officer supported by the head of administration and head of accounts with
representatives of each department. The main role of the team should be critical
evaluation of the organization and to do a cost-benefit analysis for each activity.
b) Implementation of strategic service unit: Total productivity management views a
hospital as a group of Strategic Service Unit (SSU), each SSU with individual
resource input, methods of productivity assessment, measures to enhance
productivity in terms of volumetric turnover and control mechanism for quality
improvement and maintenance. If the strategic service unit concept is applied to
each department, then it is very easy to track down resource utilization for each
department and the cost factor associated with each resource.
c) Identification of department: Once the hospital is broken down into the SSUs, it
is very easy for the finance department to identify the department with maximum
utilisation of a particular resource, link it to the departmental productivity and
identify the department with a discrepancy in the resource cash inflow and service
cash outflow.
d) Study of the activity chain: A study of the activity chain has to be carried out and
the operation research tools and techniques can be applied to diagnose the
sequence of the events. If each department has well domented Standard Operating
1 Procedure (SOP), then it is very easy to analyse the activity chain. The focus
(Supportive Services) should be on identifying the resources and the quantum required to complete each
activity in the chain.
e) Application of business process re-engineering: Business Process
Re-engineering (BPR) is a problem-solving approach that emphasises radical
redesign of business process to achieve dramatic improvements in critical
contemporary measures of performance such as cost, quality, service and speed.
Application of BPR will help in realignment of the activity chain, thereby helping
in the elimination of the wasteful activites and reduction of the cost. The biggest
issue in the use of BPR technique is compromise with the seamless environment,
customer convenience and medical operations. Any cost containment exercise
should not affect the clinical outcome.
19.5 COST CONTAINMENT STRATEGIES

a) Daily Planning: In addition to long range or annual planning it is essential to plan
for the next day and ensure that all resources/supplies are organised and all
concerned staff are informed. The patient load, availability of staff and
requirement of supplies can be determined with a high level of reliability the
previous day. Emergency procurements and delays in service delivery increase the
cost.
b) Clinical Process: A patient protocol based on an integrated path for diagnosis,
investigations, admission, surgery and follow-up would substantially reduce
delays and associated costs.
c) Personnel Costs: Hospital is a labour intensive organisation. Staff salaries
constitute a major percentage of the total operating expenditure. Hence, it is
important that salary packages are designed keeping this in view. Incentives
linked to surgeries adversely affect the cost reductions that come from increased
productivity.
d) Work Culture: Developing a positive work culture reduces bureaucracy, promotes
teamwork and a commitment to patient care. All of these have a very direct
impact on costs.
e) Local Production of Consumables: Many housekeeping supplies, bandages,
cotton pads, swabs, etc. can be produced locally. This also gives an opportunity to
involve the clinical staff when there is no patient care.
f) Managing Seasonal Variations: Productivity is governed by the patient load,
which tends to have seasonal and also daily fluctuations. It is necessary to find
ways of accommodating the demand and, when this is not possible, activities like
staff training, painting or vacation time for staff can be scheduled accordingly.
g) Appropriate Use of Human Resources: Since salaries are a major element of
fixed costs, these require special attention. The ophthalmologist's time is both
expensive and in limited supply. Delegating routine, repetitive and measurement
related clinical tasks to well trained ophthalmic technicians can significantly
increase the productivity of the ophthalmologists.
h) Community Participation in Outreach: One resource that is hardly used is the
community. In many programmes, the hospital staff does the publicity, arranges a
campsite, necessary furniture, etc. All these activities can be better carried out by
the community, often at no cost to the hospital. When the community comes in as
an equal partner, the camp attendance also goes up.
i) Other Strategies: These include developing in-house competence for instruments/
equipment maintenance, instituting appropriate recycling systems for waste
products, regular review of cost data and administrative systems, such as daily
review of revenues and expenditures, control over expenses through formal 1
Cost Containment
procedures for approval, and independent audit of all internal records. Measures
Check Your Progress
1. Explain the ethical basis of health care.
……………………………………………………………………………….
……………………………………………………………………………….
2. Explain the clinical process of cost containment.
……………………………………………………………………………….
……………………………………………………………………………….
19.6 COST CONTAINMENT MEASURES

19.6.1 Human Resource Interventions
1. Activity linked recruitment: Hospitals should evaluate the quantum of patient
flow to the various departments and adhere to the activity linked recruitment and
deployment. The occupancy level of the wards and utilisation pattern of the
Operation Theatre should be critically scrutinised to find the optimum staff levels.
It is always advisable to pay more salary to the staff and get the optimum level of
work done rather than over staffing the hospital. The ideal bed to staff ratio is 1:4.
Organizations with a ratio of less then 1:4 are ideally staffed but hospitals with
bed to staff ratio more than 1:4 need to undertake right sizing exercise.
2. Automation of HR functions: Automation of HR functions may appear to be a
costly and time-taking measure, but in the long term it helps tremendously in
cutting cost. For example, if a hospital has a provision of computerised
application bank, then huge amount of data can be stored and applications can be
retrieved on need basis and money can be saved as number of advertisement
released will reduce.
3. Training and development interventions: Hospital's training programme should
be focused around "Train the trainer" concept wherein HR department should
identify line managers who can effectively impart training and train them in
conducting in-house programme. This helps in cutting the cost of the external
training programme and also the effect will be much more as line managers will
be using live examples to train the staff.
4. Multi-tasking of the staff: HR department should carry out through job analysis
and write detailed job responsibilities. This will help in eliminating the
duplication of job activities and help in cutting the cost of HR. Also opportunities
to merge job responsibilities should be identified to implement the concept of
multitasking. For example, point Liftman cum security guard cum driver for
hospital security. On the job training should be implemented to execute multi-
tasking.
5. Reassessment of the employee benefits: In many hospitals, employees are given
certain benefits like free hospitalisation, medicines, subsidized food, free
beverages etc. in order to cut cost. Hospitals can set the limits and systems
wherein every employee benefit is accounted. For example, free medicine to the
employee can be given on hospital doctor's prescription only. Setting up limits,
like medicine worth a fixed amount will be given per annum per employee will
help tremendously in cost containment.
1
19.6.2 Material Management Interventions
1. Collective procurement: Hospitals with a common interest of cost containment
can come together to form a collective procurement group. There are many items
from medicine to stationary which are required commonly by all hospitals. If such
items can be identified and hospitals can define average consumption per item per
month then it is quite possible to negotiate with the vendors and get huge quantity
discounts. This type of model can be very well utilized with mutual trust, faith and
confidence even by the competing hospitals.
2. Effective inventory control: Inventory control programme of hospital should be
focused on the extent of probable use, storage cost, obsolescence, transport cost,
investment cost, cost to purchase, market condition and price trends, time required
for delivery, availability of a substitute, cash flow and substitutes available. Every
hospital should try and reduce the inventory levels and see that unnecessary
inventories are avoided. Probably in case of operation theaters, we can have three
day inventory management for planned cases and a week's inventory pattern for
emergency cases.
19.6.3 Energy Saving Interventions

Hospital management should publicise the objective of energy conservation in a very
aggressive manner. Hospitals can put posters in cafeteria, employee mess, change
rooms, clean utility, and dirty utility to educate people on energy conservation.
Employees as well as patients should be sensitized to the fact that conserving energy
in a small, individual way adds up to significant saving when multiplied with all users.
If hospital is under construction or on an expansion drive, then the design should cater
for maximum use of sunlight. Light harvesting is a costly option but can be tried to
reduce the cost in long term.
In short, if these few interventions are practiced it is quite possible to reduce the cost
of service delivery and then the onus lies on the finance team to do costing and price
the services in such a way that healthcare and the hospital becomes affordable to all.
The objective of cost-containment cannot be achieved only through planning.
Execution needs an organisation culture which has to cascade from the top. The cost-
containment philosophy should be drilled down to the lowest level of hierarchy. The
major challenge lies in bring a behavioral change in the employees guided by
appropriate leadership which motivates the change.
19.7 SPECIFIC MEASURES TO SAVE ENERGY AND CUT

DOWN COST
a) Reduce Hospital Cooling Costs:
Recover heat from central plant equipment by installing heat-recovery coils in
the exhaust air handlers to capture waste energy without the risk of
contamination.
Recover waste heat from exhaust stacks of boilers to preheat boiler makeup
water or combustion air.
Recover heat from sterilization equipment, laundries, dishwashers, and
cleaning equipment to pre-heat fresh hot water.
Install a waterside economizer for nighttime cooling.
Downsize to a new high-efficiency chiller in conjunction with lighting and
other retrofits.
Use condensing boilers with large turn-down ratios whose efficiencies 1
Cost Containment
improve with turn-down. Measures
Switch over to direct digital controls.
Install variable air volume air handling systems with variable speed drives.
Install premium-efficiency motors.
Install demand-controlled ventilation.
Ventilate garages in response to environmental conditions.
Upgrade the energy management system. Optimize settings to reflect usage,
respond to changing weather patterns, and control peak electric loads. The
energy management system can automatically shut off lighting and set back
HVAC systems in spaces occupied only during the daytime.
Install a combined heat and power generation system to supply electricity,
heating needs, and cooling needs. When properly sized and designed, such a
system can save substantial money and avoid the large thermal losses
associated with conventional power generation at utility plants.
Change all HVAC and PTAC filters. This enhances the performance and
efficiency of your equipment.
Clean all PTAC and HVAC coils. This enhances the performance and
efficiency of your equipment.
Educate your staff to turn off lights and turn down heating/air conditioning
when rooms are unoccupied.
Consult outside sources to evaluate the total system when replacing major
mechanical equipment
Teach housekeeping staff to conserve energy when cleaning rooms.
Avoid placing televisions, computers, lamps and hair dryers near thermostats.
The heat from these and other appliances or equipment may affect thermostat
readings and lead to increased energy consumption for cooling.
b) Reduce Hospital Lighting Costs:
Switch to compact fluorescent light bulbs in patient rooms, lobbies, and
hallways. Use sensors and/or timers for areas that are infrequently used.
Install energy-efficient lighting in all other spaces, being sure to replace T-12
fixtures with T-8 or T-5 fixtures with electronic ballasts.
Install and calibrate automatic lighting controls in conjunction with skylights
and clerestories in open areas to dim lights in response to daylight.
Replace exit signs with Light Emitting Diode (LED) exit signs.
Where fluorescent lighting is impractical, convert lighting to low wattage
bulbs wherever possible. Remember that "watts" cost and lumens measure
light output.
Increase patient-room light levels by installing translucent lampshades.
Install motion sensors in offices and shops (including laundry and
housekeeping). This makes sure the lights are off when no one is in the room.
Great for public restrooms also.
Switch to high-pressure sodium or low-wattage metal halide lamps for
outdoor lighting.
Upgrade garage parking lighting.
1 c) Hospital Building Envelope:
(Supportive Services) Install high-efficiency, specularly-selective glazing carefully chosen for sun
exposure on each facade and other variables.
Install interior or exterior shading devices.
Install insulation in strategic locations.
Undertake air sealing, including duct work.
Install window film to lower heating and cooling loads and reduce glare in
patient rooms.
Check for worn and cracked caulking and weather stripping on doors and
windows of all rooms, including those that have been permanently closed.
Use proper insulation and reflective roof coverings.
Install a cool roof.
d) Reduce Hospital Water and Laundry Costs:
Switch to low-flow toilets or install toilet-tank fill diverters.
Replace old washing machines with both water and energy conserving
models.
If the hospital has a pool and/or hot tub, install a solar water heating system
and use pool and hot tub covers when the pool area is closed.
Wash full loads of laundry Only. Partial loads waste energy.
Use cold water laundry washing where possible. Ask your chemical supplier
for a cost-benefit analysis.
Check and repair ALL leaky toilets, tubs, showers and sinks in patient rooms,
public areas and the kitchen.
Check and replace all defective sink aerators. Sink aerators save water.
Reduce the landscaping water cycles where possible. Use mulch, it reduces
recurring water bills.
Switch to drought resistant native plants in garden areas. Replace mowed
landscaping with native ground cover.
e) Reduce Other Hospital Energy Costs:
Use low-energy sleep functions on computers, printers, and copiers.
Choose Efficient office equipment and appliances.
Install Vending Miser on vending machines.

Effects of Cost Containment Measures on Health Care: Cost containment activities
affect health care systems in several ways. First, cost containment can affect the
quality of care received by patients. Second, financial risk shifting changes the
fundamental ethical basis of the health care system. Finally, cost containment
potentially restricts access not only to types of services but to minorities, underserved
populations, and others who already have limited access.
1. Assuring Quality Care in the Managed Care Product: Quality health care
requires a high level of health care services that assist an individual in remaining
free from physical and mental incapacity while maximizing social capacity. In a
third-party payer-driven market, the main challenge is structuring quality
assurance activities to protect quality care in the face of counterproductive 1
Cost Containment
financial incentives. The Council on Medical Service for the AMA defines high Measures
quality care as that which "consistently contributes to improvement or
maintenance of the quality and/or duration of life." Another definition of quality
care is the "component of the difference between efficacy and effectiveness that
can be attributed to care providers, taking into account the environment in which
they work." Both definitions are strikingly nonspecific and create, rather than
solve, problems of definition. In an effort to help clarify its definition, the Council
established eight factors that it believes are necessary for quality care delivery:
the production of optimum improvement in the patient's physical condition
and comfort;
the promotion of prevention and early detection of disease;
the timely discontinuation of unnecessary care;
the cooperation and participation of the patient in the care process;
the skilled use of necessary professional and technological resources;
concern for the patient's welfare;
efficient use of resources; and
sufficient documentation of medical records to ensure continued care and for
evaluation of the care by peer review.
2. Maintaining the ethical basis of health care: The ethical basis of the health care
system is necessarily founded on a certain amount of trust. When a patient seeks
care from a physician, the patient must believe that the physician will act in the
patient's best interest and will not put other interests before that of the patient. The
patient usually does not have the training to judge the reasonableness of the
physician's decisions about her health care needs and alternative means of meeting
those needs. Thus, the physician, not the patient, combines the components of care
into treatment.
This trust will clearly be undermined by cost containment efforts. Even the
suspicion that physicians no longer act in patients best interest will cause anxiety
and increase distrust. When there are actual injuries, the distrust will be reaffirmed
and intensified. As the distrust becomes more and more significant, distrust may
further exacerbate any unfavorable health outcomes.
3. Maintaining Access to Health Care: Changing the payment structure and the
underlying system motivations not only affects quality and the physician-patient
relationship, it also negatively affects access to health care. Access problems
caused by cost containment efforts occur in several ways.
The first occurs when plans have systemic variations in the level of financial
protection for the individual against health care costs. Under those circumstances,
access will be affected as patients' ability to afford health care changes. Furthermore,
as plans further shift financial risk to providers, patient access will be affected as
providers who are intent on avoiding cost containment penalties or obtaining cost
containment rewards do not order services for patients.
Thus, the effectiveness of a plan's cost containment efforts will affect the patients'
ability to obtain certain health care services. In addition, third-party payers can control
costs by severely limiting the availability of certain resources. Finally, access will be
limited by differences in the quality of services. If patients perceive a managed care
product to provide poor services, they are likely to forego the services, even though no
other services may be available.
18
Cost containment is a continuous organisational process. A narrow and too simple
approach will not necessarily be of benefit. It is a complex interaction of technical,
organisational and human factors, which needs committed leadership, good attitudes
of staff and a system approach. Higher expenses per surgery do not necessarily mean
higher quality. Hospitals that provide quality service, and in large volume relative to
their size, tend to have lower unit costs through better systems. On the whole, cost
containment should be viewed as one of the strategies to enhance efficiency in patient
care delivery.

Analyze the major steps to be taken in cost containment measures in hospital. Derive a
useful program and system that would give effective cost containment effect in
hospitals.
19.11 KEYWORDS
Cost containment: A continuous organisational process.
Variable Cost: expenditures that vary according to the requirement.
Fixed Cost: recurring expenditures that are fixed like salaries of staff.

1. What do you mean by cost containment measures?
2. Explain the factors contributing to cost containment measures.
3. Explain in detail how the cost containment can be effectively managed.
4. List down some of the cost containment strategies.
5. Explain in detail some measures that would be taken for cost containment in
hospital.
6. Explain the issues and challenges related to cost containment measures in
hospitals.

1. The ethical basis of the health care system is necessarily founded on a
certain amount of trust. When a patient seeks care from a physician, the
patient must believe that the physician will act in the patient's best interest
and will not put other interests before that of the patient.
2. A patient protocol based on an integrated path for diagnosis,
investigations, admission, surgery and follow-up would substantially
reduce delays and associated costs.

A Guide to Integrating Value Engineering, Life-Cycle Costing and Sustainable
Development Federal Facilities Council, 2001.
Air Force Military Construction and Family Housing Economic Analysis Guide 1996.
Building Economics for Architects by Thorbjoern Mann. New York: Van Nostrand
Reinhold, 1992. ISBN 0-442-00389-7.
Building Economics: Theory and Practice by Rosalie Ruegg and Harold Marshall. 18
Cost Containment
New York: Van Nostrand Reinhold, 1990. ISBN 0-442-26417-8. Measures
Facilities Standard for the Public Buildings Service, P100 (GSA)—Chapter 1.7 Life-
Cycle Costing GSA LEED® Cost Study.
Life-Cycle Costing Manual for the Federal Energy Management Program (PDF
9.73MB, 224 pgs) NIST HB 135 1995 Edition.
NAVFAC Economic Analysis Handbook 1993.
Project Estimating Requirements, P120 (GSA).
Standards on Building Economics, 5th ed. ASTM, 2004. ASTM Stock.
U.S. Department of Energy (DOE) Office of Federal Energy Management Programs
(FEMP).
190
LESSON UNIT IV 191
Transportation Services
20
TRANSPORTATION SERVICES
CONTENTS
20.1 Introduction
20.2 Who can use the Transportation Services?
20.3 Types of Transportation Services
20.3.1 Outpatient Transportation Services
20.3.2 Inpatient Transportation Services
20.4 Let us Sum up
20.6 Keywords

z Understand transportation services and its uses
z Understand types of transportation services used in hospitals
z Understand users of transportation services in hospitals
20.1 INTRODUCTION
Part of Hospital’s commitment to the patients is that they serve transportation service.
The hospital will provide transportation for those times when the patient is in critical
condition and have to go to the hospital or the doctor’s office and are unable to
arrange other transportation.
20.2 WHO CAN USE THE TRANSPORTATION SERVICES?

z Patients utilizing Hospital’s inpatient or outpatient services. The transportation
service will pick up from the patients place in case of emergency and take you to
the hospital.
z Patients using the services of any Hospital active staff physician. The service will
transport you to or from your doctor’s office.
z Long-term care facilities sending patients to Hospital for inpatient or outpatient
services or to Hospital staff physician's offices for non-emergency care. Patients
who will be going to a long-term care facility after their stay at Hospital may also
use the transportation service for the trip, as long as they are able to sit up and
travel without assistance.
1 z Patient transportation within the hospital from one department to another.
(Supportive Services) z Hospital staff, service providers, visitors, doctors, physicians etc., can use the
service within the hospital through various means of elevators, lifts, dump waiter
and ramps in course of fulfillment of their duties.
20.3 TYPES OF TRANSPORTATION SERVICES

Broadly seen the transportation service rendered by the hospital can be divided into
two as:
z Outpatient Transportation services, and
z Inpatient Transportation services.
20.3.1 Outpatient Transportation Services

Outpatient’s Hospital’s transportation program provides van service to the hospital
and affiliated metropolitan area physician’s offices for patients coming from nearer
areas.Riders will be billed for the ride and can select from a number of payment
options, including cash, check, Visa or MasterCard. They are also called as Patient
Transport Service (PTS).
Providers of transportation services are also classified as emergency or non-
emergency: Emergency transportation includes ambulance and helicopter providers.
Nonemergency transportation includes medicar, taxicab, service car, private
automobile, bus, train, and commercial airplane providers.
1. Service Definitions:
a) Emergency Ambulance: Transportation of a patient whose medical condition
requires immediate treatment of an illness or injury. The destination of an
emergency ambulance is a hospital or another source of medical care when a
hospital is not immediately accessible.
b) Emergency Helicopter: Transportation of a patient when the responsible
physician determines such mode to be a medical necessity. Such
determination must be documented in writing by the physician.
c) Non-emergency Ambulance: Transportation of a patient whose medical
condition requires transfer by stretcher and medical supervision. The patient’s
condition may also require medical equipment or the administration of drugs
or oxygen, etc., during the transport.
d) Medicar: Transportation of a patient whose medical condition requires the use
of a hydraulic or electric lift or ramp, wheelchair lockdowns, or transportation
by stretcher when the patient’s condition does not require medical
supervision, medical equipment, the administration of drugs or the
administration of oxygen, etc.
e) Taxicab: Transportation by passenger vehicle of a patient whose medical
condition does not require a specialized mode.
f) Service Car: Transportation by passenger vehicle of a patient whose medical
condition does not require a specialized mode.
g) Private Automobile: Transportation by passenger vehicle of a patient whose
medical condition does not require a specialized mode.
h) Other Transportation: Transportation by common carrier, e.g., bus, train or
commercial airplane.
2. About the Service: Hospital Transportation provides transportation services, one-
way or round trip, to the main hospital campus, the Center for Outpatient Care
and affiliated physician’s offices in the Cities metropolitan area. They are mainly 1
in the form of: Transportation Services
Emergency and Non-emergency ambulances

Cars driven by drivers in uniform
One vehicle for discharge patients
Voluntary' car drivers, who are accountable to the hospital and are paid on the
basis of mileage
In some circumstances a taxi will be provided in place of a hospital vehicle
Voluntary van service arranged on regular champ basis .
3. Eligibility criteria: Eligibility will be assessed on the following criteria, which
you should read through before applying:
Does the patients have any means of getting to and/or from the hospital by
public or private transport or with family or friends?
Are they in receipt of the Mobility component of the Disability Living
Allowance?
Do they suffer from the following disabilities?
Severe eyesight problems?
Severe mobility problems as a result of illness, injury to the lower limbs,
heart or respiratory problems?
An uncontrolled illness, for example uncontrolled epilepsy?
Does the treatment have physical side effects?
Is the appointment for a child with a disability or special needs?
Do the patient need to be accompanied on the journey by a carer or nurse?
Whether the patient have been referred to the hospital or its affiliated
physicians by their hometown physician
Whether can meet the service at designated sites within a stipulated mile
radius of the hospital
Can get into and out of a van with minimal assistance and travel
independently up to noted hours.
Which form of transport is most suitable for the patient:
1. Car Seat or Van seat
2. front seat
3. Car seat with help to get in and out
4. Transport for you but you need a wheelchair once you reach the hospital
5. Transport for you in your wheelchair
6. Stretcher
7. Oxygen cylinder
If the patient use transport on a long-term basis, the medical need will be
regularly reviewed to ensure that the patient is still eligible for the type of
transport.
4. Pickup and Drop off Locations: Usually Vans are scheduled to visit specific
communities on specific days. Each Van Service community has a designated
1 pick up location. The Van Service coordinator will confirm the time and place of
(Supportive Services) pickup when the reservation is verified. Patients should be available at the
stipulated time, prior to their scheduled pickup time. Due to time restrictions, the
van can only wait few minutes after the scheduled pickup time.
There may also be a delay on the return trip based on all passengers’ needs that
day, especially if another patient’s appointment runs later than expected. In most
situations, the van driver will make every effort to depart as close to the scheduled
time as possible. The drivers may also stop at a patient’s request anytime during
the trip.
5. Additional Assistant Services:
A fully equipped wheelchair van service for senior citizens and people with
physical disabilities who require special assistance, are taken special
consideration by the hospital.
The Assisted Transportation Van provides safe, convenient, door-to-door
transportation and the same courteous service as in case of emergency
medical situation.
The Transportation Service is excellent for trips to the rehabilitation
appointments, outpatient procedures or medical tests at the hospital or
physician’s office, visiting family or friends, or trips anywhere in and around
the hospital location.
All vehicles are fitted with satellite navigation, telephones and are fully fitted
with blue lights for emergency use if required.
The non-emergency ambulances are crewed by Ambulance Care Assistants
who are trained to look after the particular needs of their patients. This service
is supported by a team of Voluntary Car Service drivers.
In foreign countries, Individuals with a hospital appointment who are
claiming the following benefits are entitled to make a claim in respect of their
travel expenses: Income Support, Job Seekers, Disability Working Allowance,
Working Family Tax credit, Pension Credit (with guaranteed credit &
savings).
6. Responsibility: The Chief Executive is responsible for ensuring the Policy to be
implemented. Operations Director for Theatre, Anesthetics and Ambulatory
Services are responsible for managing the Patient Transport Service Operations
Directors and level 4 Managers are responsible for the implementation and
monitoring of patient transport issues within their own areas of responsibility in
liaison with the Patient Service Manager for Patient Transport.
Level 3 Managers Ensures the Policy is distributed and implemented in each ward and
department, Ensures that any issues are investigated and action taken in liaison with
the Patient Service. The Manager for Patient Transport, identifies staff who will
authorise and book transport and ensure that they complete the necessary training and
Maintain training records of all staff that have undergone Patient Transport Training.
Check Your Progress
1. Who can use the transportation services in hospitals?
……………………………………………………………………………….
……………………………………………………………………………….
2. What is outpatient transportation services?
……………………………………………………………………………….
……………………………………………………………………………….
20.3.2 Inpatient Transportation Services 1
Transportation Services
It actually refers to the transportation aids that help the patients in the hospital in
course of their treatment. This is very essential irrespective of the size of the hospital,
sophistication and the means of transportation .It is one such service without which all
the other activities in course of treatment will become more tougher.
Functions
It includes a wide range of activities and covers almost all areas in the hospital. Some
of the notable functions of hospital Inpatient transportation services are as follows:
z Inpatient escort service upon admission and during discharge.
z Patient transportation to and from different departments.
z Movement of staff and visitors within the facilities offered.
z Movement of supplies, materials and equipment within the hospital.
z Movement of patient food, in trolleys through elevators from the dietary
department to their respective rooms.
z Ambulance services – For the movement of the patients in course of their
treatment.
Means of Transportation
Generally the different means of transportation used within the hospitals include the
following:
1. Elevator: An elevator or lift is a transport device used to move goods or people
vertically, from one floor to another. In British English, elevators are known more
commonly as lifts. Today, all new elevators are computer-controlled and
microprocessor based.
They usually handle any types of traffic including Patients. Visitors, personnel
and service. Under emergency situations the patients has to be moved quickly for
which the elevator is a must in all hospitals. Patients are usually taken in wheel
chairs to different departments through these elevators. Hence in large hospitals
the traffic is on a great percentage reduced.
Elevators are crucial for transportation within a hospital. There are often separate
elevators for different purposes. Hospital staff and visitors need elevators to take
them to the patients’ floors. The number of visitors and visiting times vary
depending on the culture in different countries. Usually 1.0-3.0 visitors and
1.5-3.0 employees per bed are assumed when planning elevators. Elevators are
planned to be able to transport all passengers up in less than 40 minutes.
The different types of elevators used in every hospitals to carry patients and to
carry equipments and other necessary service items are as follows:
a) The passenger elevators use a collective control system. The calls given by
the passengers at landing floors are continuously allocated. Collective control
searches for the nearest car to serve the call on the way up or down. The call
is finally reserved for a car at the stage the elevator starts decelerating to the
floor. Several landing calls can be served during an up or down trip.
b) For bed transportation, the elevator car dimensions are sufficiently large that
it is possible to transport a bed. Typically, the car is 1,800mm wide and
2,700mm deep. Bed elevators are normally planned so that 25% to 50% of all
beds can be transported within an hour. In case of a bed call, an elevator is
changed to bed service mode. One bed call is served at a time, and new bed
1 calls are set in a time queue where the oldest call is served first
(Supportive Services) (interconnected queue control system).
c) Automated Goods Transportation -In hospitals, separate elevators are needed
for service, food and linen, and medical supplies and goods transportation. In
modern hospitals, automated guided vehicles (AGVs) can be used instead of
employees. Companies that produce AGVs usually offer an interface for
elevator manufacturers to use. When an automated vehicle arrives at an
elevator lobby, the elevator control receives a signal from the AGV system
and sends a car to the floor. The elevator is in a special AGV mode
throughout the vertical trip until the vehicle leaves the car. AGV
transportation logistics can be scheduled so that the elevators are used during
light traffic hours, for instance at nighttime. The transportation capability of
elevators is therefore also utilised efficiently.
Passenger Elevator Capacity: Passenger elevators capacity is related to the
available floor space. Generally passenger elevators are available in typical
capacities from 1,500 to 5,000 lb (680 to 2,300 kg) in 500 lb (230 kg) increments.
Generally passenger elevators in buildings 4 stories or less are hydraulic, however
concerns with hydraulic elevators in recent years have limited their installations.
In buildings up to 10 stories, electric elevators are likely to have speeds up to
300 ft/min (1.5 m/s), and above 10 stories speeds begin at 500 ft/min (2.5 m/s) up
to about 1200 ft/min (6 m/s).
Controlling Elevators
General Controls
A typical modern passenger elevator will have:
Call buttons to choose a floor. Some of these may be key switches (to control
access). In some elevators, certain floors are inaccessible unless one swipes a
security card or enters a pass code or both.
Door open and door close buttons to instruct the elevator to close immediately
or remain open longer. In some elevators, holding the door open for too long
will trigger an audible alarm.
A stop switch to halt the elevator (often used to hold an elevator open while
freight is loaded). Keeping an elevator stopped for too long may trigger an
alarm. Often, this will be a key switch.
An alarm button or switch, which passengers can use to signal that they have
been trapped in the elevator.
Some elevators may have one or more of the following:
An elevator telephone, which can be used in addition to the alarm by a
trapped passenger to call for help.
A fireman's key switch, which places the elevator in a special operating mode
designed to aid firefighters
A medical emergency key switch, which places the elevator in a special
operating mode designed to aid medical personnel
Other controls, which are generally inaccessible to the public (either because
they are key switches, or because they are kept behind a locked panel,
include:
a. Switches to control the lights and ventilation fans in the elevator
b. An inspector's switch, which places the elevator in inspection mode
c. An independent service switch, which selects whether the elevator's 19
operation will be coordinated with other elevators in an elevator bank. Transportation Services
d. Up and down buttons, to move the car up and down without selecting a
specific floor. Some older elevators can only be operated this way.
Elevator Convenience Features:

a) Elevators may feature talking devices as an accessibility aid for the blind. In
addition to floor arrival notifications, the computer announces the direction of
travel, and notifies the passengers before the doors are to close.
b) In addition to the call buttons, elevators usually have floor indicators often
illuminated and direction lanterns. The former are almost universal in cab
interiors with more than two stops and may be found outside the elevators as
well on one or more of the floors.
c) Floor indicators can consist of a dial with a rotating needle, but the most
common types are those with successively illuminated floor indications or
LCDs. Likewise, a change of floors or an arrival at floors is indicated by a
sound, depending on the elevator.
d) Direction lanterns (lightings) are also found both inside and outside elevator
cars, but they should always be visible from outside because their primary
purpose is to help people decide whether or not to get on the elevator. If
somebody waiting for the elevator is going up but a car comes first indicating
that it is going down, then the person may decide not to get on the elevator.
e) If the person waits, then one will still stop going up. Direction indicators are
sometimes etched with arrows or shaped like arrows and/or use the
convention that one that lights up red means "down" and green means "up".
Since the color convention is often undermined or over rided by systems that
do not invoke it, it is usually used only in conjunction with other
differentiating factors.
f) In addition to lights, most elevators make a sound to indicate if the elevator is
going up or down either before or after the doors open, usually in conjunction
with the lanterns lighting up. Universally, one bell sound is for up, two is for
down, and none indicates an elevator that is 'free'.
2. Dumb Waiter: Hospitals are responsible, among many other things, for healing
the sick and maintaining a safe environment. They transport linens, clothes, food,
and cleaning supplies regularly between floors. In order to provide a means to
transport these types of materials, many hospitals invest in dumbwaiters.
A small box elevator designed for the carriage of lightweight freight is called a
dumb waiter. This will be used for a hospital is often much larger than a
residential dumbwaiter. They are used frequently to transport food trays and
linens, but are used for much more. As with any dumbwaiter it is imperative that
they are not used to transport humans. A dumbwaiter for use in a hospital will
likely be outfitted to open on more than one side. This means that it will likely be
configured with at least two doors, one on each side. They are also ran to each
floor so there will need to be a set of call controls at each opening.
Dumbwaiters are generally driven by a small electric motor with a counterweight
and there capacity is limited to about 750 lb (340 kg). They may also be hand
operated using a roped pulley. The main purpose of using this type of service is to
transport sterile supplies and instruments from one room to another but both the
rooms has to be one below the other in the same building but different floors.
There are two types of dump-waiters: one with conventional waist-loading type
and the floor-loading type. It can be equipped with automatic loading and
19 unloading devices. Large dumbwaiters can be used to transport bulky equipment
(Supportive Services) like food trucks or trolleys and laundry trucks.
3. Lifts: Usually the word elevator and lifts are used interchangeably primarily both
of them mean the same thing and is used to move materials from one floor to the
other. They carry all kinds of traffic and materials too.
Lifts began as simple rope or chain hoists. A lift is essentially a platform that is
either pulled or pushed up by a mechanical means. A modern day lift consists of a
cab also called a "cage" or "car" mounted on a platform within an enclosed space
called a shaft, or in Commonwealth countries called a "hoistway". In the past, lift
drive mechanisms were powered by steam and water hydraulic pistons. In a
"traction" lift, cars are pulled up by means of rolling steel ropes over a deeply
grooved pulley, commonly called a sheave in the industry. The weight of the car
is balanced with a counterweight. Sometimes two lifts always move
synchronously in opposite directions, and they are each other's counterweight.
The Lift Control System can be of Car Switch or Automatic Type. The Car switch
type is for operation by an attendant, whereas the Automatic type comprises of
feather touch buttons at each landing which call the lift car and a series of buttons
in the car which correspond to the floors to be served and operated by the
passengers using the lift. Each lift is fully equipped with the latest safety devices.
This Vertical transportation system for modern hospitals have special requirement
such as spacious and durable car, smooth and comfortable travel, accurate stop
with inch up and inch down push button control in car, emergency control features
and above all, reliability with safety. The car dimensions are as per the Indian
Standard requirements for Hospital lifts.
4. Stairways and Ramps: In case if lifts exists in a hospital, there stairs are of only a
minimum use. Again in case where there is a breakdown of the lifts, the stairs
will be of much help. Hence due care has to be take n in locating as many number
of stairs in different location, to control traffic especially in case of big and large
hospitals.
The minimum width of 1.11 metres (3ft.8 in) and landings are necessary for
handling stretches in an emergency, when patients have to be excavated during a
fire. Continuous hand railings on both sides at a height of approximately 0.9 metre
(3 feet) are necessary for ease as well as safety of patients and personnel .due
consideration should also be taken to have a non slippery surface.
5. Ramps: They are used in case of transporting stretcher patients. It must have a
gradient of 1: 10; width – 2.5 metres, width at landing at the U turn 3.0 metres
(10 feet); concrete railings at a height of 9.0 metres (3 feet).The floor of the ramp
should have grooves perpendicular to the slope to avoid skidding the floor may be
tiles, stone slabs.
20.4 LET US SUM UP

Transportation is an essential function in every hospital regardless of its size,
sophistication and means of transportation. It encompasses a wide range of activities
and areas in any hospital like inpatient escort service, patient transportation too and
fro ancillary departments, movement of staff and visitors, movement of supplies,
materials and equipments, food etc. Some times movement of patients from their
homes in the form of ambulatory services.
19
20.5 LESSON END ACTIVITY Transportation Services
Make a study regarding the various transportation services from the early ages of
civilization till the present modern trends. And analyze the ways of managing
transportation services today.
20.6 KEYWORDS
Lifts: A transport device used to move goods or people vertically.
Dumbwaiter: A small box elevator designed for the carriage of lightweight freight.

1. Explain the different means of transportation services in hospitals.
2. What do you mean by inpatient and outpatient transportation services?
3. Critically evaluate each of the transportation systems and suggested the suitable
means of transportation services in hospitals?

1. Following people can use the transportation facilities of hospitals:
Patients utilizing Hospital’s inpatient or outpatient services.
Patients who will be going to a long-term care facility after their stay
at Hospital may also use the transportation service.
Hospital staff, service providers, visitors, doctors, physicians etc.,
2. Outpatient’s Hospital’s transportation program provides van service to the
hospital and affiliated metropolitan area physician’s offices for patients
coming from nearer areas.

Kevin McAnaney Chief, Industry Guidance Branch Complimentary Local
Transportation Program.
Bradford Teaching Hospitals, NHS Foundation Trust Cliff Hammond, Deputy
Director of HR & Environment, HUHFT, Version 4, August 2006.
Liisa Siikonen and Kari Suihkonen, People flow monitor Board Member, Finnish
Operation Research Society (FORS).
200
LESSON
21
MORTUARY SERVICES
CONTENTS
21.1 Introduction
21.2 Meaning
21.3 Types
21.4 Usage
21.5 Functions
21.6 Organization and Management
21.7 Location and Space Requirements
21.8 Building Design
21.9 Quality Management System
21.10 Personnel Facilities
21.12 Let us Sum up
21.14 Keywords

z Understand the meaning of mortuary services
z Know its types and functions
z Study the organization and functions of mortuary services
z Analyze the location, space requirements and building design of the service
z Understand the staffing function related to this service
z Analyse the issues and challenges of this field
21.1 INTRODUCTION
It is inevitable that mortuaries occupy a special place in the perceptions of the
community. Institutions and their staff involved in mortuary services have a clear
obligation to look after the deceased in a respectful way and in accordance with
community expectations. Failure to do so is not only unacceptable but will raise valid
community concerns about what takes place in mortuaries.
Mortuary services in hospitals have generally been given little attention by clinicians,
the media, or the public. However, recent stories about improper storage of bodies and Mortuary Services
organs have generated public interest in both pathology and mortuary services.
Response to the media stories shows that the public expects the standards of care and
attention given to the deceased to be the same as those for living patients. However,
the experience and that of pathology colleagues, suggests that clinical staff do not pay
enough attention to the documentation related to deceased patients. Ideally every
hospital should have a mortuary suitable for temporary shelter of the dead, with
proper facilities and space requirements.
21.2 MEANING
A morgue or mortuary is a building or room used for the storage of human remains.
Morgue is predominantly used in North American English, whilst mortuary is more
common in British English. (Mortuary is also often synonymous with funeral home in
American English). The euphemisms "Rose Cottage" and "Rainbow room" (for
children) are widely used in British hospitals to enable discussion in front of patients.
The term morgue is derived from French morguer, which means 'to look at solemnly,
to defy'. The term was first used to describe the inner wicket of a prison, where
prisoners were kept for some time, during which the jailers and turnkeys would spend
time looking at the prisoners so that they would be able to recognize them. The person
responsible for handling and washing the bodies is the Diener.
21.3 TYPES
Morgue - Morgue or mortuary cold chamber. There are two types of mortuary cold
chambers:
z Morgue-Positive temperature: +2/+4°C which is the most usual for keeping the
bodies a few days or a few weeks, but does not prevent decomposition of the
corpse, which continues, albeit at a slow rate.
z Morgue-Negative temperature: -15°C/-25°C which is usual in forensic institutes,
especially for bodies which have not yet been identified. At these temperatures,
the body is completely frozen and decomposition totally halted.
21.4 USAGE
The mortuary cold chamber is used to keep the deceased as long as is necessary for:
z identification purposes,
z post-mortem examination, or
z while awaiting burial.
In many countries, the family of the deceased must make the burial within 72 hours of
death, but in some countries it is usual that the burial take place some weeks or some
months after the death. This is why some corpses are kept as long as one or two years
at a hospital or in a funeral home. When the family has enough money to organize the
ceremony, they take the corpse from the cold chamber for burial.
In some funeral homes, the morgue is in the same room, or directly adjacent to, the
specially designed ovens, known as retorts, that are used in funerary cremation. Some
religions dictate that, should a body be cremated, the family must witness its
incineration. To honor these religious rights, many funeral homes install a viewing
window, which allows the family to watch as the body is inserted into the retort. In
this way, the family can honor their customs without entering the morgue.
Check Your Progress
(Supportive Services) 1. Explain the types of a mortuary?
……………………………………………………………………………….
……………………………………………………………………………….
2. List down the different uses of mortuary services?
……………………………………………………………………………….
……………………………………………………………………………….
3. Where does the mortuary services located in a hospital?
……………………………………………………………………………….
……………………………………………………………………………….
21.5 FUNCTIONS
The mortuary has the following functions:
z To hold dead bodies until burial can be arranged.
z To provide a place where a pathologist can investigate causes of death and make
scientific investigations.
z To allow viewing and identification of bodies by relatives and other people.
z Waiting Mortuary is a mortuary building designed specifically for the purpose of
confirming that deceased persons are truly deceased. Prior to the advent of
modern methods of verifying death, people feared that they would be buried alive.
To alleviate such fears, the recently deceased were housed for a time in waiting
mortuaries, where attendants would watch for signs of life. The corpses would be
allowed to decompose partially prior to burial.
21.6 ORGANIZATION AND MANAGEMENT

When a mortuary is the administrative responsibility of an institution other than that
which administers the hospital or the institution in which the mortuary is located, the
administration arrangements should be clearly set out in a document of agreement
between the institution in which the mortuary is located and the institution having
administrative responsibility for providing autopsy and related services.
a) Responsibility: All services provided by the mortuary and its operational
procedures should be clearly and fully documented in a Mortuary Procedures
Manual. The mortuary should have an organisation chart which clearly depicts its
administrative structure and the reporting relationships for its entire staff.
Comprehensive job and person specifications should exist for all mortuary staff.
b) Supervision: The mortuary should have an appropriate supervisory structure. In
the absence of a designated manager or a supervisor, the administrative duties
should be delegated to a person having appropriate knowledge of mortuary
procedures and familiarity with current guidelines concerning the performance of
autopsies.
c) Administrative Practices: Where possible, the administrative structure shall
include a specialist pathologist. If the health unit administering the mortuary lacks
a specialist pathologist on its staff, it is strongly recommended that formal
arrangements are in place for a specialist pathologist experienced in mortuary
practice to be retained in an advisory capacity. The mortuary shall maintain an up-
to-date equipment inventory which shall include maintenance and repair records.
The mortuary staff shall comply with institutional, human resources, OH and S Mortuary Services
and other relevant policies and authorised documentation of these policies should
be readily accessible to all staff.
21.7 LOCATION AND SPACE REQUIREMENTS

If possible, the mortuary should be located near the pathology department or the
laboratory. It should be easily accessible from wards and the emergency and operating
departments. A separate access should be available for staff, relatives and undertakers.
Space Requirements: Suitable and sufficient spaces are needed to carry out the
activities like storing, maintaining and the disposal of the human tissues. Specifically
it includes the following:
z Covered access
z Body store
z Staff changing room with lockers and toilets
z Soiled garments holding area
z Post-mortem facilities
z Viewing room
z Visitors waiting room
z Cleaning materials storage room
z Cleaner’s room
z Prayer and religious rites room.
21.8 BUILDING DESIGN

a) Water Supply: A hot and cold water supply should be readily accessible in the
mortuary. Cleaning arrangements should avoid the creation of aerosols.
b) Power Supply: Power supply outlets must be protected from wetting by having
protective covers. An emergency back-up system for the power supply should be
available for refrigeration, high priority equipment and illumination.
c) Disposal of Hazardous Materials Derived from the Autopsy Procedure: Such
materials comprise the following:
Human organs and tissues
Syringes, needles, blades and other sharps
Contaminated disposable items such as paper towels and rubber gloves
Formalin and other chemical waste associated with the processing of tissue
samples
Gowns and other protective clothing
Wound dressings, cannulae, tubing, catheters and prostheses.
The Mortuary Procedures Manual shall contain protocols for dealing with each of
these types of materials, in accordance with relevant legislation. Organs and
tissues for disposal following a hospital autopsy should be disposed of in
accordance with the wishes of the next of kin and in compliance with institutional
policies and relevant statutory requirements.
d) Body Storage: A body cold store having a capacity appropriate for the mortuary
(Supportive Services) workload should be maintained at a temperature of about 4°C. If long-term
storage is required, a freezing facility operating at about –20°C should be
available. The body cold store should have adequate space for the accommodation
of each body. There should be storage space suitable for large bodies. The
operating temperatures of all cooled and freezing facilities should be continuously
monitored. The facilities should be fitted with alarms which are activated when
the temperature exceeds a predetermined level. Action to be taken if an alarm is
activated must be specified in the Mortuary Procedures Manual.
e) Lighting: Adequate lighting shall be available in all areas. Shadow-free lighting
shall be provided for the autopsy table and dissection benches.
f) Air-conditioning, Heating and Ventilation: To maintain a high level of staff
concentration and to minimize the possibility of accidents, the temperature of the
mortuary theatre should be maintained within a comfortable range not exceeding
25°C. The ventilation system for the mortuary shall be designed to minimise the
spread of odours and airborne pathogens by being isolated from other ventilation
systems, where possible. Adequate ventilation must be available on the benches
where formalin-fixed organs and tissues are handled.
g) Flooring: Non-slip flooring is essential for all work areas. The floor surface
should be impervious, easy to clean, sealed with coving at the edges and have
adequate drainage. Floors should have drains with appropriately filtered traps.
h) Storage Facilities: Adequate storage space is necessary to ensure that the
mortuary is uncluttered and has clear identified separation of clean and dirty
areas. Tissues immersed in formaldehyde should be stored in an area equipped
with an exhaust system positioned to extract vapours heavier than air.
i) Body Reception and Release: Persons having access to the bodies of deceased
persons must only do so in accordance with institutional policy or, documented
procedures. Bodies may only be released from the mortuary with the appropriate
approval of institutional management. At the time of transfer of a body to a
funeral director, the funeral director should sign an acknowledgment that the body
was received in an acceptable condition.
j) Security and Access: The mortuary should have a security system in place which
prevents access by unauthorised persons to the mortuary or body store.
k) Body Viewing and Identification Area: The viewing and identification area shall
be located at a suitable distance from the mortuary theatre to avoid the possibility
of visitors seeing or hearing an autopsy in progress. It is recommended that
relatives initially view the body through glass but they should be able to readily
enter the body room if they choose to do so. The viewing facility should have a
suitably located waiting area for relatives, fitted out in an appropriately dignified
fashion, with easy access to washroom facilities.
l) Autopsy Theatre: The main autopsy theatre should utilise only appropriate tables
or trolleys. The provision of height-adjustable equipment is encouraged. Working
bays should be of sufficient size to allow staff to be able to work in uncrowded
space. Instruments, containers and other items needed during the conduct of an
autopsy should be readily accessible within each work bay.
m) Dissection Facilities: The air conditioning system should ensure that the volume
and direction of air flow is satisfactory in each working bay. Each working bay
should have illuminated benching for the examination and dissection of removed
organs and tissues. Facilities for weighing and measuring organs should be readily
available within the mortuary theatre. Facilities for photography are
recommended.
n) Radiology and Photography: Safe arrangements to prevent exposure to radiation
and spread of contamination must be in place when undertaking radiology or Mortuary Services
photography in the mortuary.

o) Cleaning: The Mortuary Procedures Manual shall specify the arrangement for the
cleaning of all areas of the mortuary, including procedures for disinfection and the
cleaning of instruments and equipment.
21.9 QUALITY MANAGEMENT SYSTEM

The mortuary and its staff should participate in available external quality programs
and have a quality management system or participate in the quality management
system of its parent institution. The quality system must include a requirement for
documented audits of mortuary procedures.
a) Documentation: Documentation within the quality system for the institution
providing the autopsy service shall include a procedures manual which should be
readily available to all users of the mortuary. All departures from documented
policies and procedures within the relevant section must be documented and
approved by the appropriate manager. All records should be dated and identify the
person making the record and should be stored in such a manner as to ensure that
they are readily retrievable. All amendments to approved documents and records
should be initialed and dated and amendments to data stored on computers must
also be recorded.
b) Management Review: A management review should be undertaken annually by a
Senior Officer of the administering institution.
c) Complaints: There shall be documented procedures for dealing with complaints.
Signed records should be kept of all complaints, the actions taken to deal with
them and any follow-up action needed.
21.10 PERSONNEL FACILITIES

a) Clean Changing Area: Suitable changing rooms with shower facilities should be
located adjacent to the main mortuary theatre. The locations and procedures for
discarding clothing and boots and for washing should be clearly displayed on
appropriately sited notices.
b) Personal Protective Equipment:
Standard infection control procedures shall apply to autopsies which are not
high-risk. The Mortuary Procedures Manual must specify arrangements for
high-risk autopsies, which must include the protective equipment to be worn.
The wearing of surgical theatre-type clothing is recommended for all staff
working in the mortuary theatre and staff must wear an impervious apron and
gloves when performing an autopsy.
Impermeable footwear having non-slip soles must be worn by all persons
working in the theatre area.
Surgical or post-mortem gloves should be worn by all personnel involved in
the autopsy procedure. Double gloving is recommended when thin surgical
gloves are used. Sharp proof gloves must be available and staff should be
encouraged to wear them on the non-dominant hand.
Wrap-around eye protection such as safety glasses or visors should be worn
during autopsies. Hoods and high filtration grade masks should be available
for use in appropriate circumstances.
Respirators having appropriate filters should be available for use in suspected
(Supportive Services) or known high-risk microbiological or chemical contamination.
c) Occupational Health and Safety Standards:
A member of staff of the institution providing the autopsy service shall be
designated the Occupational Health and Safety Officer for the mortuary and
all incidents must be reported and recorded in accordance with institutional
policy.
Containers for sharps should be located to facilitate their disposal at their
point of generation.
A well-maintained continuous eye wash facility must be readily accessible
within or close to the main mortuary theatre.
A well-stocked first aid kit should be readily available.
A clean hand-washing basin with elbow or sensor-controlled taps and paper
towel facilities should be readily accessible in appropriate areas of the
mortuary.
The procedures manual or the institutional safety manual shall contain
instructions for dealing with hazardous chemicals and their spillage.
d) Training and Development Program:
Staff assisting in mortuary or autopsy procedures should be encouraged to
undertake training in mortuary practice.
New staff shall undergo a comprehensive induction program covering all
skills required to do their job and to comply with occupational health safety
requirements of the mortuary.
All staff working in the mortuary should be trained in manual handling
procedures, including specialised techniques to facilitate moving of bodies
without incurring back or other injury.
Staff should be trained and receive regular updates in infection control.
Staff should receive training in fire awareness and basic first aid to deal with
emergency situations.
A record of training received should be maintained for each member of staff
and competency for each skill or task should be reviewed annually.
Appropriate vaccinations and follow up of immunity status should be offered
to all mortuary staff and records should be maintained, including any refusal
of an offer of immunization. As a minimum there should be vaccination
against Hepatitis B and regular screening for exposure to Tuberculosis.

Some common problems faced by all mortuaries in and around the world are as
follows:
1. Over half of the countries mortuaries could have significant problems with some
failing to meet health and safety standards, according to a top level inspection
team. Many hospitals fall under this cadre suffering severe criticism by inspectors.
2. Facilities there were described as "woefully inadequate" with some equipment
"out of date and unsafe". There were also fears that there was no way it could be
brought into line with current health and safety facilities.
3. The service had suffered from chronic under funding and lack of care for years.
The lack of investment was leading to a gradual deterioration of services, which Mortuary Services
often went unnoticed.

4. The service tend to be in fairly old bits of the hospital that tend to get left by
management and nobody tends to look at them until something happens.
5. Many hospitals in and abroad has lost its accreditation following a meeting when
it was revealed that despite the best efforts of staff the service was sub standard.
6. One reason is that the services are never visited by hospital administrators. Those
in the hierarchy will occasionally leave their clear desks for a visit to wards,
outpatient departments, even an operating theatre, but they would not even know
where the mortuary is.
7. A second problem is unclaimed bodies, which may occupy a berth in the fridge
for weeks, and the undertaker with inadequate or no storage facilities who uses the
mortuary as a storage area, collecting the body only on the day of the funeral.
8. Facilities for proper viewing of the dead person and an area for sharing grief and
for reflecting on past events are often inadequate and tasteless and improper
storage of bodies and organs in hospital mortuaries have generated public interest
nowadays in both pathology and mortuary services.
9. Regular audits are essential for a mortuary to run effectively and safely and to
gain public confidence.
21.12 LET US SUM UP

Ideally all hospitals should have a mortuary suitable for the temporary shelter of the
dead, with proper refrigeration facilities for an adequate number of bodies. Facilities
for autopsy should be provided, if local regulations permit or require it. Hospital
policies and procedures must be laid down for the mortuary and for autopsies.

State the techniques in implementing and enhancing facilities of the mortuary services
in a hospital.
21.14 KEYWORDS
Morgue or Mortuary: a place used for the storage of human remains.
Retorts: Specially designed ovens that are used in funerary cremation.

1. Give the meaning of the term mortuary. Explain its types.
2. List down the different uses of mortuary services.
3. Explain how the mortuary services are organized and managed.
4. Where does the mortuary services located in a hospital?
5. What are the factors to be considered in designing the mortuary service in a
hospital?
6. Explain in detail the issues and challenges that are to be faced by a mortuary
service in a hospital.

1. There are two types of mortuary cold chambers:
Morgue - Positive temperature (2/+4 °C) used for keeping the bodies
a few days or a few weeks.
Morgue - Negative temperature (-15°C/-25 °C) used in forensic
institutes, especially for bodies which have not yet been identified.
2. The mortuary cold chamber is used to keep the deceased as long as is
necessary for:
identification purposes,
post-mortem examination, or
while awaiting burial.
3. If possible, the mortuary should be located near the pathology department
or the laboratory. It should be easily accessible from wards and the
emergency and operating departments.

Hayward, Cynthia. ChiPlanTM A Space Planning Guide for Healthcare Facilities.
Canada, 1979.
Construction, 1993.
209
LESSON Hospital Security Services
22
HOSPITAL SECURITY SERVICES
CONTENTS
22.1 Introduction
22.2 Functions
22.3 Services
22.4 Scope
22.5 Factors in Designing Hospital Security Management
22.6 Concept Definition
22.7 Security Management Process
22.8 Security Risk Mitigation Strategies
22.10 Let us Sum up
22.12 Keywords

z Understand the hospital security services and its functions
z Study the factors in designing hospital security management
z Study the security management process
z Analyze the security risk mitigation strategies
z Study the issues and challenges related to this field
22.1 INTRODUCTION
Securing the environment of care is a challenging and continual effort for most
healthcare security managers, who face unique challenges in balancing the open
campus environment with the protection needs of the hospital’s patients, employees,
and other assets. No hospital is without risk and effectively managing risk is crucial to
maintaining the protection and openness balance. By conducting a comprehensive risk
assessment, hospital security managers can prioritize identified risks, develop an
effective hospital security program, and reduce risk to a manageable and acceptable
level.
2 Every hospital today own a mission to empower hospitals to protect their patients,
(Supportive Services) staff, visitors and property from harm. A comprehensive security assessment and
vulnerability analysis covers all facets of the hospital's physical and procedural
security. Health care Security provides a wide range of administrative, assessment,
and management services to hospitals, clinics, and community providers. Compliance
with standards security is accomplished through competency training methods, crime
prevention programs, risk and vulnerability surveys of security sensitive areas, and
overall management of the protection program.
22.2 FUNCTIONS
Security directs and monitors the overall safety for all hospital patients, visitors and
staff. The main purpose is to provide the patients with a secure environment during
their stay. To ensure this the hospital security department has to take care of necessary
activities like:
z Patient/Guest/Employee Escort Service
z Personal Safety
z Parking Enforcement
z Fire Safety In-service
z Hospital Issued Employee Locks
z Property Damage Investigations
z Incident Report Investigations
z Lost and Found Services
z Patient Valuables Lockups
z Hospital Key Replacement
z Response to all security calls
Services are provided by experienced and caring staff who focus on the physical,
emotional, social, cognitive and spiritual well being of the clients in order to prepare
for their return and integration into community life.
22.3 SERVICES
The anticipated quantifiable benefits of the hospital security programs are to deliver
reductions in violent crime against staff and patients and a reduction in property crime
associated with hospital premises and assets in the showcase hospitals in accordance
with the following aims:
z reduce violence against staff and patients in the hospital
z reduce the loss of staff time due to violence
z provide better evidence for the police in pursuing criminal convictions against
violent individuals in the pilot hospitals
z reduce property theft within the hospital
z improve the control drugs in the ambulances to prevent theft and monitor use
z reduce all incidents without increasing labour costs
z provide a case study of best practice in the public sector
z provide information regarding the project to all trusts via a website.
z produce a full assessment report on safer hospitals for use in the Government 2
sector (amongst participating departments) within the stipulated time Hospital Security Services
22.4 SCOPE
Security professionals should look at the threats likely in specific and wide areas:
z the emergency/trauma department (gang fights, vendettas, domestic conflicts,
child custody conflicts, VIP patients);
z infant care area (infant abduction, need for CCTV and infant security);
z pharmacy/drug storage area (alarm and access control systems);
z prisoner care area (receiving, elevator lock-off, surveillance, command center);
z operating rooms (access control, delayed egress hardware, CCTV),
z labs (access control, duress alarms, CCTV);
z nuclear medicine area (access control, CCTV);
z geriatric care area (patient locators, CCTV);
z psychiatric care area (lock-down capability, access control, staff duress, solitary
room);
z morgue (decedent services area, access control, alarm system, CCTV); and
z PBX area (late-night security, rest room security, door release, duress alarm).
z parking lot (lighting, access control, CCTV in stairwells, duress alarm at fee
collection
z booth),
z food service area (duress alarm),
z gift shop (burglar alarm, duress alarm) and
z shipping/receiving areas (CCTV, patrol).
z biohazard waste storage and disposal (CCTV, access control).
New products such as alarm pagers, infant abduction detection systems, patient
wandering systems, CCTV video pursuit systems, people trackers and asset protection
systems can each enhance hospital security, Indeed hospital security is unique, but
with good planning, protection of its assets can be enhanced.
22.5 FACTORS IN DESIGNING HOSPITAL SECURITY

MANAGEMENT
While designing a hospital security management program the following factors has to
be considered:
Level of Physical Security

z Physical design and layout of campus and surrounding property
z Local criminal demographics report
z Facility buildings and infrastructure
z Access Control
z Locks and Alarms
z CCTV/CCDV systems
z Asset tracking and inventory control
z Parking Area Security
2 Security Management Program:
(Supportive Services) z Quality of the Security Management Program
z Previous security Sentinel Events
z Preparedness for terrorism & mass casualties
z Employee security awareness associated with on-going educational programs
z Administration and management support
Policies, Protocols & Procedures:

z Administrative Security Policies
z Security Protocols
z In-place Security Procedures
Standards & Requirements:

z Results of Mock Surveys
z Statement of Conditions Preparation and Electronic Filing
z Tracer Reviews in Patient Care Areas
z Environment of Care and Risk Assessments
z National Patient Safety Goals Education
z Emergency Management Plans & Terrorism Preparedness
Check Your Progress
1. Explain the hospital security service and its functions.
……………………………………………………………………………….
……………………………………………………………………………….
2. Briefly explain security management process.
……………………………………………………………………………….
……………………………………………………………………………….
22.6 CONCEPT DEFINITION

a) Risk management: as the name implies, is the management of risks to an
organization. For most healthcare facilities, risk management includes not only
security functions, but also insurance, legal issues, and health and safety. The
primary component of risk management is the risk assessment process whereby
risks are monitored and addressed on a continual basis.
b) Threats: are acts or conditions that can damage, destroy, or take hospital assets. 2
Examples include natural disasters and criminal perpetrators. Hospital Security Services
c) Vulnerabilities: are weaknesses or gaps in a security program that can be

exploited by threats to gain unauthorized access to an asset. Vulnerabilities are
those things that make the hospital more prone to security related problems, such
as crime, unauthorized access, and damage from natural disasters.
d) Risk: is the result of threats and vulnerabilities.
A simplified example may be a small town hospital which has open access to the
facility and limited visitor management (vulnerability), but no historical security
incidents (threat), thus the risk to the hospital is low.
Risk = Threat + Vulnerability
22.7 SECURITY MANAGEMENT PROCESS

This section discusses a 5-step risk assessment process that enhances the hospital
security program by effectively mitigating risks to the hospital.
Step 1: Asset Identification: Identifying assets, is the first step of the risk assessment
process. Asset identification is the process of determining what people, property and
information are critical to the mission of the hospital. People assets may include
doctors, nurses, and patients along with other persons such as visitors and support
personnel. A hospital’s property assets consist of both tangible and intangible items.
Tangible assets are usually simple to identify, while intangible assets, such as the
hospital’s reputation, are more difficult to identify and assign a dollar value. For all
hospitals, information assets include medical records. While all assets have value, not
all assets are critical to the hospital’s mission. Critical assets, then, are those assets
necessary for the hospital to carry out its mission of providing healthcare, for without
them functions and processes will fail and cause the hospital’s mission to fail.
Depending on the type of care and treatment provided, a hospital’s critical assets
invariably include patients, medical professionals, support personnel, medical records,
equipment, supplies, and pharmaceuticals.
Step 2: Security Inventory: The second step of the hospital security risk assessment
process is the security inventory. Typically, a hospital has already deployed various
security measures throughout the facility or campus to resolve past security
problems.These security measures may include policies and procedures, physical
security equipment, security personnel, or some combination of these measures.
Security policies and procedures may include a security management plan, an
emergency management plan, workplace violence prevention policy, medical records
protection procedures, visitor management policies, and bomb threat procedures.
Physical security equipment can include alarm systems, closed circuit television
systems, access control systems, perimeter security systems, and lighting. Security
personnel include the proprietary security force, contractual security personnel, off-
duty law enforcement officers, and other personnel who serve in a protection capacity.
The risk assessment team should identify each component of the security program,
what asset(s) it used to protect, and its level of effectiveness. There are two methods
for inventorying current security measures, inside-out or outside-in:
z Outside-in approach: It is the risk assessment team begins at the facility’s
perimeter and works their way in toward the identified critical assets through each
line of defense.
z Inside-out approach: It is the opposite with the team starting at each critical asset
and working their way out to the perimeter.
2 In addition to these methods, the inventory process should also include reviewing any
(Supportive Services) available security documentation including security plans, policies and procedures,
security officer’s post orders, and physical protection system documentation.
Step 3: Threat Assessment: The third step in the risk assessment process is the threat
assessment. Threats are specific events or conditions that seek to obtain, damage, or
destroy a hospital asset. Historical information is the primary source for a threat
assessment; however other threats may emerge without a historical context.
Regardless of whether hospital security decision makers are dealing with an emerging
or existing threat, they should share information regarding criminal incidents, security
breaches, and other threats with other hospitals in close proximity. While hospitals
sharing information is an informal approach to threat assessments, formal threat
assessments are more detailed analyses used to evaluate the likelihood of adverse
events, such as terrorism, natural disasters, and crimes that may affect hospital
operations.
The most common form of threat assessment is crime analysis. Broadly speaking,
crime analysis is the logical examination of crimes which have penetrated preventive
measures, including the frequency of specific crimes, each incident’s temporal details
(time and day), and the risk posed to a property’s inhabitants, as well as the
application of revised security standards and preventive measures. While the above
definition of crime analysis is holistic, it can be dissected into three basic elements:
z The logical examination of crimes which have penetrated preventive measures.
z The frequency of specific crimes, each incident’s temporal details (time and day),
and the risk posed to a property’s inhabitants.
z As well as the application of revised security standards and preventive measures.
Examining crimes perpetrated at the hospital is commonplace in today’s healthcare
environment, however it is normally limited to internal security data. External data in
the form of crime analysis should also be evaluated to develop a complete picture of
threats to the hospital.
Crime analysis guides security professionals in the right direction by highlighting the
types of crimes perpetrated (crime specific analysis), problem areas on the property
(spatial analysis), and when they occur (temporal analysis). Using this information, it
is much easier to select appropriate countermeasures aimed directly at the problem
Step 4: Vulnerability Assessment: The fourth step of the risk assessment process is
the vulnerability assessment, a systematic approach used to assess a hospital’s security
posture and analyze the effectiveness of the existing security program. Vulnerability
assessments measure the security programs effectiveness, compare it against valid
security metrics, and provide recommendations to hospital security decision makers
for improvements. In essence, the vulnerability assessment assists hospital security
decision makers in determining the need for additional security measures, security
equipment upgrades, changes in policies and procedures, and manpower needs. The
primary tool of a vulnerability assessment is the security survey which identifies and
measures the vulnerabilities at the hospital by determining what opportunities exist to
attack, obtain, or damage the hospital’s assets.
Security surveys are simply questions and checklists that guide the assessment team
during off-site preparations and on-site inspections of the facility. Surveys may range
from a few basic questions to highly detailed lists comprising thousands of questions.
A typical security survey contains general information about the hospital, including
geographic characteristics, and physical layout of the facilities. The security survey
also evaluates security deployment schedules, operational requirements, security
equipment capability, and internal security incidents which have impacted the hospital
security.
Step 5: Risk Assessment: The actual risk assessment is the fifth and final step in the 2
process and is basically the logical analysis of the previous steps which included asset Hospital Security Services
identification, security inventory, threat assessment, and vulnerability assessment.

While assessing risk is more of an art than a science, the risk assessment should be
benchmarked against industry standards and guidelines. The purpose of risk
assessment step is to identify risk mitigation strategies which can be employed to
reduce the hospital’s risk to an acceptable and manageable level. Mitigating risk
involves identifying strategies that can reduce threats and vulnerabilities through the
implementation of additional security measures or other means.
22.8 SECURITY RISK MITIGATION STRATEGIES

Given a specific threat, there are five risk mitigation strategies available to the
hospital security decision maker. Generally, the five strategies for managing risk
include:
1. avoidance
2. reduction
3. spreading
4. transfer and
5. acceptance.
1. Risk avoidance: It requires the removal of the target (asset) from the equation.
Avoidance is an extreme measure since it can hamper the hospital’s operations.
Reducing risk involves the deployment of security measures to reduce risk to an
acceptable level.
2. Risk reduction: It is the driving force for a hospital’s security department whose
role it is to provide protection for assets.
3. Risk spreading: It is a strategy to move assets to different geographic areas so if
one area is attacked; the consequence is limited to that area. Storing necessary
pharmaceuticals and other medical supplies off site is good way to spread the risk,
thus if an area of a hospital is attacked or damaged by natural disasters, there is
another supply available elsewhere.
4. Risk transfer: It is a strategy used to remove the risk from the owner to a third
party. Insurance is the best example of risk transfer whereby the insurance
company assumes the risk for a fee.
5. Risk acceptance: It is another strategy for mitigating risk. As the name implies,
risk acceptance is simply where the hospital assumes the risk to an asset, typically
after reducing the risk level to an acceptable level.

1. Hospitals are not paying enough attention to security issues, and the steps they are
taking are often ineffective. Most hospitals are putting too much emphasis on
compliance and not enough on real security vulnerabilities.
2. There is an over-reliance on employee education and disciplinary action as
effective prevention and response techniques that do not address the incidence of
willful and careless intent that is responsible for the hospital's largest and most
damaging breaches.
3. There is some irony in the pay differential received by hospital security personnel.
Despite the lower pay, hospital security personnel on a daily basis work with
security challenges far more difficult than many industries. The difficulty of the
security challenge arises from the desire of most hospitals to maintain a sense of
2 openness, while at the same time adequately protecting patients, visitors and
(Supportive Services) employees.
4. Developing a comprehensive security plan requires methodical and deliberate
analysis. Starting with a macro understanding of an organization and progressing
to micro security tasks, it takes structure to compile and analyze a security plan. of
its configuration and its layout
5. Few security programs are products of a comprehensive analysis; most are
developed on an ad-hoc basis in response to a security incident. In fact, many
security operations are designed for investigations after an event occurs, not for
prevention.
6. The object of a security analysis is to identify security exposures in a methodical
and thorough manner so that a security program is based on broad analysis and
not simply on the last security incident. Analysis ensures that expenditures for
security are directed appropriately based on local needs, thus protecting critical
resources while accepting the risks stemming from lesser concerns.
7. An underlying concept is that an asset cannot be protected completely, without
absorbing extravagant costs and without inhibiting business operations. The goal
instead is to make it difficult — but not impossible — for an adversary to breach
security. The level of difficulty depends upon the value of the asset and the
organization's tolerance for risk.
8. Healthcare facilities are complex environments where information is stored and
hared in a number of ways that are critical to patient well-being.Until healthcare
organizations expand their data security measures to address the threat of data
compromise as well as privacy and compliance, patients will continue to be at
risk.
9. Regulatory loopholes in data management standards1 allow data breaches to go
unreported, preventing an accurate measurement of frequency.
10. Security policies place a greater emphasis on preventing violation of privacy than
preventing fraud and malicious intent.
11. Patient safety extends beyond clinical care. This data tells us that organizations
must also broaden their data security and risk management measures to address
the threat of patient data breach."
22.10 LET US SUM UP

Fraud and theft are a booming business in any society. Like corruption, they have
become a gobal phenomenon. They can strike from anywhere and often rear their ugly
heads where they are least expected. Figures relating to loss due to fraud and theft are
incredibly high. The management has a moral obligation to safegaurd the assets of the
institution by making theft and fraud as difficult as possible, if not impossible.

Analyze the existing security system of a hospital and give your points to improve
security as needed and suggest measures for further improvement.
22.12 KEYWORDS
Threats: acts that can damage, destroy, or take hospital assets.
Vulnerabilities: weaknesses that make the hospital more prone to security related
problems.
Risk: logical analysis of the situation.
2
22.13 QUESTIONS FOR DISCUSSION Hospital Security Services
1. Explain the hospital security service and its functions.

2. What are the factors to be considered in designing the hospital security system?
3. Explain the security management process.
4. Explain the various security mitigation strategies.
5. What are the challenges to be faced in security management systems?

1. Hospital Security Service directs and monitors the overall safety for all
hospital patients, visitors and staff. The main purpose is to provide the
patients with a secure environment during their stay.
2. Security Management Process:
Step 1: Asset Identification
Step 2: Security Inventory
Step 3: Threat Assessment
Step 4: Vulnerability Assessment
Step 5: Risk Assessment

Facilities Standards for the Public Buildings Service, by the General Services
Administration (GSA).
Mitigation Planning How-To Guide Series, FEMA 386 Series.
The National Strategy for "The Physical Protection of Critical Infrastructure and Key
Assets", The White House. February 2003.
Protection of Federal Office Buildings Against Terrorism by the Committee on the
Protection of Federal Facilities Against Terrorism, Building Research Board, National
Research Council. Washington, DC: National Academy Press, 1988.
Understanding Your Risks: Identifying Hazards and Estimating Losses, FEMA
United for a Stronger America: Citizen's Preparedness Guide.
Uses of Risk Analysis to Achieve Balanced Safety in Building Design and Operations
by Bruce D. McDowell and Andrew C. Lemer, Editors; Committee on Risk Appraisal
in the Development of Facilities Design Criteria, National Research Council.
Washington, DC: National Academy Press, 1991.
websites
The Infrastructure Security Partnership (TISP).
220
LESSON UNIT V 221
Disaster Management
23
DISASTER MANAGEMENT
CONTENTS
23.1 Introduction
23.2 Definitions used under this Context
23.3 Types of Disasters
23.4 Aims and Objectives of Disaster Preparedness
23.5 Disaster Preparedness Measures
23.6 Hospital Disaster Plan – When a Disaster Strikes
23.7 Let us Sum up
23.9 Keywords

z Understand the meaning and related concepts of disaster management
z Derive the types, and thereby to bring out the objectives of disaster management
z Derive the disaster plan both at the time when the disaster strikes and before the
disaster
23.1 INTRODUCTION
Better management of current hospital resources and staff could greatly improve
preparedness. To date, disaster medical response has predominantly focused on pre-
hospital issues such as triage, evacuation, and transport of casualties, and has largely
assumed that hospital management would occur as planned. As recent events have
shown, hospitals can quickly be overwhelmed in the event of a disaster. This is also
the case in countries where hospital facilities are thought to be large, modern and
sufficiently equipped.
Co-operation between hospitals in the vicinity of a disaster must improve, with
improved communications, better training and planning, and triage algorithms that can
help move hospital staff as opposed to patients. Currently, for a large-scale disaster
patients are segregated to specific facilities according to condition or patient-based
resource allocation. Planning and preparedness would allow for a better, more
efficient exchange of material and human resources when needed. In all, the most
pressing needs are education and training, and more detailed planning that
acknowledges the specific disaster medical needs of hospitals and ICU's worldwide.
212
Hospital Operation-II 23.2 DEFINITIONS USED UNDER THIS CONTEXT
1. Disaster: is an extreme disruption of the functioning of a society that causes
widespread human, material, or environmental losses that exceed the ability of the
affected society to cope using only its own resources. Events such as earthquakes,
floods, and cyclones, by themselves, are not considered disasters. Rather, they
become disasters when they adversely and seriously affect human life, livelihoods
and property.
2. Disaster Preparedness: seeks to prepare for and reduce these adverse effects.
3. Standby Orange Alert: Prepare for the possibility of an Orange Alert. Usually
precedes the alert. Dispense in-house employees to the Personnel Pool for sign in,
call in on-call staff, and lock all doors except the Front Entrance and the
Emergency Room doors.
4. Orange Alert: Impending disaster with a count of victims being rescued and
transferred to the hospital. Organize treatment and triage areas, continue with
Disaster Plan assignments, initiate calling of employees, prepare to triage and
treat victims. Establish Control Center.
5. All Clear: Discontinue Disaster Plan. Disaster is finished. All victims have been
treated. Disaster treatment areas can be dismantled.
6. Messenger: Writes down messages and transports them to the intended receiver.
7. Transporter: Transports victims by carts, wheelchairs or accompanies them
ambulatory and remains with the victims until released by the person in charge of
the area.
8. Guard: Stationed at doors and checks identification of persons attempting to gain
entrance to the facility. Sends people without proper identification to Control
Center for identification.
9. Internal Disaster: A need for extra hospital personnel to care for patients and
possible evacuation of them due to an accident within the facility such as fire,
tornado or explosion.
10. External Disaster: A disaster which occurs outside the hospital, somewhere in the
community, when there is a disproportionate amount of hospital staff to care for
the incoming Emergency Room patients or victims.
11. On-Call Staff: The members of the various hospital departments who are on call
for hospital business on a 24 or 48 hour basis.
12. Critical: Vital signs are unstable and not within normal limits. Patient is acutely
ill or unconscious. Indicators are questionable or unfavorable.
13. Non-critical: Vital signs are stable and within normal limits. Patient’s conscious
and can be either comfortable or uncomfortable. Indicators are favorable or
excellent.
23.3 TYPES OF DISASTERS

There are different ways to classify disasters. Classifications matter because
preparedness, response and risk reduction measures as well as the specialists and
agencies involved depend on the type of disaster. Disasters are often classified
according to their cause, their speed of onset (sudden or slow) and whether or not they
are due to "acts of nature" or "acts of humans"—a classification which is often
contested, because it is argued that human actions, in fact, also precipitate natural
disasters.
a) Hazards causing disasters: Disasters classified according to cause are named 213
after the hazard which results in the disastrous social and economic consequences. Disaster Management
Thus, this classification includes earthquakes, floods, cyclones, tornadoes,

landslides, mud flows, droughts, pest and insect infestations, chemical explosions,
etc.
b) Speed of onset: The speed of the disaster's onset is another way to distinguish
between disasters and the types of responses that may be required. A rapid onset
disaster refers to an event or hazard that occurs suddenly, with little warning,
taking the lives of people, and destroying economic structures and material
resources. Rapid onset disasters may be caused by earthquakes, floods, storm
winds, tornadoes, or mud flows.
c) Slow onset disasters occur over time and slowly deteriorate a society's and a
population's capacity to withstand the effects of the hazard or threat. Hazards
causing these disaster conditions typically include droughts, famines,
environmental degradation, desertification, deforestation and pest infestation.
d) Acts of nature or acts of humans: Disasters are sometimes classified according to
whether they are "natural" disasters, or "human-made" disasters. For example,
disasters caused by floods, droughts, tidal waves and earth tremors are generally
considered "natural disasters." Disasters caused by chemical or industrial
accidents, environmental pollution, transport accidents and political unrest are
classified as "human-made" or "human-caused" disasters since they are the direct
result of human action.
23.4 AIMS AND OBJECTIVES OF DISASTER

PREPAREDNESS
Disaster preparedness refers to measures taken to prepare for and reduce the effects of
disasters. That is, to predict and where possible prevent them, mitigate their impact on
vulnerable populations, and respond to and effectively cope with their consequences.
Disaster preparedness is best viewed from a broad perspective and is more
appropriately conceived of as a goal, rather than as a specialized programme or stage
that immediately precedes disaster response.
Disaster preparedness is a continuous and integrated process resulting from a wide
range of activities and resources rather than from a distinct sectoral activity by itself.
It requires the contributions of many different areas—ranging from training and
logistics, to health care to institutional development. Viewed from this broad
perspective, disaster preparedness encompasses the following objectives:
z Increasing the efficiency, effectiveness and impact of disaster emergency response
mechanisms. This includes:
the development and regular testing of warning systems and plans for
evacuation or other measures to be taken during a disaster alert period
to minimize potential loss of life and physical damage
the education and training of officials and the population at risk
the training of first-aid and emergency response teams
the establishment of emergency response policies, standards, organizational
arrangements and operational plans to be followed after a disaster
z Strengthening community-based disaster preparedness. This could include
educating, preparing and supporting local populations and communities in their
everyday efforts to reduce risks and prepare their own local response mechanisms
to address disaster emergency situations.
214 z Developing activities that are useful for both addressing everyday risks that
(Supportive Services) communities face and for responding to disaster situations.
Check Your Progress
1. Disaster
………………………………………………………………………………
………………………………………………………………………………
2. Disaster preparedness
………………………………………………………………………………
………………………………………………………………………………
3. Types of disasters
………………………………………………………………………………
………………………………………………………………………………
23.5 DISASTER PREPAREDNESS MEASURES

Disaster preparedness, is a broad concept that describes a set of measures that
minimizes the adverse effects of a hazard including loss of life and property and
disruption of livelihoods. Disaster preparedness is achieved partially through
readiness measures that expedite emergency response, rehabilitation and recovery and
result in rapid, timely and targeted assistance. It is also achieved through community-
based approaches and activities that build the capacities of people and communities to
cope with and minimise the effects of a disaster on their lives.
A comprehensive disaster preparedness strategy would therefore include the following
elements:
1. Hazard, risk and vulnerability assessments
2. Response mechanisms and strategies
3. Preparedness plans
4. Coordination
5. Information management
6. Early warning systems
7. Resource mobilization
8. Public education, training, and rehearsals
9. Community-based disaster preparedness
23.6 HOSPITAL DISASTER PLAN – WHEN A DISASTER

STRIKES
I. Purpose:
1. To provide policy for response to both internal and external disaster situations
that may affect hospital staff, patients, visitors and the community.
2. Identify responsibilities of individuals and departments in the event of a
disaster situation.
3. Identify Standard Operating Guidelines (SOG's) for emergency activities and 215
responses. Disaster Management
II. Situations and Assumptions:

Several types of hazards pose a threat to the hospital:
1. Internal disasters: fire, explosions, and hazardous material spills or releases.
2. Minor external disasters: incidents involving a small number of casualties.
3. Major external disasters: incidents involving a large number of casualties.
4. Disaster threats affecting the hospital or community (large or nearby fires,
impending tornado, flooding, explosions, etc.).
5. Disasters in other communities.
III. General Considerations:

(A) Lines of Authority: The following persons, in the order listed, will be in
charge:
1. Administrator.
2. Director of Nursing.
3. Nursing Supervisor on duty at time of disaster.
4. Emergency Room Supervisor.
(B) Communications:
1. A Command Center will be set up at the Security Desk to handle and
coordinate all internal communications. All department heads or their
designee will report to this office and call as many of their employees as
needed.
2. The person in charge when the disaster happens will assign a nurse to the
communications system. This nurse will answer all radio calls from this
station.
3. The radio shall be manned immediately at the nurse's station by a unit
coordinator but only for informational purposes and she should not
verbally respond.
4. At least one messenger will be assigned to each radio operator to deliver
messages, obtain casualty count from triage, etc.
5. Person directing personnel pool shall send a runner to all departments to
advise them of the type of disaster and number of victims and extent of
injuries when this information is available.
a) Nursing will be notified by the Unit Coordinator or designated
persons.
b) Department Heads will be notified by the Supervisor or designated
staff.
c) Department Heads will notify their key personnel.
6. A "Visitor Control Center" will be set up in the front lobby. Families of
casualties will be instructed to wait there until notified of patient's
condition. Normal visiting hours will be suspended during the disaster
situation (orange alert).
216 a) A hospital staff member will stay with the family members. (Social
(Supportive Services) Services will be assigned here after reporting to the Command Center
and other personnel assigned as needed)
b) A list of the visitor's names in association with the patient they are
inquiring about should be kept. Volunteers may be needed to escort
visitors within the facility.
7. Telephone lines will be made available for outgoing and incoming calls.
One line will be designated as the open line to the external Command
Center. The person in charge will designate assigned staff to monitor the
phones.
8. Assistance in providing additional radio communications to all
departments within the hospital may be obtained.
C. Supplies and Equipment:
1. Extra supplies will be obtained from Purchasing personnel through
runners.
2. Outside supplies will be ordered by the Purchasing Director and brought
into the hospital via the loading dock.
D. Valuables and Clothing:
1. Large paper or plastic bags are available in the treatment Areas and the
storeroom for patient's clothing and valuables.
E. Public Communication Center:
1. A communication center for receiving outside calls and giving
information to the press, radio and relatives shall be set up in Medical
Records.
2. The press can use the restaurant as their headquarters.
F. Morgue Facilities:
1. Patients pronounced DOA will be tagged with a Disaster Tag...do not
remove personal effects. The top sheet from the tag will be taken to the
Command Center in Emergency Department for casualty list purposes.
2. Bodies will be stored in the hallway by Purchasing. Personnel will
remain with bodies until removed by Funeral Director.
3. After bodies have been identified, the information will be filed on the
Disaster Tag and Medical Records notified as to the identification of the
patient.
4. The bodies will be removed via the loading dock to the Funeral Director.
A complete record of all bodies must be maintained along with the name
of the agency removing them, e.g., police, fire department, undertaker,
etc.
IV. Staffing
A. Administrator:
In a major disaster will do the following functions:
1. Check with local authorities to verify the disaster and obtain additional
information.
2. Authorize announcement of disaster to hospital personnel.
3. Ask for help from local police and volunteer organizations as deemed
necessary.
4. Stay in the area of administrative offices to be available to assist, as 217
requested, by disaster coordinator. Disaster Management
B. Director of Nursing:
1. In a major disaster will do the Administrator's functions, if he is absent.
2. Is responsible for notifying all department heads or alternates.
3. In a major disaster be responsible to see that families of victims are
notified as soon as possible. These calls may be made by the physician
who treats the victim, the Director of Social Services, or the Director of
Nursing or her designee.
C. Nursing Supervisor:
1. Is responsible for determining the extent of the disaster, whether it is a
"major" or a "minor" disaster. If it is a major disaster, then the
Administrator and Director of Nursing will be notified.
2. Will set up a Command Center - All department heads would report in to
the supervisor before going to their departments.
3. Will attempt to find adequate numbers of nursing personnel.
D. Admitting Office:
1. Assign responsible person to switchboard as soon as possible.
2. Department head or designee will call in their own personnel as needed
after having reported to the Command Center.
3. Notify Emergency Communications Center if internal disaster is
involved.
4. After notification of disaster by authorized person, He is responsible for
sounding the "Orange Alert" alarm.
5. Do not accept routine non-emergency admissions except OB's.
6. Refer all public information calls and press to desk in Reception Area.
E. Nursing Personnel Assigned to Disaster Victims:
1. Obtain information and fill out available information and time on disaster
tags. Even if no information is available as to identity, give information
as to condition, types of injuries, etc.
2. Be sure top sheet of disaster tag is made available to Medical Records
with pertinent information.
3. Do not leave your patient unattended. Patient may be signed off to person
in charge when admitted to a unit.
4. Give aggressive first aid treatment.
5. Make out the appropriate lab slips and x-ray requisitions with disaster
number. It is essential that they have these slips made out.
6. Patients who have been admitted to the hospital should have the
information slips placed with the Command Center in the Emergency
Department.
7. If a patient is transferred, be sure to indicate on the tag to which hospital
he has been sent.
8. If a patient is admitted to our hospital, be sure and send all oxygen
equipment to his room with him.
218 V. Responsibilities of different Departments:
(Supportive Services) 1. Dietary
a) Department head or designee will call in their own personnel as needed
after reporting to Command Center.
b) Prepare to serve nourishments to ambulatory patients, house patients and
personnel as need arises.
c) Clear hallway of all tray carts.
d) Utilize dining room and west hospital solarium for extra eating space.
e) Be responsible for setting up menus in disaster situation and maintain
adequate supplies.
2. Maintenance
b) Maintain full operation of all facilities.
c) All doors should be locked immediately except employee entrance,
Emergency Department door, and front lobby.
d) Be responsible for setting up extra beds in hospital if needed, as well as
transporting storeroom supplies and bringing in extra supplies from other
areas.
e) Be willing to help with movement of victims from ambulance to Triage.
3. Housekeeping and Laundry
b) Be available to help clean receiving area, and clean rooms between cases
in treatment areas.
c) Be sure all hallways or traffic areas are clear of cleaning carts, equipment
and etc.
4. Operating Room, CSR, PAR, Anesthesia, & OP
a) Supervisor will supervise Operating Room and call all needed personnel
b) Call additional surgeons as needed.
c) Check area for supplies and equipment.
d) Ask for additional help to carry out surgery and treatments in Operating
Rooms and Recovery Room.
e) Assign and direct scrub nurses and circulate.
f) Notify Triage when Operating Rooms and Recovery Room is available
for more patients.
g) Keep minimum list of supplies on hand and be prepared to process
additional sterile supplies quickly.
h) Notify anesthetists who will maintain adequate anesthesia and drug
supplies.
5. Hospital Unit - Supervisor will:
a) Assign nurse or unit coordinator to communications system.
b) Prepare for expansion by notifying maintenance of number of extra beds 219
needed and where to set them up. Disaster Management
c) Discharge and movement of hospital patients to create more room for

casualties.
d) Send for extra supplies needed from Purchasing, CSR, Laundry, and
Dietary.
e) If internal, prepare for evacuation of patients to safe area.
f) Send designated personnel to Command Center with wheelchairs.
g) Periodically send messenger to Command Center to check for update.
h) The elevators will be used only for the transportation of patients or
equipment all personnel will use the stairway.
6. ICU - After notification of disaster, the ICU nurse will:
a) Evaluate patients in the Intensive Care Unit for possible discharge. Use
established discharge criteria as a guide. Transfer patients out if indicated.
b) Prepare to admit more critically ill patients.
c) Send runner to Command Center or phone for help.
7. Swing Bed Unit
a) Know current empty bed count and number of personnel available who
could assist in other units. Send number to Command Center.
b) Remain in your unit until notified differently.
c) Will make wheelchairs available.
8. OB Unit
a) Staff from OB can be used to assist in triage if department is covered.
Volunteers can be used from OB to assist in disaster.
b) Patients other than OB's will be triaged by Command Center before being
transferred to OB.
9. Chemical Health Recovery Unit
a) Department Head or designee will call in their own personnel as needed
after reporting to Command Center and staff holding area.
b) Department Head will send designated personnel to Triage with
wheelchairs to hold in Emergency waiting room until needed
10. Medical Imaging
a) The department head or designee will find out the number of patients
involved and any other pertinent information from the Command Center.
b) The department head or designee will be responsible for calling in any
and all personnel needed to sufficiently handle the patient load.
Evening Shift:
a) The technologist on duty or on call for the Radiology Department will be
alerted by the night supervisor. This technologist will be considered the
designee of the x-ray department and will report to the information center
for further information.
b) It will be the duty of this technologist to call in extra help as needed. All
extra help called in will report directly to Radiology.
220 Duties of Medical Imaging Personnel Department Head will:
(Supportive Services) a) Call any or all personnel needed.
b) Arrange for extra supplies to be brought in if needed.
c) Coordinate flow of work and delegation of work areas.
d) Other Technologists will:
i. Perform all x-ray exams as needed and assigned.
ii. Perform all clerical duties.
11. Laboratory
b) Call personnel from nearby hospitals and clinics as necessary.
c) Have arrangements made to obtain additional blood, equipment and
supplies from area agencies.
12. Materials Management - Purchasing
b) Be prepared to supply all departments with needed supplies.
c) Director will designate assistant to supply runners or volunteers to deliver
supplies.
d) Have an up-to-date list of suppliers who can quickly supply extra
materials.
13. Pharmacy
a) Report to Command Center, then remain in department.
b) Have list of drug suppliers that can provide emergency supplies quickly.
c) Keep minimum supply of emergency drugs on hand at all times.
d) Pharmacy should remain open and have a runner to deliver needed meds
to areas.
14. Respiratory Therapy
b) Keep adequate supply of bubblers, cannulas, masks and flowmeters
available in Respiratory Therapy Department.
c) Be prepared to obtain additional respirators and equipment as needed.
d) Be prepared to assist in treatment areas.
e) Keep resuscitation equipment in good operating condition and well
marked.
15. Physical Therapy
b) Be prepared to accept walking wounded victims. Be prepared to provide
assistance to RN's as needed.
c) Request a runner from Command Center as needed.
16. Occupational Therapy 221
Disaster Management
17. Stress/EKG Department
a) Reports to Respiratory Therapy Head or designee.
b) Be prepared to obtain additional equipment and supplies.
c) Be prepared to assist in treatment areas.
18. Social Services
a) Report to the Command Center and be prepared to stay with relatives of
victims in hospital lobby.
b) Will provide Command Center with a list of the family members that are
here.
19. Director of Community Relations
b) Be prepared to call in volunteers who are familiar with physical plant of
hospital to serve.
c) Have volunteers set up downstairs classroom for babysitting personnel's
children.
20. Quality Improvement/Risk Management - Utilization Review
a) Report to Command Center and assist with relatives of victims in hospital
lobby. Also assist Education Coordinator with press information.
21. Security
a) Report to Command Center.
b) Assist RN's as needed.
22. Infection Control
a) Report to Command Center.
b) Be prepared to assist in Pharmacy as needed.
23. Medical Records
after reporting to the Command Center.
b) Assign person to be responsible for maintaining casualty lists and assist
with paperwork as needed at Command Center.
c) Supply extra forms as needed.
d) Be responsible for releasing information to the press after the families of
the victims have been notified.
23.7 LET US SUM UP

There is no specific or tailor-made programs for any of the hospitals in meeting or
overcoming the disasters. It usually differs on the basis of size of the hospitals,
facilities, type of staff and their ability to render emergency treatment. Some may
provide only basic amenities and some to more advanced level. Whatever might be
the situation it is the responsibility of each and every hospital to face and overcome
the disaster. Hence each hospital should have a disaster preparedness plan, that can be
put to action at the time of emergency.
222
Hospital Operation-II 23.8 LESSON END ACTIVITY
Prepare a plan with measures to cover the disaster in a hospital & state how it is useful
at the time disaster strikes.
23.9 KEYWORDS
Disaster: disruption of the normal functioning of life.
Natural Disaster: disaster caused by nature like cyclone, earthquake etc.
Human / Artificial Disaster: disaster caused by man’s activities.

1. Define disaster and disaster preparedness.
2. List down the objectives of disaster preparedness.
3. State and explain the different types of disasters.
4. Explain in detail the measures that would be taken at the time when disaster
strikes.
5. Explain the term disaster preparedness plan.

1. Disaster: is an extreme disruption of the functioning of a society that
causes widespread human, material, or environmental losses that exceed
the ability of the affected society to cope using only its own resources.
2. Disaster preparedness is a broad concept that describes a set of measures
that minimizes the adverse effects of a hazard including loss of life and
property and disruption of livelihoods.
3. Types of Disasters:
a) Hazards causing disasters includes earthquakes, floods, cyclones,
tornadoes, landslides, mud flows, droughts, pest and insect
infestations, chemical explosions, etc.
b) Rapid onset disaster refers to an event or hazard that occurs suddenly,
with little warning, taking the lives of people, and destroying
economic structures and material resources.
c) Slow onset disasters occur over time and slowly deteriorate a society's
and a population's capacity to withstand the effects of the hazard or
threat.

Disaster management, Main Category: Aid / Disasters Article Date: 27 Jan 2005.
Department of health & family services - Hospital Disaster Plan Disaster Preparedness
Training Programme, Participant resource & learning module, International
Federation of Red Cross and Red Crescent Societies.
Emergency Medicine Section, Department of Internal Medicine, Seth G.S. Medical
College & K.E.M. Hospital, Parel, Mumbai, India.
Mehta S, “Disaster& mass casualty program in a hospital- how well they are
prepared?” PubMed Postgrad Med 2006, 52:89 –June 2008.
233
LESSON Fire Protection
24
FIRE PROTECTION
CONTENTS
24.1 Introduction
24.2 Definitions
24.3 Authority and Responsibility
24.4 Policy and Procedures
24.5 Fire Safety Performance Indicators
24.6 Staffing for Fire Safety
24.7 Fire Safety Systems
24.8 Fire Protection Program
24.8.1 Workplace Assessment
24.8.2 Fire Prevention and Control
24.8.3 Emergency Plan
24.8.4 Fire Inspections
24.9 Fire Evacuation Procedure
24.10 Equipments
24.11 What to do in Case of Fire
24.12 At the Scene of Fire
24.13 Let us Sum up
24.15 Keywords

z Understand the fire protection measures employed in a hospital
z Have a glance of policies, procedures, authority and responsibilities of hospital
towards hospital
z Understand the fire safety and fire protection procedures and programs
z Fire evacuation procedure and the needed equipments
z Analyze what to do in case of fire and at the scene of fire
224
Hospital Operation-II 24.1 INTRODUCTION
Fire detection in healthcare facilities is rapidly becoming a major concern in all
countries around the world. An ever-growing population combined with increased
requirements to cater for the elderly sees more demand for the construction and
extensions of these facilities. Hospitals, clinics, aged care facilities and so on have a
real need for good fire protection to ensure the safety of their patients, staff and
visitors.
While most codes and standards govern the fire requirements in these facilities, these
requirements are often the minimal requirements needed to provide a satisfactory level
of fire safety for the risk and application. This does not mean the fire safety systems
designed by competent engineers and installed professionally are inadequate, more
that they are based on several criteria including a cost to the community.
Numerous fire hazards exist within healthcare facilities, these are not fireproof - the
fact is that there is potential in any building for a fire and particularly where electrical
equipment, oxygen and flammable combustible products exist, a fire can start
anywhere and at anytime.
24.2 DEFINITIONS
Fire Safety Manual: A dedicated manual that contains. Fire Safety Policy, Strategy,
Associated procedures, Audit criteria and relevant Divisional records.
Fire Precautions: measures taken to prevent and limit fire spread including for
example fire detection, fire doors and exits, fire compartmentation, fire fighting
equipment, fire training, fire procedures.
Fire Compartmentation: A ward, department, corridor or room(s) that are designed to
limit fire spread.
Fire Safety Procedures: Specific procedures to support the Trust, Divisions and
Corporate Departments to comply with the requirements of legislation, Guidance and
Fire Safety Policy.
Fire Wardens: An individual nominated on behalf of a department/ward and having
received specific fire warden training.
Divisional Risk Lead: An Individual appointed by the divisions to work closely with
Service Managers, department risk co-ordinators and staff to ensure that local plans
are developed, agreed, managed and monitored.
Responsible Person: The term used by The Regulatory Reform (Fire Safety) Order
2005 in relation to the Chief Executive’s role as the employer.
24.3 AUTHORITY AND RESPONSIBILITY

The Board of Hospitals and the Trust is committed to maintain high standards of Fire
Safety in order to minimize the loss of loss of life and personal injury through the
effects of Fire, Smoke and associated fire hazards. The Board has to confirm its full
commitment to the effective management of Fire Safety and recognizes its Statutory
duties under the regulatory reforms and orders. The Board of Hospital Trust undertake
following activities like:
z Ensures that it will implement Fire safety precautions thorough investment in the
Estate and Personnel.
z Recognizes the continuous development of Policies and Procedures to ensure
effective management of the Fire safety process
z Supports proactive management of Fire safety by the assessment of risks in order 225
to contribute to the effective operation of the Trust and all who occupy its Fire Protection
premises.
z Expects partnership initiatives with other agencies and bodies to practice and
promote the provision of Fire safety.
z Expects training curriculums to be developed and delivered that reflect all
employee responsibilities.
z Expects Divisional Boards to identify and action any interpretation services
that may be required to satisfactorily implement this policy.
z The Trust reviews its performance on Fire safety issues by the implementation of
this policy, developing an associated strategy, the provision of support procedures
and working towards full compliance with Legislation, Fire code and Standards
for Better Healthcare.
24.4 POLICY AND PROCEDURES

This policy aims to protect people, the business and the environment through control
of ignition sources and fire load (reduced fire risk) in association with early detection
of fire, adequate containment and rapid evacuation of all people to a place of safety
when necessary. This is achieved by having the following in place:
z Fire Safety procedures
z Adequately trained staff
z Adequate fire extinguisher cover based on the business risks
z Means of escape
z Methods for detecting a fire to provide early warning
z Methods for raising the alarm
z Practical fire evacuations
z Control of hot work
z Inventory of flammable substances
z Fire suppressant systems in high risk areas
z Correct design/alteration of buildings
z Planned preventative maintenance
The Trust Board will endorse this Fire safety policy, all supporting Fire safety
procedures, developed for more detailed implementation will be considered and
endorsed by the Trust Health and Safety Committee.
24.5 FIRE SAFETY PERFORMANCE INDICATORS

1. Have the Trust Board endorsed the Fire Safety Policy?
2. Have Divisional boards formally assessed fire hazards within their Division?
3. Do Divisional Boards have suitable and up to date Fire procedures as set out in
the Trust Fire Safety Policy?
4. Do Divisional Boards monitor Fire precautions in accordance with the Fire safety
Monitoring & Audit procedure?
5. Are systems in place to effectively reduce Unwanted Fire Signals?
226 6. Is an Annual Fire Safety audit submitted by the Fire/Health & Safety Manager to
(Supportive Services) the Trust board?
7. Is the Trusts Fire safety infrastructure maintained and tested in accordance with
Legislation and Approved Codes of Practice.
8. Are corporate Fire Safety Risk Assessments completed, valid and entered on
Datix for all occupied premises?
9. Has the Chief Executive signed and returned the Annual Statement of Fire Safety
to the Department of Health?
10. Is there a Trust Fire Safety Training needs analysis?
Check Your Progress

1. Explain with whom the authority of fire protection lies in a hospital.
…………………………………………………………………………..
…………………………………………………………………………..
2. What to do in case of fire?
…………………………………………………………………………..
…………………………………………………………………………..
3. What is monitoring and auditing of fire safety?
…………………………………………………………………………..
…………………………………………………………………………..
24.6 STAFFING FOR FIRE SAFETY

Following are the personnel list to carry out the fire protection and safety measures in
any hospital:
z Executive Director with special responsibility for fire
z Executive Directors
z Fire/Health and Safety Manager
z Divisional Boards
z Fire/Health and Safety Advisor
z Local Line Management
z Local Fire Warden
z Risk Management/Health and Safety Committee
Duties of the Personnel

i) The Chief Executive has overall responsibility for ensuring:
That management systems are in place to protect the safety of all employees,
patients, visitors and contractors.
That adequate resources are provided and responsibilities for Fire safety
are effectively assigned accepted and fulfilled at all levels of the organisation.
That clear guidelines are provided to assist Managers in fulfilling their
responsibilities.
That an Executive Director is appointed to assist with the implementation 227
of Fire Safety responsibilities. Fire Protection
Subsequent review of the Fire Safety Policy.

ii) General Duties:
The Trust Board of Directors has responsibility for:
Authorising the Trusts Fire Safety Policy and ensuring that resources are
available to support the requirements of the policy.
Authorising the Trusts Strategy for Fire Safety Improvement ensuring the
Strategy includes the requirements set by relevant external bodies including
the Department of Health, Cheshire Fire and Rescue Services and the Health
and Safety Executive.
Reviewing the Annual Fire Safety Report and measuring performance against
the Fire Safety strategy.
Reviewing the Trusts Risk Register on a regular basis and addressing risks
rated 15 and above.
Reviewing the effectiveness of the Fire Safety Policy and the personnel under
their control to whom fire safety responsibilities have been assigned.
The Director of Finance has delegated responsibility for Fire Safety and has
responsibility for:
z Assisting the Chief Executive with Board level responsibilities for Fire safety.
z Ensuring compliance with the Trusts Fire safety strategy.
z Implementation of Fire code or that the objectives of Fire code are met with
alternative measures within the organization.
z Taking responsibility for development, dissemination and implementation of the
Fire Safety Policy.
z Ensuring full staff participation in Fire training and drills.
z Ensuring Fire response teams are in place.
z Supporting the Fire/Health & Safety Manager.
z Appointing the Deputy Director of Risk Management to fulfill his responsibilities
in periods of absence.
The Head of Estates and Facilities has responsibility for:
z Acting as the Trusts Duty Holder with respect to the associated regulations
regarding the management of the electrical system, building design, planned
maintenance regimes, waste management and gas safety.
z Maintaining the Fire integrity of buildings regarding Fire protected areas
including corridors, service voids, hazard rooms, Fire doors and fanlights above
doors and general Fire compartmentation.
z Ensuring procedures are in place to enable development and maintenance
personnel to stipulate correct Fire design criteria within tenders, contracts and
quotes.
z Installing and maintaining appropriate Fire safety engineering controls including
Fire alarm systems, portable Fire fighting equipment, door closures, Fire dampers,
electrical systems, lighting systems and lightning protection systems.
z Maintaining a valid set of up to date Fire safety drawings.
228 z Introducing systems to control the activities of contractors and directly employed
(Supportive Services) labour, which present a Fire risk.
z Ensuring systems for the safe storage, prompt collection and disposal of all waste
materials.
z Ensuring relevant sections within his/her Division have effective systems in place
to enable them to perform their nominated roles in the event of a Fire alarm
activation.
Fire/Health and Safety Manager has responsibility for:
z Taking the lead in all Fire safety activities.
z Assisting the Executive Director in the development, dissemination and
implementation of the Fire safety policy.
z Ensuring the effective and appropriate translation of the Fire safety strategy into
practical application.
z Ensuring that Fire safety statutory compliance is co-ordinated and maintained.
z Assisting the Executive Director in the implementation of Firecode.
z Co-ordinating the annual audit by implementing and developing audit criteria on
Fire issues and assisting the Executive Director in compiling an annual report to
the Board.
z Signature and return of the Annual Certificate of Fire safety management to the
Department of Health.
z Liasing with Divisional Boards to ensure that Fire safety is managed in line with
the Trusts Fire Safety Policy and supporting procedures.
z Reviewing the Trusts Fire Safety Policy.
Fire/Health and Safety Advisor has responsibility for:
z Supporting and deputizing for the Fire/Health and Safety Manager.
z Contributing to periodic reports to management regarding Fire safety provision in
the premises occupied by the Trust.
z Performing Fire risk assessments within the premises as required by Legislation
and Fire code.
z Preparing reports to management recommending prioritized actions in respect to
Fire safety improvements.
z Preparing and delivering training programmes in line with the training curriculum
developed by the Fire/Health & Safety Manager.
Divisional Risk Leads are responsible for:
z Working closely with Service Managers, department risk co-ordinators and staff
to ensure that local plans are developed, agreed, managed and monitored.
All Managers are responsible for:
z The effective management of Fire safety within their area of responsibility.
z Appointing Fire wardens within their Division to ensure trained staff are available
should an outbreak of Fire occur and that regular Fire safety inspections are
carried out.
z Ensuring that all staff under their control are informed of the Fire risks identified
through risk assessments, audits and inspections, and are trained in measures
necessary to eliminate or reduce such risks.
z The implementation and monitoring of identified and appropriate control 229
measures within their area of managerial responsibility. Fire Protection
z Maintaining a good standard of housekeeping.

z Minimising and controlling the quantity of combustible and flammable materials
within their division.
Fire Wardens are responsible for:
z Undertaking monthly Fire safety inspections, recording and reporting the findings
to their line manager.
z Acting as a focal point for Fire safety issues for local staff.
z Attending “live” Fire fighting training.
z Assisting with Emergency Fire evacuations and Fire drills.
The Supplies Department is responsible for:
z Ensuring systems are in place for the procurement of flame retardant soft
furnishings, textiles and furniture.
All Employees
It is essential that you as an employee know how to raise the alarm; evacuate the
buildings, assist others where necessary and use the various types of fire fighting
equipment provided. All employees are therefore responsible for:
z His/her actions and for Promoting Fire safety and assisting in the reduction of
unwanted Fire signals.
z Co-operating with supervisors and line managers to achieve a safe workplace and
for taking reasonable care of themselves.
z Complying with the Fire Safety Policy and associated Fire safety procedures.
z Raising issues regarding Fire safety with their Fire Warden and/or line manager.
z Attending and participate in Fire safety training and Fire drills.
z Assisting with Fire risk assessments and audits as necessary.
24.7 FIRE SAFETY SYSTEMS

i) Design: Inadequate design, alteration or maintenance of Trust premises can have
a detrimental impact on the Fire integrity of the buildings that could expose the
Trust and occupants to significant risks. The Estates & Facilities Division has
responsibility to ensure the correct design, construction and operation of new
projects, plant and equipment regarding fire safety provisions is specified in
tender/quote/contract documentation and the standards adopted when works
proceed. Estates & Facilities will ensure relevant procedures are established and
adopted that identify correct specifications along with the employment of
qualified competent designers, engineers and maintenance personnel.
ii) Maintenance of Fire safety systems and associated Fire hazards: The Estates &
Facilities Division has responsibility for maintaining the Fire integrity and
building services of all Trust properties and will ensure procedures are established
that:
Identify all planned maintenance regimes.
Demonstrate the building structure is adequately maintained including fire
protected areas/corridors; service voids; hazard rooms; fire doors and
230 fanlights above doors; general fire compartmentation; fire alarm systems
(Supportive Services) emergency lighting; directional escape lighting.
Demonstrate building services (Medical and town gas, Electrical, Fire water
main, telecommunications systems) are adequately maintained.
Additionally the Estates & Facilities Division will hold and maintain
appropriate fire safety drawings and records.
iii) Information, Instruction and Training: The Trust acknowledges that the
efficient application of the Fire Safety Policy and supplementary procedures is
subject to staff understanding their content, the risks and knowing what to do in
the event of a Fire incident. Relevant Fire safety training will be provided and be
addressed through the following routes:
Delivery of the Trusts corporate training objectives (Induction and Mandatory
training programmes).
Specific training programmes for the Fire response team and Fire Wardens.
Practical fire evacuation drills and techniques.
iv) Monitoring and Auditing of Fire Safety: Regular Auditing and Monitoring of
Fire safety is required to ensure that there are effective arrangements in place for
managing Fire safety and to ensure the Trust achieves compliance with relevant
statutory provisions. The Trust will operate two monitoring systems for the
measurement of Fire safety performance, active and reactive monitoring.
a) Active Monitoring: will check the adequacy, development and implementation
of the Fire safety system and compliance with relevant regulations and
statutory provisions. Arrangements for active monitoring are:
Health Technical Memorandum Firecode Risk Assessments: An exercise
undertaken by the Fire/Health & Safety Manager to assess the
effectiveness of compliance with relevant statutory provisions and the full
suite of Firecode documents.
Fire Action Plans: Produced to enable the Trust and Divisions to achieve
measurable improvements in performance on a continual basis. Plans
include the outcomes of Risk Assessments and legislative needs.
Key Performance Indicators (Assurance): Selected by the Trusts Health &
Safety Committee, these form the basis of measuring Trust performance
and will be produced on a quarterly and annual basis.
Workplace Inspections: Periodic workplace inspections carried out in
accordance with the Trusts Workplace Health & Safety Inspection
Procedure (TSP 31) and monthly Fire Warden inspections.
Preventative Maintenance: Maintenance of the building structure and
building services carried out by the Estates & Facilities Division.
Audits: Periodic Internal and external audits conducted by competent
auditors at predetermined intervals.
Fire Drills: Unannounced fire drills in non-patient areas. Suitable
arrangements to give “effect” of fire drills will be carried out in those
areas that carrying out a full fire drill would present unacceptable risk to
patient care.
b) Reactive Monitoring: will check for failures in the Fire safety system and Fire
alarm activations. Investigations into all Fire alarm activations by competent
Fire/Health & Safety professionals to identify root causes.
231
Fire Protection
24.8 FIRE PROTECTION PROGRAM
The basic elements of a fire protection program are discussed below:
24.8.1 Workplace Assessment

The first step is to do a workplace assessment. The evaluation will be for workplace
monitoring:
z fire hazards
z effectiveness of controls
z emergency preparedness
Collect as much information as possible on each of the areas. This should include
hazard and control information, as well as relevant legal standards and requirements.
An inventory of hazardous materials used in your workplace will prove useful. The
factors to be assessed are given below. Rate all identified hazards based on severity
(high, medium or low), frequency and probability of injury. The hospital will now be
able to establish a priority for action needed to meet your needs. Carry out a complete
re-assessment whenever you make changes in your workplace, such as a change in
process, work activity or materials used.
Areas to be Assessed
a) Work Processes/Activities
potential fire hazards (sources of ignition, and their location)
high risk areas (e.g., open tanks)
appliances, mechanical/electrical equipment used hazardous materials –
quantities used, characteristics (flammable, combustible, explosive, reactive,
toxic.
corrosive, oxidizing, compressed gases)
hazardous by-products (e.g., explosive dusts)
b) Building
floor layout (stairs, exits, access to exits)
building materials (fire-resistance ratings)
storage areas
emergency lighting
ventilation systems
fire detectors and suppressors (smoke detectors, fire alarms, automatic
sprinklers)
c) People (employees, visitors, community)
number that might be affected
characteristics (consider any disabilities that would affect their ability to
evacuate)
location: inside building (control rooms, offices)
outside building (storage yards)
neighborhood (industries, homes, hospitals, schools)
232 d) Controls
(Supportive Services) engineering controls
work practices
administrative controls
primary containment (containers, tanks, piping systems)
fire containment (extinguishers)
flammable or combustible liquid spills containment
24.8.2 Fire Prevention and Control

The best way to protect your employees, your property and the environment is to
prevent a fire from happening. The most effective way to do this is to eliminate or
minimize all fire hazards. If a fire does occur, however, immediate steps should be
taken to control it, and prevent it from spreading. Fire prevention and control are
achieved by combining engineering, work practice and administrative controls. The
following list provides some examples of each of these controls.
Engineering
z Process alteration
z Substitution with less hazardous
z process materials
z Workplace design
z proper storage facilities (properly marked and separated)
z proper and adequate ventilation
z fire proofing of buildings
z proper fire doors, fire walls and separators
z installation of fire/heat/smoke detectors sprinkler systems
z control of explosive atmospheres (e.g., dusts)
z adequate spill containment
Electrical Equipment
z intrinsically unsafe
z must conform to the Electrical Safety Code
z Consult a fire protection engineering consultant, if necessary
Work Practices
Housekeeping
z adequate waste disposal
z exit/fire escape access
z unobstructed aisles
z control of flammable dusts
z Proper storage of flammables and combustibles
Company Policies 233
Fire Protection
z no smoking
z hot work permits
Spill control procedures for flammable or combustible liquid spills
z minor spills
z major spills
z safety considerations
z waste handling and disposal
Use of approved portable safety containers for the dispensing of flammable liquids.
Bonding/grounding
z Proper use of electrical equipment
z Proper maintenance of equipment and machinery (to prevent leaks and
breakdowns)
z Proper maintenance of ventilation systems
z Proper selection and use of fire extinguishers
Administrative Controls
z Fire Safety Plan
z Standards-develop and enforce standards for all program elements and activities
Fire Inspections
z establish schedule (daily, weekly, monthly)
z by whom (internal: fire brigade members; external: fire department, insurance
company)
z by work area or department
z record keeping and follow-up
Review
z new construction
z change in process design
z similar industry experiences
z changes to legislation (fire/building codes)
z smoking policy
z hot work permit procedures & plant security
Employee training (including orientation training and retraining) in:
z preventive measures
z inspection techniques
z fire extinguisher use
z hazard reporting
z spill control procedures
z emergency procedures
234 Test
(Supportive Services) z employee knowledge of fire prevention
z procedures
z application of knowledge
Measurement and Evaluation

z measure performance against standards (number of and reasons for deviations)
z monitor and evaluate effectiveness of programs (number of fire incidents, spills,
etc., review investigation results)
z correct for continual improvement
24.8.3 Emergency Plan

A fire emergency plan outlines a sequence of steps to be taken when a fire strikes. Its
purpose is to ensure the safety and health of employees and to minimize the damage to
property and the environment. Following are the guidelines for an emergency Plan
Preparation:
i) Communications: Install a communications system, and establish procedures to:
Alert occupants-alarm systems
Mobilize fire fighters –municipal fire departments, plant fire brigade
Meet fire department on arrival, and advise them on- location of fire, contents
in and near the location trapped people
Make contact with- neighboring industries that could be at risk ,police,
ambulance, hospital , workplace security
Test communications system regularly
Mark all exists clearly -Provide floor plan showing location and identity of
hazardous materials.
ii) Fire Extinguishing: Organize a fire brigade, and provide training in:
Proper procedures - take into account the volume of flammable materials,
potential for exposure to toxic materials, and areas at high risk of destruction.
Shutdown of processes Use of equipment- hoses, personal protection etc.
Use of emergency lighting and power sources.
Emergency plant access for fire trucks and ambulances.
iii) Safety of People: To ensure the safety of all persons in your workplace:
Make sure exits and fire escapes are adequate - properly marked accessible
Plan and drill for evacuation - removal of all persons (including the
handicapped, and those in special areas, e.g., washrooms) ensuring that all
persons (including visitors) are accounted for – this includes prompt access to
daily attendance record use of alternative exits escape from toxic gases that
may be generated during the fire
Provide temporary refuge for those unable to evacuate
Plan and drill for rescue operations - availability of equipment first aid
24.8.4 Fire Inspections 235
Fire Protection
Establish a regular schedule of fire inspections. These will help detect any deviations
from, or shortcomings in, your control standards and emergency procedures. Take
corrective action as soon as possible. The information collected during your
workplace assessment, and subsequent action taken, will help to come up with
detailed checklist. Review and revise the checklist at regular intervals for fire
protection.
24.9 FIRE EVACUATION PROCEDURE

The hospital is designed and segregated into fire resistant compartments that have a
range of fire defense equipment to minimize the loss of life and personal injury. This
includes fire compartmentation, sophisticated fire detection systems, first aid fire
fighting equipment, automatic and manually operated fire door release mechanisms,
emergency lighting and emergency signage.
These systems will provide early warnings and contain the fire and the effects of
smoke for such a time to enable evacuation to take place. The Trust does not have
sprinkler systems. It is not usually necessary to evacuate hospitalized patients to the
external environment each time the fire alarm activates, as this would present
unnecessary risks to patient safety.
Where evacuation is necessary, the principle to be adopted is movement of patients
and staff away from the Fire on the same level by lateral evacuation through Fire
resisting doors towards a place of safety. To assist with the quick evacuation of bed
bound patients staff should evacuate them by utilizing the bed as a suitable moving
mechanism.
24.10 EQUIPMENTS
a) Smoke Alarms: There are many different brands of smoke alarms available on the
market but they fall under two basic types: ionization and photoelectric.
Ionization alarms sound more quickly when a flaming, fast moving fire
occurs.
Photoelectric alarms are quicker at sensing smoldering, smoky fires.
There are also combination smoke alarms that combine ionization and
photoelectric into one unit, called dual sensor smoke alarms.
In addition to the basic types of alarms, there are alarms made to meet the needs
of people with hearing disabilities. These alarms may use strobe lights that flash
and/or vibrate to assist in alerting those who are unable to hear standard smoke
alarms when they sound.
b) Fire Extinguisher: Different types of fires require different types of
extinguishers. For example, a grease fire and an electrical fire require the use of
different extinguishing agents to be effective and safely put the fire out. Basically,
there are five different types of extinguishing agents. Most fire extinguishers
display symbols to show the kind of fire on which they are to be used.
236
Hospital Operation-II Types of Fire Extinguishers
Class A extinguishers put out fires in ordinary
combustible materials such as cloth, wood, rubber,
paper, and many plastics.
Class B extinguishers are used on fires involving

flammable liquids, such as grease, gasoline, oil,
and oil-based paints.
Class C extinguishers are suitable for use on fires

involving appliances, tools, or other equipment
that is electrically energized or plugged in.
Class D extinguishers are designed for use on

flammable metals and are often specific for the
type of metal in question. These are typically
found only in factories working with these metals.
Class K fire extinguishers are intended for use on

fires that involve vegetable oils, animal oils, or
fats in cooking appliances. These extinguishers are
generally found in commercial kitchens, such as
those found in restaurants, cafeterias, and caterers.
Class K extinguishers are now finding their way
into the residential market for use in kitchens.
There are also multi-purpose fire extinguishers – such as those labeled "B-C" or
"A-B-C" – that can be used on two or more of the above type fires.
c) Fire Indicator Panel (FIP Systems): The Fire Indicator Panel (also known as a
FIP System) is the hub of the fire alarm system in a building. It is usually located
on the ground floor near the entrance close to the nearest road. The panel may be
located in the cabinet or on a wall. On the panel is a number of lights and buttons.
These lights indicate which fire sensor has been activated in the building.
d) Emergency Warning System: If an emergency is declared, all affected Zone
Wardens will be informed and they, in turn, will inform occupants of their areas
of any action required. Depending upon the circumstances, this communication
may be through the use of an Emergency Warning System. Emergency Warning
Systems provides an audible sound throughout buildings, in which a two stage
system is utilised. The Alert Signal (repetitive 420Hz tone burst) is sounded
automatically on activation of the fire alarm system or manually for other
emergencies. The Chief Warden then manually activates the Evacuation Signal
(repetitive 500Hz to 1200Hz ramped tone) if required.
e) Fire Doors, Exit Doors, Solid Core Doors and Sliding Fire Doors: Fire Doors,
Exit Doors, Solid Core Doors and Sliding Fire Doors are installed to minimise the
spread of fire, including the passage of smoke through a building. Fire Doors,
Exit Doors, Solid Core Doors and Sliding Fire Doors may be automatically
operated by heat activated mechanisms or smoke detectors. The securing of fire
doors must be such that persons leaving an area via door can do so without the
use of keys or similar at all times.
Sliding Fire Doors are usually specified where the use of conventional side hung 237
doors are impractical due to limited space or where maximum opening sizes are Fire Protection
required for the movement of plant or equipment. Sliding Fire Doors are available
in configurations of single leaf/single action/right or left hand, two leaf/single
action, single leaf/double action, two leaf/double action, sing leaf/sliding and two
leaf/bi-parting/sliding.
f) Drencher Systems: Drencher systems provide the necessary curtain of water for
protection against internal and external exposure to fire. Drencher systems are
used to separate one risk from the other in case of a fire, or to check the spread of
fire, for example to limit the fire not to spread beyond a certain volume.
g) Automatic Smoke Shutters: Automatic Smoke Shutters are designed to limit
smoke spread in public places, such as elevator lobbies, corridors, etc. Mounted
above the ceiling, automatic smoke shutters coil out of sight and yet, after
activation of automatic closing, they become effective smoke and draft barriers.
The smoke shutter is often used with a smoke detector, heat detector or other
alarm system that starts the release device.
h) Automatic Fire Detection and Alarm Systems: Fire Protection's automatic fire
detection and alarm systems are intended for the protection of life and property.
Automatic fire detection and alarm systems are either installed throughout all
areas of a building, installed only for the protection of escape routes, installed
within those parts of the escape routes comprising circulation areas and
circulation spaces (such as corridors and stairways), or installed to satisfy a
specific fire safety objective.
i) Fire Hose Reels: Fire Hose Reels are located to provide a reasonably accessible
and controlled supply of water to combat a fire risk. Our fire hose reels are
efficient, durable and easy to operate. The length of a full extended fire hose is 36
meters with a diameter of 19mm (outside diameter). Various types of reels are
available to meet your specific requirements. A control nozzle attached to the
hose enables the operator to control the direction and flow of water to the fire
j) Fire Blankets: Made from a woven fire glass material, fire blankets are very
effective for smothering flames. You can use a fire blanket to cover a pan of
burning cooking oil on a stove, or burning clothing on a child. Fire blanket
containers display instructions for their use. A fire blanket is best located where it
can be easily reached in an emergency. Place the fire blanket near your normally
used path to exit the kitchen, ideally near the kitchen door.
k) Exit and Emergency Lighting: Using cold cathode technology, Andrews Fire
Protection provides exit and emergency lighting systems which are in accordance
with the Australian Standards. The cold cathode lamp element has two solid
ferrous cathodes in a tri-phosphor coated medium voltage discharge lamp. The
lamp element is installed in a tough 7mm diameter outer protective glass housing
with rugged shaped ends. The lamp is the same length as a 10 watt fluoro lamp.
24.11 WHAT TO DO IN CASE OF FIRE

If you discover a fire in your area, observe the following points:
i) Use Code: Do not panic, run, yell, or use the word “Fire”. Use the code: Doctor
Red or Code Red.
ii) Evacuate: Remove persons from immediate danger of smoke and fire. Only
patients in immediate danger need be relocated in area on the same floor but away
from the fire. If the fire is in the patient room(s),remove the patients(s) and close
the door behind you.
238 iii) Sound Alarm: Sound the fire alarm from the nearest fire alarm box. This will
(Supportive Services) notify the telephone operator and fellow hospitals employees of the situation. The
alarm box will set off a series of sounds or hoots.
iv) Dial Telephone Operator: Give the exact location-the floor, wing, area, etc., and
the extent of fire. This is important because the telephone operator should be very
sure of these details before calling up the fire department. The telephone operator
will immediately write the location down. The telephone operator will announce
Doctor Red on the public address system followed by the location of the fire three
times. This announcements will be repeated every 30 seconds for a period of two
minutes.
To avoid panic among patients and visitors, emergencies in the hospital are
announced using codes, for example, “doctor red” for fire. The operator will also
notify important officials like the CEO, nursing director, security chief, engineer
and leader of the Doctor Red Aleart team. If the situation warrants and with the
approval of the CEO or the person in charge at that time, the telephone operator
will notify the fire department and summon help.
v) Shut off Ventilation Fans, etc.: On notification, the engineering department will
shut off all ventilating fans, oxygen (after checking with the area supervisor), gas,
electric power to the affected area and if necessary, to any adjoining area
threatened by fire.
vi) Prevent Smoke or Fire Gases from Spreading to Other Floors: There is a great
danger of people dying of suffocation even on the floor far removed from where
the fire broken out. Smoke and fire gases spread to other floors through air-
conditioning ducts, pipe tunnels, etc. This can be avoided by closing all the
dampers in the air-conditioning ducts.
vii) Avoid Using the Elevators: Walk down the stairs.
viii) Establish a Control Centre: The CEO or a senior officer will take charge.
24.12 AT THE SCENE OF FIRE

z Seal off the area of fire. Close windows and all patient room doors. Place wet
blankets or towels along the door edges to prevent leakage of smoke. This is an
effective fire-fighting technique.
z Fight the fire with appropriate fire extinguishers. Use carbon dioxide type
extinguishers on electrical and flammable liquid fires. Use fire extinguishers if the
fire is small and fire hose if it is large. Do not operate the fire hose if you are not
trained to do so. It is risky as you may be swept off your feet. Remember that two
people are needed to operate afire hose.
z Supervisor of the area will take charge.
z The Doctor Red Alert Team will go to the scene of fire. The team leader will
direct operations as they pertain to the actual fire situation.
z When the fire department personnel arrive, they will be in complete charge.
z Personnel on the general floor and other patient care areas will remain calm and
reassure the patients. They will remain with their patients at all times until
properly relieved.
z There should be written procedures for evacuation of patients and on who can
make that decision.
239
z In case you are trapped and are unable to leave your room, do the following: Fire Protection
Feel the door. If warm, do not open.
Place wet towels, bedding or blankets under the door(s).
Stay low on the floor where smoke and heat are the least and the air cleaner.
Go to the window and open it.
Attract the attention of the fire fighters by hanging a sheet or blanket outside
the window.
Stay at the window for rescue.
z All clear signals should be given by a responsible person and code green
announced after the fire is controlled.
24.13 LET US SUM UP

Every facility and dwelling contains potential fire hazards. Fires can occur in all types
of structures, often resulting in loss of life and costly damage. However, if fire can be
contained in one area, with the aid of fire protection and a combination of detection
and protection systems, an effective solution can be achieved minimizing the risk.

Devise your own fire evacuation plan for a hospital and reason it out.
24.15 KEYWORDS
Fire blankets: Made from a woven fire glass material they effective for smothering
flames.
Fire Indicator Panel (FIP): The hub of the fire alarm system in a building.

1. Explain with whom the authority of fire protection lies in a hospital.
2. List down the policies and procedures that are to be listed down in Fire Protection
plan?
3. Explain the staffing function in relation to fire protection plan in a hospital.
4. Explain the term fire safety systems.
5. Explain the fire protection program and procedure in a hospital.
6. List down the equipments to be used in fire protection plan.

1. The Board of Hospitals and the Trust is committed to maintain high
standards of Fire Safety in order to minimize the loss of loss of life and
personal injury through the effects of Fire, Smoke and associated fire
hazards.
Contd…
240
(Supportive Services) 2. What to do in case of fire:
1. Use Code
2. Evacuate
3. Sound Alarm
4. Dial Telephone Operator
5. Shut off Ventilation Fans, etc
6. Prevent Smoke or Fire Gases from Spreading to Other Floors
7. Avoid Using the Elevators
8. Establish a Control Centre
3. Monitoring and Auditing of Fire Safety: Regular Auditing and Monitoring
of Fire safety is required to ensure that there are effective arrangements in
place for managing Fire safety and to ensure the Trust achieves compliance
with relevant statutory provisions.

Federal Emergency Management Agency (FEMA) website, U.S. Fire Administration
Fire Safety Policy, Date of Issue: February 2007 Review Date: February 2009.
Approved by the Health & Safety Committee, January 2007.
A Health and Safety Guideline for Your Workplace © Industrial Accident Prevention
Association 2007.
Fire Protection Fire Protection Handbook, 19th Edition (2003).
Fire Protection Guide to Hazardous Materials, 13th Edition, The National Fire
Protection Association, Batterymarch Park, Quincey, Massachusetts, USA
http://www.nfpa.org/
251
LESSON Engineering Hazards
25
ENGINEERING HAZARDS
CONTENTS
25.1 Introduction
25.2 Definition
25.3 Meaning and Types of Hazards
25.4 Risk Assessment
25.5 Risk Reduction Programmes
25.6 Steps in Hazard Management Programmes
25.7 Let us Sum up
25.9 Keywords

z Understand the meaning of the word hazard and engineering hazard
z Listing the different types of hazards
z Study the meaning of risk assessment and risk reduction programmes
z List down the steps in hazard management programmes
25.1 INTRODUCTION
Utilizing their knowledge of human factors, regulatory processes and principles of
design and safety engineering, Medical/clinical engineers have a major impact on
reducing injuries, deaths, and clinical complications resulting from medical errors.
These processes, which are part of the biomedical/clinical engineering curriculum, are
inherent in minimizing healthcare hazards as well as reducing the risk of bad clinical
outcomes resulting from the technology assessment process in selection of new
medical devices.
Medical equipment standardization and initial user training are essential concepts that
must be employed to create a lower risk environment. Removing equipment that does
not conform to the standardization process will provide a uniform process of clinical
standards for patient treatment and thus increase the familiarity of medical equipment
use. This familiarity will lower the risk of clinical errors related to technology
frustration and inadvertent user error. Hospital engineers should be at the core of the
242 technology assessment process and make their expertise known to hospital
(Supportive Services) administrators.
25.2 DEFINITION
Hazards refers to potential danger, something that is potentially very dangerous.
Engineering refers to application of science to designing things: the application of
science in the design, planning, construction, and maintenance of buildings, machines,
and other manufactured things.
Engineering Hazards refers to engineering dangerous outcome, a dangerous or
otherwise unwanted outcome, especially one resulting from the failure of an
engineered system.
25.3 MEANING AND TYPES OF HAZARDS

Hospitals present numerous hazards in common with other complex employment
settings and industries as well as having some unique hazards. A great variety of jobs
are performed in health care facilities including: direct patient care, laboratory and
research work, laundry, food preparation, trades, security work, waste disposal,
driving, office and library work, housekeeping and maintenance, and pharmacy. The
myriad of occupational hazards to which hospital workers may be exposed can be
classified into five broad categories: biological, chemical, physical, ergonomic/safety
and psycho-social hazards.
a) Biological Hazards: Biological hazards are infectious agents such as bacteria,
viruses, fungi or parasites which may be transmitted via contact with infected
patients or contaminated objects, body secretions, tissue, or fluids. Health care
workers, particularly those in hospital settings, are regularly exposed to biological
or infectious agents.
b) Chemical Hazards: Numerous chemicals found in hospitals may be toxic or
irritating to body systems. They may be present as dusts, vapours or gases, or
liquids and they may be medications and other substances used for therapeutic
purposes. Chemicals can enter the body through contaminated food or cigarettes,
absorption through the skin, inhalation or by accidental needle stick. The major
routes of entry are by inhalation or skin absorption.
c) Ergonomic and Safety Hazards: Ergonomic and safety hazards cause or worsen
accidents, injuries, strain or discomfort. Ergonomics is the application of scientific
knowledge to the design of environments, tools, workstations and the content of
work to suit the mental and physical limitations and capabilities. Work
environments and procedures that incorporate ergonomic principles can anticipate
accidents and avert injury and error. Health care safety hazards include: slippery
floors, cluttered hallways or blocked exits, explosive gases used in laboratories
and operating rooms, various power tools and other maintenance equipment, sharp
utensils and instruments, and materials handling. Injuries also frequently
experienced by health care workers include cuts, bruises and needle sticks.
Another problem is Repetitive Strain Injuries (RSIs) of the upper limbs related to
improper workstation and task design. RSI risk factors include: high rates of
manual repetition, use of excessive manual force, and awkward postures of the
wrists and shoulders. Workers in dietary and laundry departments and clerical
positions, such as data entry operators and medical transcriptionists, may be at
increased risk.
d) Physical Hazards: Ionizing and non-ionizing radiation, electricity, noise and heat
are examples of physical hazards found in hospitals.
i) Ionizing radiation is used in diagnostic procedures such as x-ray, fluoroscopy, 243
and angiography, and in treatments using radioactive implantations or Engineering Hazards
injections. Cumulative and long-term health effects include genetic damage

and adverse reproductive outcomes. The risks of long-term low-level
exposure to ionizing radiation are not fully known. Measures to minimize
exposure include maximizing distance between the radiation source and the
worker, using appropriate shielding and minimizing exposure time. Special
attention should be given to the maintenance of portable fluoroscopy and x-
ray equipment which may scatter radiation during procedures.
ii) Non-ionizing radiation includes microwaves, magnetic fields, and lasers. The
intensity of the light beam of lasers poses a risk especially to the eyes and
skin. Procedures for the safe use of lasers should include training, posting
warning signs, using appropriate safety eyewear, and using non-reflective
tools.
iii) Excessive noise and heat are commonly found in kitchens, laundries, and
boiler rooms. Cold, heat and sunlight are hazards for grounds and building
maintenance personnel. Permanent hearing loss can result from long term
exposure to noise in excess of 80 decibels (a measure of sound intensity). At
lower levels, noise from equipment, alarms, conversation and other sources
can impede communication and interfere with concentration. Comprehensive
hearing conservation programs should reduce noise through engineering
controls, detect hearing loss early, provide worker education, and provide
hearing protection devices.
iv) Skin burns can result from exposure to hot surfaces or liquids or from
exposure to excessive sunlight. Cold temperatures can produce frostbite or a
dangerous generalized cooling of the body (hypothermia). Engineering
controls to prevent contact with hot surfaces or to reduce hot indoor
temperature, protective clothing such as hats and long sleeved shirts to reduce
sun exposure, and administrative guidelines for working in hot and cold
environments are important measures to reduce the risk of injury.
e) Psycho-social Hazards: Many factors in the hospital environment can affect the
psychological and social well-being of workers. Examples of work organization
which can have an adverse impact on workers include: little decision-making
latitude, excessive job demands, role ambiguity, poor management ability,
inadequate resources, and shift work. Rotating shifts and night work can have a
negative impact on general well-being and performance because of the constant
disruption of an individual's biological clock. Shift work can also negatively
affect workers' social roles.
Among the listed items complete Ergonomics, safety and Physical hazards and a part
of Biological and Chemical hazards are included in Hospital Engineering hazards.
25.4 RISK ASSESSMENT

The probability that the hazard of a substance will cause harm is termed as risk and
the severity of that harm in hospital environment may have the following properties:
z contains infectious agents
z contains hazardous chemicals or pharmaceuticals
z radioactive
z contains sharps
z Toxic
z Corrosive
244 z Flammable
(Supportive Services) z Reactive
z Explosive
z Shock sensitive
z Genotoxic
Who is at Risk?
z Doctors and nurses
z Patients
z Hospital support staff
z General public
Potential health effects:
z AIDS
z Hepatitis B and C
z Gastroenteric infections
z Respiratory infections
z Blood stream infections
z Skin infections
z Effects of radioactive substances
z Intoxication
z Accidents etc.
25.5 RISK REDUCTION PROGRAMMES

a) The Medical Equipment Management Plan and the policies and procedures that
support to achieve a safe, functional, supportive, and effective environment for
patients, staff members, and other individuals in the hospital. The plan outlines
the policies and processes the hospital uses to assure the medical equipment is
appropriate for the intended use, that staff is trained to use the equipment, and that
the equipment is maintained appropriately by qualified individuals.
This document serves as the written management plan describing the processes
the hospital uses to manage the effective, safe, and reliable operation of medical
equipment. This plan specifically addresses managing risks of medical equipment
by ensuring that equipment is appropriate for its intended use, that equipment is
maintained according to strategies intended to minimize risks, that maintainers
and users of medical equipment are trained and qualified, that performance
according to the requirements of this policy is measured and analyzed, and that
performance improvement recommendations are implemented and effective.
Contents of plan includes:
Selection and Acquisition of Medical Equipment
Medical Equipment Inventory Inclusion Criteria
Medical Equipment Maintenance
Maintenance Intervals
Medical Equipment Hazard Notices and Recalls
Monitoring and Reporting Incidents as Required by the Safe Medical Devices 245
Engineering Hazards
Emergency Procedures
Medical Equipment Maintenance, Testing, and Inspection
Program Evaluation/Effectiveness
b) Safety Officer: There needs to be a safety officer, either in a full-time or a
collateral duty position depending on the size of the facility. The safety officer
needs to be supported by a safety committee, which includes members from
different departments of the healthcare facility, different disciplines and different
levels of employees for good input. The safety programme has to be well
documented and therefore there are various reports that have to be generated and
reviewed by the safety committee, which will then send summary reports on to
healthcare facility management.
c) Safety committee: The safety committee is the key part of the healthcare facility
safety programme and it needs to have a minimum membership, which includes
healthcare facility engineering. It should also include administrative personnel at a
high management level. In fact, the safety committee is most effective when it is
chaired by a person from the upper-level management of the healthcare facility. It
also needs to have an infection control practitioner as a member of the committee.
The committee needs members from the clinical staff, including a physician, a
nurse and other practitioners. One of these members should be in charge of the
patient safety programme. From engineering, there needs to be, in addition to the
hospital engineer, a biomedical or clinical engineer. The safety officer is the
secretary for the committee.
Check Your Progress
1. Chemical Hazards
………………………………………………………………………………
………………………………………………………………………………
2. Excessive noise and heat
………………………………………………………………………………
………………………………………………………………………………
3. Safety Committee
………………………………………………………………………………
………………………………………………………………………………
25.6 STEPS IN HAZARD MANAGEMENT PROGRAMME

1. Assess present situation and carry out a survey
2. Identify opportunities for minimization and Rescuing activities
3. Identify handling, treatment and disposal options
4. Evaluate options
5. Prepare a management plan
6. Establish a record keeping system
7. Estimate related costs
246 8. Prepare training programme
(Supportive Services) 9. Prepare implementation strategy
Implementation of Hazard Management Programme

The implementation is the responsibility of the Head of the establishment and this
could be undertaken in phases like:
z Phased introduction
z Opportunities for expansion
z Identify key personnel network
z Arrange training
z Implement
z Review the plan annually
z Prepare annual report for national government
Implement a national training programme – should contain the following phases of
training:
z Develop the programme
z Train the trainers
z Identify Institutions to deliver training
z Implement
25.7 LET US SUM UP

Following are some basic rules and principles that everyone should bear in mind and
observe:
z The only correct way to do a job in the hospital is the safe way. Urgency is not the
justifiable excuse for neglecting safety.
z Jobs has to be understood thoroughly and no guess work can be indulged.
z Without authorization no machinery or equipment can be handled or operated.
z In case of faultness, unsafe conditions, report immediately to the concerned
persons.
z Good health is essential to stay physically and emotionally fit.
z Personal hygiene is important. Wash hands often. In many areas of the hospital,
this is absolutely necessary.
z Cooperate with the hospital infection control committee by observing established
procedures.
z Proper uniform or clothing is very essential. It should not be too tight nor loose.
z Don’t run, when you are carrying delicate, breakable articles or instruments.
z Pay attention to all the warning boards.
z Work procedures has to be made familiar to all.
z Use handrails on stairways or ramps.
z Check and double-check medications regarding instructions, labels and patient
identity.
z Label all bottles and containers.
247
25.8 LESSON END ACTIVITY Engineering Hazards
Make a study on engineering hazards of a hospital of your own choice and Give your
suggestions to overcome the engineering hazards in that hospital.
25.9 KEYWORDS
Hazards: potential danger.
Engineering: application of science to designing things.
Engineering Hazards: dangerous outcome of engineering.

1. Define Hazards and Engineering Hazards.
2. Give the different types of hazards in a hospital.
3. Explain in detail the steps in risk reduction programmes.
4. What are the usual steps in managing a hazard in a hospital?

1. Chemical Hazards Numerous chemicals found in hospitals may be toxic
or irritating to body systems. They may be present as dusts, vapours or
gases, or liquids and they may be medications and other substances used
for therapeutic purposes.
2. Excessive noise and heat are commonly found in kitchens, laundries, and
boiler rooms. Cold, heat and sunlight are hazards for grounds and
building maintenance personnel. Permanent hearing loss can result from
long term exposure to noise in excess of 80 decibels (a measure of sound
intensity).
3. The safety committee is the key part of the healthcare facility safety
programme and it needs to have a minimum membership, which includes
healthcare facility engineering. It should also include administrative
personnel at a high management level.

Bruno Hersche, Olivier C. Wenker, Principles Of Hospital Disaster Planning. The
Internet Journal of Disaster Medicine. 2000. Volume 1 Number 2.
Guidelines on Prevention and Control of Hospital Associated Infections.
John Mayeda “Awareness of Building Vulnerability and Protection” PE Hospital
Engineering Trends, march/April 2005.
Paul McCown “Creating an Energy Efficient Building” Hospital Engineering Trends,
CEM LEED ®AP Jan /Feb 2005.
William H. Nesbitt, CPP, Security Management Support Program for Hospitals,
2008.
Wisconsin Department of Health and Family Services. Protecting and promoting the
health and safety of the people of Wisconsin, November 22, 2004.
258
LESSON
26
RADIOLOGY HAZARDS
CONTENTS
26.1 Introduction
26.2 Types of Radiology
26.3 Nature of Work
26.4 Radiology Hazards
26.5 Management of Radiology Hazards
26.6 Checklist of Highlighted Hazards in Radiology
26.7 Let us Sum up
26.9 Keywords

z Understand the meaning and definitions of radiology
z List the different types of radiology
z Understand the meaning of radiology hazards and the way to manage these
hazards
z Try to bring the checklist of radiology hazards in hospital
26.1 INTRODUCTION
Radiology is the specialty directing medical imaging technologies to diagnose and
sometimes treat diseases. Originally it was the aspect of medical science dealing with
the medical use of electromagnetic energy emitted by X-ray machines or other such
radiation devices for the purpose of obtaining visual information as part of medical
imaging. Radiology that involves use of x-ray is called roentgenology.
Following extensive training, radiologists direct an array of imaging technologies such
as ultrasound, Computed Tomography (CT) nuclear medicine, and magnetic
resonance imaging) to diagnose or treat disease. Interventional radiology is the
performance of Procedures with the guidance of imaging technologies. The
acquisition of medical imaging is usually carried out by the radiographer or radiologic
technologist. Outside of the medical field, radiology also encompasses the
examination of the inner structure of objects using X-rays or other penetrating
radiation.
249
26.2 TYPES OF RADIOLOGY Radiology Hazards
Radiology can be classified broadly into Diagnostic radiology and Therapeutic

radiology.
z Diagnostic radiology: is the interpretation of images of the human body to aid in
the diagnosis or prognosis of disease. It is divided into subfields by anatomic
location and in some cases method:
Chest radiology.
Abdominal & Pelvic radiology. Sometimes together termed "Body Imaging".
Interventional radiology uses imaging to guide therapeutic and angiographic
procedures. Also known as Vascular & Interventional radiology.
Neuroradiology is the sub-specialty in the field of central nervous system, i.e.
brain and spinal cord, peripheral nervous system, osseous spine and its neural
contents, and head and neck imaging.
Interventional Neuroradiology uses imaging to guide therapeutic and
diagnostic angiographic procedures in the head, neck and spine.
Musculoskeletal radiology is the sub-specialty in the field of bone, joint, and
muscular imaging.
Pediatric radiology.
Mammography Subdivision of radiology that images the breast tissue.
Nuclear Medicine is a subdivision of radiology that uses radioisotopes in the
characterization of lesions and disease processes, and often yields functional
information.
z Therapeutic radiology: utilizes radiation (radiation therapy) for therapy of
diseases such as cancer.
While originally encompassed within radiology, radiation oncology is now a
separate field.
26.3 NATURE OF WORK

Patients have the following procedures to provide images for radiological decisions to
be made:
z Radiographs: are often used for evaluation of bony structures and soft tissues. An
X-Ray machine directs electromagnetic radiation upon a specified region in the
body. This radiation tends to pass through less dense matter (air, fat, muscle, and
other tissues), but is absorbed or scattered by denser materials (bones, tumors,
lungs affected by severe pneumonia).
z In Computed Radiography (CR): the x-rays passing through the patient strike a
sensitized plate which is then read and digitized into a computer image by a
separate machine. In Digital Radiography the x-rays strike a plate of x-ray sensors
producing a digital computer image directly.
z In Film: Screen Radiography, radiation which has passed through a patient then
strikes a cassette containing a screen of fluorescent phosphors and exposes x-ray
film.
z Angiography: are special applications of X-ray imaging, in which a fluorescent
screen or image intensifier tube is connected to a closed-circuit television system,
which allows real-time imaging of structures in motion or augmented with a
radiocontrast agent. Radiocontrast agents are administered, often swallowed or
injected into the body of the patient, to delineate anatomy and functioning of the
250 blood vessels, the genitourinary system or the gastrointestinal tract. Two radio-
(Supportive Services) contrasts are presently in use.
z CT: imaging uses X-rays in conjunction with computing algorithms to image the
body. In CT, an X-ray generating tube opposite an X-ray detector (or detectors) in
a ring shaped apparatus rotate around a patient producing a computer generated
cross-sectional image (tomogram).
z Ultrasound: to visualize soft tissue structures in the body in real time. No ionizing
radiation is involved, but the quality of the images obtained using ultrasound is
highly dependent on the skill of the person (ultrasonographer) performing the
exam. Ultrasound is also limited by its inability to image through air (lungs,
bowel loops) or bone
z Magnetic Resonance Imaging (MRI): uses strong magnetic fields to align
spinning atomic nuclei (usually hydrogen protons) within body tissues, then uses a
radio signal to disturb the axis of rotation of these nuclei and observes the radio
frequency signal generated as the nuclei return to their baseline states.
z Nuclear Medicine: imaging involves the administration into the patient of
radiopharmaceuticals consisting of substances with affinity for certain body
tissues labeled with radioactive tracer.
z Teleradiology is the transmission of radiographic images from one location to
another for interpretation by a radiologist. Teleradiology can also be utilized to
obtain consultation with an expert or sub-specialist about a complicated or
puzzling case.
26.4 RADIOLOGY HAZARDS

Some of the most common hazards that are encountered in a radiology department are
as follows:
a) Darkroom Disease: In the 1980s, the term darkroom disease was coined by
Marjorie Gordon, a former Radiology Technician (RTs), to describe the condition
caused by exposure to chemicals found in the developer and fixer of film
processors. One of the first people to be affected by the disease, Ms Gordon was
exposed to chemical vapors from a processor and her immune system was
compromised to such a degree that she had to leave the field of radiology.
Symptoms such as tinnitus, a painful sore throat, and a heart arrhythmia led Ms
Gordon to begin researching the cause of her condition. She discovered that the
chemical glutaraldehyde, which has been used in automatic processing machines
since 1967 but was added at a greatly increased amount in the 1980s, was the
source of not only her own health problems, but that other RTs were becoming ill
with similar symptoms.
RTs are exposed to high levels of acid substances and is listed as a main agent in
triggering an allergic response. It is also used as a sterilant and is known as a skin
sensitizer. To add to this chemical mix, dry laser printers use chemicals that are
listed as irritants.
Most chemical injuries come from solvents, according to William J. Rea, MD,
founder and director of the Environmental Health Center in Dallas, Tex. In his
work, Dr Rea has described patients who, because of their MCS allergies, cannot
go to hospitals because of the chemicals used there. Some studies classify
darkroom disease as a type of MCS and the similarities of symptoms support this
assertion. Symptoms that are common between MCS and darkroom disease
include headache, runny nose, itchy eyes, nausea, asthma, and fatigue.
b) Latex Allergies: The number of individuals affected by latex allergies has steadily 251
increased since the introduction of universal precautions in the 1980s. Following Radiology Hazards
the standard precautions of radiology, gloves are required for the majority of
procedures. RTs must often wear gloves because they are in contact with blood
and bodily fluids, specifically when performing barium enemas, intravascular
ultrasounds, all angiography/interventional cases, biopsies, trauma, and room
cleanup.
When the gloves are used it creates an aerosolized irritant. Powder-free gloves can
be purchased but chlorine is used in the manufacturing of these, which also can
trigger an allergic reaction. RTs and patients are at risk for developing allergic
reactions to latex proteins. Allergic reactions can occur through skin, respiratory,
or mucomembranous absorption. The most common allergic response to latex is
generally linked to 1 of the 200 chemicals added during the manufacturing
process of latex.
c) Multiple Chemical Sensitivity (MCS): MCS does not have a standard definition
for diagnostic purposes. Generally, it is acknowledged as a condition experienced
by individuals when they are exposed to low levels of chemicals found in
everyday substances. These individuals have an adverse allergic reaction when
exposed to a variety of chemicals. MCS, a multisymptom disease, is not
recognized by mainstream medicine. There are ongoing debates about whether
MCS is a physical or psychological classification some suggest that this dispute
may be politically motivated. It is important to chemical companies that it be
labeled as a psychological condition.
The process of MCS occurs in 2 stages: initiation and triggering. Initiation
(causation) is the first stage, in which there is 1 massive exposure or multiple low-
level exposures to an agent. The second stage, triggering, is a consequence of the
first stage. Once a person is sensitized, a variety of substances will cause an
allergic reaction. Common triggering agents include: cleaning agents, chlorine,
lead, and formaldehyde. MCS follows the same pattern as drug addiction:
acquisition, maintenance, withdrawal, and relapse. Drug abusers and those
affected by MCS report the same stimulatory and withdrawal symptoms. Both
groups adopt strategies to avoid the withdrawal symptoms. However, the
difference between the 2 groups is that the addict searches for another fix and the
individual with MCS tries to avoid further exposure.
Similarities: Darkroom disease and type IV latex allergy have similarities to MCS,
and may even fall under the common umbrella of MCS. The common symptoms of
MCS, darkroom disease, and latex allergy are asthma, eye problems e.g, itchy and/or
sore and nasal problems e.g, runny nose and/or nasal discharge.
The common thread for darkroom disease and latex allergy to be considered forms of
MCS is a chemical cause. To use the umbrella term MCS for all 3 conditions, the
following 3 premises must be accepted:
1. Darkroom disease is a form of MCS
2. The most common latex allergy is type IV and attributable to 1 of the 200
chemicals used in the manufacture of latex and
3. There is a common set of symptoms presented.
With all three premises accepted, the evidence would allow 1 umbrella term, MCS, to
include darkroom disease and latex allergy, all of which could be addressed in 1
prevention program.
252
(Supportive Services) 26.5 MANAGEMENT OF RADIOLOGY HAZARDS
The use of an established health education or disease prevention model to modify the
attitudes of RTs toward chemical threats to health and move them toward safer
practice is necessary. The anticipated payoff is a healthier, more productive
workforce, in addition to reduced financial drain resulting from these conditions.
Although education and prevention programs are considered important in the field,
and management often supports this key to success, no programs were found in use.
However, program development and prevention were discussed as important goals in
this section.
The only complete model found in this search discussed the organizational
development change model, which was used to implement the change to a latex-safe
environment in many Hospitals. The constructs of the organizational change model
include:
z Initiation: Beginning the change process in an informed manner.
z Clarification: Defining what needs to be changed and what resources will be
needed.
z Specification/agreement: The agenda is set with goals and objectives. The
administration commits resources to the project.
z Diagnosis: A narrowing of the focus to the problem at hand.
z Goal setting: Based on the diagnosis, an action plan is developed with a time
frame.
z System intervention: The action plan is set in motion, work begins.
z Evaluation: A comprehensive assessment of the change plan and success of
efforts.
z Alterations: Adjustments are made in light of evaluation.
z Continuation: Minor adjustments and maintenance of the change.
z Termination: The dissolution of the implementation group once the change has
become institutionalized.
Check your Progress
1. Radiographs
………………………………………………………………………………
………………………………………………………………………………
2. Multiple Chemical Sensitivity
………………………………………………………………………………
………………………………………………………………………………
3. Angiography
………………………………………………………………………………
………………………………………………………………………………
253
26.6 CHECKLIST OF HIGHLIGHTED HAZARDS IN Radiology Hazards
RADIOLOGY
1. Tuberculosis (TB) Exposure:
Does the hospital's safety and health plan address safe handling of TB patients
in the radiology area?
Do facilities in which TB patients are frequently treated have an area in the
radiology department that is ventilated separately for TB patients?
Or if this is not possible, do TB patients wear surgical masks and stay in the
radiology suite the minimum amount of time possible, then are returned
promptly to their isolation rooms.
Do employees receive adequate information about the hazards of TB through
the use of labels and signs?
Do isolation rooms or areas, such as radiology examination rooms where
procedures or services are being performed on an individual with suspected or
confirmed infectious TB use signs to indicate the hazard such as, "STOP, No
admittance without wearing a type N95 or more protective respirator."
Do Healthcare facilities serving populations that have a high prevalence of TB
supplement the general ventilation or use additional engineering approaches
in general-use areas where TB patients are likely to go?
Do employees wear minimally a type 95 respirator, when present during the
performance of high hazard procedures on individuals who have suspected or
confirmed infectious TB?
When respiratory protection is required and is a complete respiratory
protection program in place in accordance with?
2. Exposure to Radiation:
Are exposures to ionizing radiation kept under the limits outlined?
Do the employer supply appropriate personnel monitoring equipment, such as
film badges, pocket chambers, pocket dosimeters, or film rings, and require
the use of such equipment?
Does the employer maintain records of the radiation exposure of all
employees for whom personnel monitoring is required?
Does the employer furnish at the request of a former employee a report of the
employee's exposure to radiation records?
Is each radiation area conspicuously posted with a sign or signs bearing the
radiation caution symbol, with the wording "Caution Radiation Area"?
3. Hazardous Chemical Exposures:
Does the written program meet the requirements of the Hazard
Communication Standard to provide for worker training, warning labels, and
access to Material Safety Data Sheets (MSDS)?
Is appropriate Personal Protective Equipment (e.g., gloves, goggles, splash
aprons) provided for handling hazardous chemicals?
Are suitable facilities for quick drenching or flushing of the eyes and body
provided within the work area for immediate emergency use where the eyes
or body of any person may be exposed to corrosive materials?
Are emergency eye washes / showers tested and kept in good working order?
254 4. Slips/Trips/Falls:
(Supportive Services) Are floors kept clean and dry?
Are passage ways clear and in good repair, with no obstruction across or in
aisles that could create a trip hazard?
5. Electrical Safety:
Is electrical equipment free from recognized hazards?
Is electrical service near sources of water properly grounded?
Are all damaged receptacles and portable electrical equipment tagged out and
removed from service?
Are damaged receptacles and portable electrical equipment repaired before
being placed back into service?
Are employees trained to not plug or unplug energized equipment when their
hands are wet?
6. Infectious Materials:
Are universal precautions used when exposure to blood and OPIM is
anticipated?
26.7 LET US SUM UP

The dangers of MCS, darkroom disease, and latex allergies are real for RTs. These
threats are largely unrecognized; therefore, continuing to ignore them may prove
costly in the long term. Problems associated with darkroom disease, MCS, and latex
allergies for radiology departments are 2-fold.
First, they threaten the health and safety of employees.
Second, they are potentially costly in terms of litigation and lost productivity.
Administrators report that implementing a safety program to address these 3 ailments
would considerably increase a department or hospital budget. The ultimate goal is to
reduce lost production caused by missed work, lower litigation and compensation
costs, and keep employees safe. With today’s shortages and legal costs, an effective
safety program will benefit a healthcare facility financially and protect it legally.

Analyze the different radiology hazards faced by different hospitals & try to bring
about a suitable solution to solve the encountered problems.
26.9 KEYWORDS
Radiology: Medical imaging technologies to diagnose and sometimes treat diseases
Teleradiology: Transmission of radiographic images from one location to another
Ultrasound: To visualize soft tissue structures in the body in real time.

1. Define radiology and radiology hazards.
2. List out the different types of radiology in hospitals.
3. Explain the nature of radiology and its work in hospitals.
4. What are the common radiology hazards faced by any hospitals?
5. Explain the steps of managing radiology hazards in a hospital.
Check Your Progress: Model Answers 255
Radiology Hazards
1. Radiographs: are often used for evaluation of bony structures and soft
tissues. An X-Ray machine directs electromagnetic radiation upon a
specified region in the body. This radiation tends to pass through less
dense matter (air, fat, muscle, and other tissues), but is absorbed or
scattered by denser materials (bones, tumors, lungs affected by severe
pneumonia)
2. Multiple Chemical Sensitivity (MCS): MCS is acknowledged as a
condition experienced by individuals when they are exposed to low levels
of chemicals found in everyday substances. These individuals have an
adverse allergic reaction when exposed to a variety of chemicals. MCS, a
multisymptom disease, is not recognized by mainstream medicine.
3. Angiography: are special applications of X-ray imaging, in which a
fluorescent screen or image intensifier tube is connected to a closed-
circuit television system, which allows real-time imaging of structures in
motion or augmented with a radiocontrast agent.

James O. Wear, Continuing Education in Hospital Engineering, BME/CE and
Hospital Safety Staff in the US.
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook
Handbook, 2008-09 Edition, Radiologic Technologists and Technicians, on the
Internet at http://www.bls.gov/oco/ocos105.htm.
Jeff Killion and James Johnston ,Radiology Department Hazards: The Cost of Doing
Business ,Department of Radiologic Science, Midwestern State University, Wichita
Falls, Texas.
McLoughlin D. Crying in the dark: Marjorie Gordon's x-ray vision. NCchem Website.
Available at: http://www.ncchem.com/snftaas/crying_in_the_dark.htm. Accessed
August 21, 2006.
Liss GM, Kerr M, McCaskell L, et al. Evaluation of work-related symptoms, asthma,
sensitization, and exposures among x-ray technologists. Ontario Workplace Safety
and Insurance Board Web site. Available at:
http://www.wsib.on.ca/wsib/wsibsite.nsf/Public/ResearchProjectsFunded2000.
Accessed January 12, 2007.
Dimich-Ward H, Wymer M, Kennedy S, et al. Excess of symptoms among
radiographers. Am J Ind Med. 2003;43:132-141.
Gupta K, Horne R. The influence of health beliefs on the presentation and
consultation outcome in patients with chemical sensitivities. J Psychosom Res.
2001;50:131-137.
Sanchez T. When it hurts to breathe: chemicals and RTs. ASRT Scanner. 1999;31:7-8.
MODEL QUESTION PAPER Mode
MBA
Second Year
Sub: Hospital Operation-II (Supportive Services)

Time: 3 hours Total Marks: 100
Direction: There are total eight questions, each carrying 20 marks. You
have to attempt any five questions.
1. Define supportive services, its types and its significance in detail?

2. Explain the meaning, design, location, functions, space facilities of nutrition and
dietary department in detail?
3. What are the factors and principles to be considered in planning and designing the
different departments in the hospital?
4. Explain how does the water, electrical, plumbing systems act as supportive
services to hospitals?
5. Elucidate with due reasons whether communication systems is really essential for
a hospital to support its services?
6. What do you mean by laundry and housekeeping services in a hospital, what are
its role and functions in aid to hospital services?
7. Explain in detail the different modes of transportation services available to a
hospital and also explain its role and significance in supporting hospitals?
8. Define disasters and explain how a disaster could be managed effectively in
hospitals both before its occurrence and during its happenings?

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Hospital Operation-II (Supportive Services)

MBA Second Year

School of Distance Education

Lesson 1 Understanding Supportive Services 

Lesson 16 Laundry Services 141

Lesson 20 Transportation Services 183

Lesson 23 Disaster Management 211

1.0 AIMS AND OBJECTIVES

1.2 NEED AND SIGNIFICANCE OF SUPPORTIVE

1.3 SUPPORTIVE SERVICES – MEANING

1.5 FUNCTIONS OF SUPPORTIVE SERVICES

1.6 LET US SUM UP

1.7 LESSON END ACTIVITY

1.9 QUESTIONS FOR DISCUSSION

Check Your Progress: Model Answers

2.0 AIMS AND OBJECTIVES

2.7 FUNCTIONAL AREAS

2.9 FACILITIES AND SPACE REQUIREMENTS

2.10 RELATED ISSUES

2.11 LET US SUM UP

2.12 LESSON END ACTIVITY

2.14 QUESTIONS FOR DISCUSSION

Check Your Progress: Model Answers

2.15 SUGGESTED READINGS

3.0 AIMS AND OBJECTIVES

3.3 ROLE AND SIGNIFICANCE OF HOSPITAL

3.5 DRUG DISTRIBUTION AND INFORMATION

3.7 DESIGN AND FUNCTIONAL AREAS

3.8 ORGANIZATION AND STAFFING

3.9 FACILITIES AND SPACE REQUIREMENTS

3.10 WORKING CONDITIONS

3.11 THE JOB

The primary responsibility of most technicians is to prepare, package, and distribute

3.13 FUTURE OF PHARMACY

New Ways of Working in Hospital Pharmacy

3.14 LET US SUM UP

3.15 LESSON END ACTIVITY

3.17 QUESTIONS FOR DISCUSSION

Check Your Progress: Model Answers

3.18 SUGGESTED READINGS

4.0 AIMS AND OBJECTIVES

4.1 MEANING AND DEFINITION

4.5 MEDICAL RECORDS – FORMAT

4.6 MEDICAL RECORDS – CONTENTS

disease states. It includes several subsets detailed below:

4.7 ADMINISTRATIVE ISSUES

 Medical emergency: In the event of a medical emergency involving a non-

4.8 TYPES OF FORMS

Forms used for Patient Care

Forms for Administrative Purposes

4.9 STANDARDIZATION IN RECORD KEEPING

4.10 LET US SUM UP

4.11 LESSON END ACTIVITY

4.13 QUESTIONS FOR DISCUSSION

Check Your Progress: Model Answers

5.0 AIMS AND OBJECTIVES

5.2 NEED AND SIGNIFICANCE

5.3 GUIDELINES IN THE PLANNING AND

5.4 PRINCIPLES IN HOSPITAL ENGINEERING

5.5 FIVE STEPS TOWARD EFFICIENCY

Step 2: Determine priorities for operating and maintaining your building

Step 4: Find someone you trust

5.6 MAIN CHALLENGES

Lesson 1 Understanding Supportive Services

Medical emergency: In the event of a medical emergency involving a non-

Enable better ROI information for projects and maintenance program

Reduced equipment or process failure.

Medium-density PE: It is more flexible, slightly thinner wall thickness