Health Industry, Hospitals, HR & Management Issues MBA

(HHSM)

Hospital Operations ManagementHHSM ZG614

Sonia Valas
Dy. General Superintendent &
In-charge, Hospital Management
Studies & Staff Training
CMC, Vellore

Healthcare –Overview

The health care industry (also called the medical industry or health economy) is an
aggregation and integration of sectors within the economic system that proves goods and
service to treat patients with curative, preventive, rehabilitative and palliative care. It
includes the generation and commercialization of goods and services lending themselves to
maintaining and re-establishing health (Wikipedia)

Pre-1947

•Healthcare was provided in the home.

•Hospitals were a “place to die”.

Hospitals –1947 to 1982

•1947 -The life expectancy of Indians was 28 years

•Both Private and Public sector
•Until the mid-seventies -Public domain
•Very few privately run large hospitals
•High custom duties on imported medical equipment's
•Hospitals are not eligible for funding from Public financial Institutions like Bank

National Health Policy -1982

–“Health For all” –Motto

–Health Sector given the Industry Status
–Now, Hospitals are eligible for funding from Public financial Institutions like Banks (IDBI)
–Custom duty lowered for imported equipment
–Public Private Partnership
–In return –Free treatment for poor

Healthcare system
The term healthcare system refers to a country’s system of delivering services for the
preventin and treatment of diseases and for the promotion of physical and mental well
being.
The healthcare system offers four broad types of services:

–Health promotion
–Disease prevention
–Diagnosis and treatment
–Rehabilitation.

Global Healthcare Systems - Models

There arefour major models for health care systems:

•The BeveridgeModel
•The Bismarck model
•The National Health Insurance model, and
•The out-of-pocket model.

The BeveridgeModel

Named after William Beveridge, the daring social reformer who designed Britain's National
Health Service.
•In this system, health care is provided and financed by the government through tax
payments, just like the police force.
•Many, but not all, hospitals and clinics are owned by the government; some doctors are
government employees, but there are also private doctors who collect their fees from the
government.
–In Britain, you never get a doctor bill.

These systems tend to have low costs per capita, because the government, as the sole payer,
controls what doctors can do and what they can charge.
•United Kingdom
•Spain
•Scandinavia and
•New Zealand.
•Hong Kong still has its own Beveridge-style health care, because the populace simply
refused to give it up when the Chinese took over that former British colony in 1997.
•Cuba represents the extreme application of the Beveridge approach; it is probably the
world's purest example of total government control.

The Bismarck Model

Named for the Prussian Chancellor Ottovon Bismarck, who invented the welfare state as
part of the unification of Germany in the 19th Century.

•Within the Bismarck model, employers and employees are responsible for funding their
health insurance system through "sicknessfunds" created by pay roll deductions. Private
insurance plans also cover every employed person, regardless of pre-existing conditions, and
the plans aren't profit-based.
•Providers and hospitals are generally private, though insurers are public. In some instances,
there is a single insurer (France, Korea). Other countries, like Germany and the Czech
Republic, have multiple competing insurers. However, the government controls pricing,
much like under the Beveridge model.

Unlike the Beveridgemodel, the Bismarck model doesn't provide universal health coverage.
It requires employment for health insurance, so it allocates its resources to those who
contribute financially.
•The primary criticism of the Bismarck model is how to provide care for those who are
unable to work or can't afford contributions, including aging populations and the imbalance
between retirees and employees.
•Used by Germany, Belgium, Japan, Switzerland, the Netherlands, France, and some employer-based
healthcare plans in the U.S.

The National Health Insurance Model

•The classic NHI system is found in Canada.

•This system has elements of both Beveridgeand Bismarck. It uses private-sector providers,
but payment comes from a government-run insurance programthat every citizen pays into.
•Since there's no need for marketing, no financial motive to deny claims and no profit, these
universal insurance programs tend to be cheaper and much simpler administratively than
American-style for-profit insurance.

The single payer tends to have considerable market power to negotiate for lower prices.
•National Health Insurance plans also control costs by limiting the medical services they
will pay for, or by making patients wait to be treated.
•USA
•Canada
•Taiwan and
•South Korea.

The Out of Pocket Model

•Only the developed, industrialized countries — perhaps 40 of the world's 200 countries --
have established health care systems.

•Most of the nations on the planet are too poor and too disorganized to provide any kind of
mass medical care. The basic rule in such countries is that the rich get medical care; the
poor stay sick or die.
In rural regions of Africa, India, China and South America, hundreds of millions of people
go their whole lives without ever seeing a doctor.
•In the poor world, patients can sometimes scratch together enough money to pay a doctor
bill; otherwise, they pay in potatoes or goat's milk or child care or whatever else they may
have to give. If they have nothing, they don't get medical care.

What is Indian Scenario?

Does India offers best or worst of Healthcare?

India offers both best and worst of Health care

India has become an attractive destination for

- Medical Tourism
- Clinical Studies
- Research and Development Programs

Segments
Definition
A hospital is an integral part of a social and Medical organisation, the function of which is to
provide for the population complete health care, both curative and preventive, and whose
outpatient services reach out to the family and its home environment; the hospital is also a
centre for the training o health workers and biosocial research. – WHO
 Health Industry, Hospitals, HR & Management Issues MBA
(HHSM)

Hospital Operations ManagementHHSM ZG614

Sonia Valas
Dy. General Superintendent &
In-charge, Hospital Management
Studies & Staff Training
CMC, Vellore

Healthcare –Overview

The health care industry (also called the medical industry or health economy) is an
aggregation and integration of sectors within the economic system that proves goods and
service to treat patients with curative, preventive, rehabilitative and palliative care. It
includes the generation and commercialization of goods and services lending themselves to
maintaining and re-establishing health (Wikipedia)

Pre-1947

•Healthcare was provided in the home.

•Hospitals were a “place to die”.

Hospitals –1947 to 1982

•1947 -The life expectancy of Indians was 28 years

•Both Private and Public sector
•Until the mid-seventies -Public domain
•Very few privately run large hospitals
•High custom duties on imported medical equipment's
•Hospitals are not eligible for funding from Public financial Institutions like Bank

National Health Policy -1982

–“Health For all” –Motto

–Health Sector given the Industry Status
–Now, Hospitals are eligible for funding from Public financial Institutions like Banks (IDBI)
–Custom duty lowered for imported equipment
–Public Private Partnership
–In return –Free treatment for poor

Healthcare system
The term healthcare system refers to a country’s system of delivering services for the
preventin and treatment of diseases and for the promotion of physical and mental well
being.
The healthcare system offers four broad types of services:

–Health promotion
–Disease prevention
–Diagnosis and treatment
–Rehabilitation.

Global Healthcare Systems - Models

There arefour major models for health care systems:

•The BeveridgeModel
•The Bismarck model
•The National Health Insurance model, and
•The out-of-pocket model.

The BeveridgeModel

Named after William Beveridge, the daring social reformer who designed Britain's National
Health Service.
•In this system, health care is provided and financed by the government through tax
payments, just like the police force.
•Many, but not all, hospitals and clinics are owned by the government; some doctors are
government employees, but there are also private doctors who collect their fees from the
government.
–In Britain, you never get a doctor bill.

These systems tend to have low costs per capita, because the government, as the sole payer,
controls what doctors can do and what they can charge.
•United Kingdom
•Spain
•Scandinavia and
•New Zealand.
•Hong Kong still has its own Beveridge-style health care, because the populace simply
refused to give it up when the Chinese took over that former British colony in 1997.
•Cuba represents the extreme application of the Beveridge approach; it is probably the
world's purest example of total government control.

The Bismarck Model

Named for the Prussian Chancellor Ottovon Bismarck, who invented the welfare state as
part of the unification of Germany in the 19th Century.

•Within the Bismarck model, employers and employees are responsible for funding their
health insurance system through "sicknessfunds" created by pay roll deductions. Private
insurance plans also cover every employed person, regardless of pre-existing conditions, and
the plans aren't profit-based.
•Providers and hospitals are generally private, though insurers are public. In some instances,
there is a single insurer (France, Korea). Other countries, like Germany and the Czech
Republic, have multiple competing insurers. However, the government controls pricing,
much like under the Beveridge model.

Unlike the Beveridgemodel, the Bismarck model doesn't provide universal health coverage.
It requires employment for health insurance, so it allocates its resources to those who
contribute financially.
•The primary criticism of the Bismarck model is how to provide care for those who are
unable to work or can't afford contributions, including aging populations and the imbalance
between retirees and employees.
•Used by Germany, Belgium, Japan, Switzerland, the Netherlands, France, and some employer-based
healthcare plans in the U.S.

The National Health Insurance Model

•The classic NHI system is found in Canada.

•This system has elements of both Beveridgeand Bismarck. It uses private-sector providers,
but payment comes from a government-run insurance programthat every citizen pays into.
•Since there's no need for marketing, no financial motive to deny claims and no profit, these
universal insurance programs tend to be cheaper and much simpler administratively than
American-style for-profit insurance.

The single payer tends to have considerable market power to negotiate for lower prices.
•National Health Insurance plans also control costs by limiting the medical services they
will pay for, or by making patients wait to be treated.
•USA
•Canada
•Taiwan and
•South Korea.

The Out of Pocket Model

•Only the developed, industrialized countries — perhaps 40 of the world's 200 countries --
have established health care systems.

•Most of the nations on the planet are too poor and too disorganized to provide any kind of
mass medical care. The basic rule in such countries is that the rich get medical care; the
poor stay sick or die.
In rural regions of Africa, India, China and South America, hundreds of millions of people
go their whole lives without ever seeing a doctor.
•In the poor world, patients can sometimes scratch together enough money to pay a doctor
bill; otherwise, they pay in potatoes or goat's milk or child care or whatever else they may
have to give. If they have nothing, they don't get medical care.

What is Indian Scenario?

Does India offers best or worst of Healthcare?

India offers both best and worst of Health care

India has become an attractive destination for

- Medical Tourism
- Clinical Studies
- Research and Development Programs

Segments
Definition
A hospital is an integral part of a social and Medical organisation, the function of which is to
provide for the population complete health care, both curative and preventive, and whose
outpatient services reach out to the family and its home environment; the hospital is also a
centre for the training o health workers and biosocial research. – WHO
 Laboratory Services in Health Care

Hospital Operations Management HHSM ZG614

Laboratory Services in Health Care Theophilus S Vijayakumar

nephrovijay@gmail.com
Christian Medical College-Vellore
Laboratory

■A laboratory is defined as

–“a facility

–for the examination of materials derived from humans

–for the purpose of providing information for the diagnosis, prevention

Laboratory in HealthCare - Overview

Role of Laboratory in Health Care

Laboratory Services

Establishing a Laboratory

Infrastructure

Instrumentation

Human Resources

Quality & Safety

Role of Laboratory in HealthCare

Diagnosis
Treatment Efficacy
Progress Monitoring
Predictive/Prognostic
Companion Diagnostics /Individualized Medicine or Personalized Medicine
 Laboratory Services
Scope of Services - What labs are required?

Depends upon the scope of clinical services offered

Pathology /Clinical Pathology

Biochemistry
Microbiology

Clinical Pharmacology etc

Scope of Services - What tests to offer?

Depends upon the scope of clinical services offered

In-house vs Commercial kits/reagents

Outsourcing -Accredited/standard labs; MOU

Outreach (Costing/tariff/increase in N)

Establishing a Laboratory - Planning Infrastructure

Based on present (current) and future (anticipated) needs

Services Offered

Work process & flow, instruments and personnel

Budget

Facility Design
Location
Area Required
Access –restricted
Anti-rodent measures

Establishing a Laboratory - Instrumentation

Basic Equipment
Specific Equipment
Safety Equipment

Budget
Equipment
Maintenance
Consumables/recurring expenditure
Cost is not the only factor e.g. CO2 incubator

Establishing a Laboratory - Human Resources

Qualified Personnel
Education & Skill
Training
Experience
Expertise
Laboratory Testing - Manuals & Training

•“What you hear you forget”;

•“What you see you remember”

•“What you do you learn”

Written Instructions (unambiguous)

Procedure Manual
Standard Operating Procedure Manual

Laboratory Management - Training

Generic Training –for all

Work Place
Quality & Safety Practices
Specific training
Work-process
Continued Training

Laboratory Management - Materials Management

Policies governing

Procurement (applicable licenses)

Supply
Storage
Usage
Disposal

Laboratory Management - Equipment Maintenance

Preventive Maintenance Contract

Calibrations
Internal maintenance team / protocol / schedule
Equipment Performance Monitoring

Laboratory Testing - Testing & Reporting

Specimen Collection Manual

Services Offered, specimens required, collection and transport procedure
Specimen Transport & Acceptance/Rejection criteria
Chute system (cost-benefit)

Turn Around Time

Reporting: (policies; documentation)
Urgent Report
Critical Report

Reports/Records
Documentation

Access Control

Confidentiality

Communication (hard copy/soft copy)

Laboratory Testing - Laboratory Information system

■Hard Copy/Soft Copy

■“A system to receive, process, and store information” associated with the testing services,
the laboratory processes and the outcome (report)

■To interface with the Hospital Information system

–CMC Hospital Information Processing
–Online –records, requests, results etc including imaging –“real-time”

Laboratory –Clinician Interface

Present and Future

Existing services
Feedback
Need for additional services
Introducing newer services
Validation

Verification

Clinical validation –cut-offs etc

Laboratory Services - Quality & Safety

Two vital components of structure and process

Laboratory

■A laboratory is defined as
–“a facility

–for the examination of materials derived from humans

–for the purpose of providing information for the diagnosis, prevention

Laboratory Services - Quality & Safety

Accreditation standards
NABH (Institution & laboratories)
NABL (laboratories)
 Factors influencing analytical variables

Laboratory Services - Quality Assurance Program

Quality Assurance Program

Quality Manual (Systems & processes)

Internal Quality Control (IQC) -to detect (immediate errors) and minimize them

External Quality Assessment (EQA) -to monitor long term precision and accuracy of
results

Laboratory Services - Quality Indicators

Key Performance Indicators

Define
Monitor
Rectify defects
Sustain standards
Raise the bar
e.g. turn around time, redos, reporting errors
Benchmarks
Laboratory Services - Audits & C.A.P.A.

Audits –Periodic-scheduled/unscheduled
Compliance and Non-conformance to expected standards
Problems/Risks
Root Cause Analysis
C.A.P.A.
Corrective action –to prevent recurrence
Preventive action –to prevent occurrence
Remedial action -

Laboratory Services - Quality –Errors

Before Testing (Pre-Analytical)

Specimen Collection

Specimen Transport

Specimen receipt (acceptance/rejection)

During Testing (Analytical)

Equipment-reagent-process (IQC & Calibration)

After Testing (Post-Analytical)

Transcriptional

Communication

Laboratory Services - Safety

Occupational Health & Safety

Safety Signage (Colors & Meaning)

Laboratory Safety - Hazard Management

■HIRA (Hazard Identification and Risk Assessment)

■Hazard Control
Laboratory Safety - Hazards

■Physical

–Slips, Trips & Falls

–Temperature
–Sound
–Humidity
–Electrical
–Mechanical

What is Hazmat?

•Any substance (solid, liquid or gas) capable of harming people, property or the
environment.
•Pose risk to Health, Property& Environment

■Chemical
Hazards –Chemical

■Physical, Health & Environmental Hazards

■Chemical Inventory –Hazmat List

■Hazard Identification & Risk Assessment

■Safety Data Sheet (SDS) -the backbone of chemical safety

■Appropriate Safety Measures for storage, usage and disposal

■Safety equipment

–Specific P.P.E.

–Emergency eye wash station/kit,

–Emergency shower

■Spill Management Protocols

Safety Data Sheet
Hazard Communication

Spill Cleanup Protocol

Mercury

Generic
■Biological

Standard Precautions (Universal Precautions)

Biosafety equipment (Biosafety Cabinet, Biosafecentrifuges etc)
Appropriate P.P.E.
Hand Hygiene
Biomedical Waste Management

Standard Precautions (Universal Precautions)

Where
When
How

Biosafety Equipment
Training
Information Resources
SOP
Personal Protective Equipment
Commission and Omission

Hand Hygiene
Provisos of various types

BIOMEDICAL WASTE MANAGEMENT

SEGREGATION at SOURCE

DISINFECTION

Prevention
Vaccination
■Hazards -Radiation

■Radiation Hazards
■Laboratories and other areas such as imaging services and radiation therapy units
■A.E.R.B. guidelines
■Appropriate P.P.E. & safety equipment
■Monitoring Exposure

■Hazard - Fire

■Sources of Fire
■Areas of High Risk
■Firefighting Devices & Training
■Fire-fighting Team
■Emergency evacuation protocols
■Mock Drills

■Hazards - Ergonomics-Physical & Cognitive

Ergonomics is the science and practice of designing tasks and workplaces considering our
capabilities and limitations OR Fitting the work to the person –User, Equipment/Work
Space & Tasks

Prevention of Work-Related Musculoskeletal Disorders (WMSD)

Reduced fatigue and discomfort; Increased productivity; Improved quality of work

■Work Area

■Work Practices

■Work Processes

■Pipetting (Repetitive motions); Microscope usage (neck & shoulder pain)

■Biosafety Cabinet (constrained knee & leg postures)

Laboratory design, Task variability

Hazards –Ergonomic –Cognitive

■Multitasking
■Increase in demand on multiple fronts
■Errors in prioritization
■Errors/failure in tasks
–Leads to
■work stress,
■depression and
■poor productivity
■Interface with patient, instrument and clinician
–Errors in information, input-output-communication

Hazards –Incident Management & Emergency Preparedness

Futuristic

■Satellite centers for specimen Collection

■Mobile collecting/testing facilities etc

Laboratory Sciences - Summary

Role of Laboratory in Health Care

Laboratory Services

Establishing a Laboratory

Infrastructure

Instrumentation

Human Resources

Quality & Safety

 Hospital Operations Management HHSM ZG614

Medical Records Management

Esther KeziaJames
MA., BMRSc.,
Sen. Sel. Gr. Tutor

What is Health Records?

It’s a clear, precise and accurate history of a patient’s life and health history and illness
written from the medical point of view.
The health record must contain sufficient data written in sequence of events to identify the
patient, support the diagnosis and justify the treatment and warrant the end results.
Health record is the Who, What, Why, Where and How of the patient care.

Health Records Department is a place where the records of the patients are usually stored,
maintained and retrieved and sent to various users of the Record.
The role of the Health Records department is to provide Health Information services

Functions of Health record and Health Information department

To facilitate ongoing care and treatment of patients

To support clinical decision making and communication among clinicians
To provide information for the evaluation of the quality and efficacy of the care provided
To provide information in support of medical research and education
To help facilitate the operational management of the facility
To provide information as required by local and National laws and regulations
To document the services provided in support of reimbursement (in countries like US)
Develop statistical and informative reports
Develop, analyze and technically evaluate health records
Maintain birth, death and MLC(medico legal cases)
registers and give necessary information to the governmental agencies
Inform the governmental agencies about the communicable diseases according to
government regulations
Uses of Health records

Patient care management

Quality review –adequacy and appropriateness of care
Education & Research
Public health
Planning & Marketing
Financial reimbursement(in other countries)

Role of Health Information Manager

Oversee health record information
Manage health-related information
Ensure that it meets relevant Medical, administrative and legal requirements

Functions of Health Information department

 Classification and coding

 Abstracting pertinent information based on predetermined data sets
 Registry development
 Storage :Implementation and oversight of computer based and paper based filing
systems
 Retrieval: Process of making information stored in various media and sites accessible
 Release: Responding to requests for information
 Analysis: Process of conducting qualitative and quantitative analysis of
documentation against standards

Coding

Coding is a system used by Physicians and other healthcare providers to classify and code
all diagnoses, symptoms and procedures recorded in conjunction with hospital care.
It provides a common language for reporting and monitoring disease. This allows the
world to compare and share data in a consistent and standard way between hospitals,
regions and countries over a period of times
Why is coding important in healthcare?

It is extensively used for Study and research purposes

ICD is the global health information standard for mortality and morbidity statistics
It is closely tied in with the process of medical billing in countries like US

Computer based Patient records

In computer based patient records you directly enter the information in the computer
It also provides users with access to complete and accurate clinical data, practitioner alerts
and reminders, clinical decision support systems and links to Medical Knowledge

Numbering and filing system of Health records

There are several types of Numbering and filing systems

Unit numbering: Patient is assigned a number on his first visit to the facility and this
number is retained throughout the subsequent visits

Serial numbering: Patient is assigned a new number each time he is treated or admitted
Serial Unit numbering: This is a combination of serial and unit numbering system

Filing

The most common types of filing are:

1. Straight numeric filing
2. Terminal digit filing

1. Straight numeric filing: Strict numerical sequence is followed. Records are filed in
numerical order. This is very easy and needs no special training
eg., 226585, 226586, 226587, 226588, ….

Terminal Digital Filing

The number is divided into 3 groups . So there can be only 100 primary, 100 secondary and
100 tertiary numbers
Example

In this filing system the entire filing area is divided into 100 sections –00 –99

36-62-01 98-99-20 98-03-26

37-62-01 99-99-20 99-03-26
38-62-01 00-00-21 00-04-26
39-62-01 01-00-21 01-04-26

Scanning is one way of electronically storing physical records

Scanning -Indexing -Uploading

Scanning
It is the process by which a document is read into an optical imaging system. Here the
records are scanned and maintained in data bases
Indexing
It is the labeling of the scanned documents so that they can be easily stored
Uploading
It is the storing of the scanned files in a centralized computer system

Medico legal case records(MLC)

A MLC is one where, besides the Medical treatment investigations by law enforcing
agencies are essential to fix the responsibility regarding the present condition of the Patient
Legal case requiring medical expertise when brought by the police for examination
Medico legal is something that involves both medical and legal aspects.
Attending Casualty Medical Officer (CMO) has the authority to decide whether the case is
to be registered as medico-legal or not
1. Admission Office

2. IP Assembling & Deficiency Checking

3. Coding

4. Birth & Death Entry

5. Discharge Analysis

6. Statistics

7. Scanning

8. Scanning MLC

9. Chart Preparation

10. Two-Line Stickers

11. Records Storage Area

12. Bar Coded Paper

 Hospital Operations Management HHSM ZG614

Public Relations
Objectives, Functions and Methods

Durai Jasper, PRO CMC Vellore.

Definitions

•A public relations professional builds awareness and interest.

•Serves as a spokesperson and manages the flow of information to the public for a person,
product or company.

•Must be an effective communicator in print, person and on the phone

•‘About reputation –the result of what you do, what you say and what others say about
you.

•Public relations is the discipline which looks after reputation, with the aim of earning
understanding and support and influencing opinion and behaviour.

•It is the planned and sustained effort to establish and maintain goodwill and mutual
understanding between an organisation and its publics.’

Job description

•Communicating the mission & vision

•Production and use of brochures, handouts, books promotional videos and multimedia
programs etc.,

•Press release, Press meets

•http://www.pressreleasewizard.net/

•Organizing hospital tours

•Maintenance of the official website

Who is a PRO ?

•Managing the organization's reputation -the public in general and clients in particular.
•At the helm of managing a hospital's public image, is the public relations manager
( Officer)
•The Manager enhances the efforts of other wings (PRO, Development, PTP) in
maintaining a favorable image of the institution

•May have to draft speeches of the hospitals top administrators for public meetings.
•Responsibility of improving the relationship between the management and its employees
•Preparing the in-house newsletter
•Working in close co-ordination with the labor relations manager (Personnel Manager)

Publics are audiences that are important to the organisation. They include customers –
existing and potential, employees and management, investors, government, suppliers, the
local community and opinion-formers etc.,
In the public relations literature you may find the terms publics and target audiences used
interchangeably.
A public is a group of individuals or organizations who have a common problem, cause or
goal. There are six major groupings

Employees

Consumers

Media

Financial markets

Government agencies

Community

What PR is not....

•Public relations is not handshaking.

•Public Relations is not drinking parties.
•Public relations is not journalism.
•Public relations is not advertising.
•Public relations is not marketing.
For PR to work there are several prerequisites

•It must first put its own house in order

•PR must have the respect of employees and community

•Management must justify its profits and prove that it is not profiteering

•Work for the community as an able corporate citizen

Advertising

•“Advertising is bringing a product (or service) to the attention of potential and current
customers. Advertising is focused on one particular product or service. Thus, an advertising
plan for one product might be very different than that for another product. Advertising is
typically done with signs, brochures, commercials, direct mailings or e-mail messages,
personal contact, etc.”

Skills
•Has to show a good understanding of the hospital's objectives and pro-activeness in
generating new ideas

•Strong leadership qualities and the ability to successfully complete projects

•To have good managerial and communications skills

•Understanding how the media works

•Maintaining a positive image of the organization

•To be able to bail one's company out of a situation of crisis

•Be able to think out of the box and react quickly

 Hospital Operations Management HHSM ZG614

Hospital Food Service

.Manimegalai.,M.Sc.,M.Phil.,RD.,
Senior Lecturer & In-Charge
Department of Dietetics

Learning Points
Uniqueness of hospital diet
Organogram of hospital dietary kitchen
Functions
Role and Responsibilities
Food Safety & hygiene
Importance of audits
Conclusion

Introduction
Hospital food service has an indispensable influence in the treatment process of in-
patients by giving nutritious food.
Hospital food service is unique just because it serves food to the patients group.
Patients get hospitalized to get treatment for their ailments and nutrition plays an
extremely critical role in many disease conditions.
The types of diets that are available in the hospital will not be available anywhere
except in the hospital food service.
Apart from the types of diets there are many other things that are very unique in it’s
own way like the role played by a clinical dietitian, guest relation executives, food
service stewards etc.
Hospital food service is just not only a food service; it is a part of the patient’s
treatment.
Hospital food service doesn’t work independently; it is a collaborative team effort of
several disciplines to provide the ultimate patient experience.

1
Uniqueness of Hospital Food Service
The uniqueness of hospital food service
Types
varieties of diets prepared in hospital kitchen.
Hospital food might not get the best reputation when compared with the Restaurant /
Hotel Foods just because of the level of expectations of the taste.
Hospital foods have the right amount and right quality of ingredients with the right
amount of salt without any taste enhancers, artificial colours and preservatives.
Hospital food service sets high quality standards when it comes to good nutritional
offerings.
Patient on hospital diet does not usually have the alternative of purchasing meals
elsewhere.
Since the patient does not have any other option, it is the obligation of the hospital
food service to provide patient acceptable nutritious diet throughout their course of
treatment in the hospital.

Functions
Therapeutic Diet Planning and Execution
Food Preparation and service matching the needs of the patient.
Providing nutritional care for in-patients.
Providing diet consultation for both in-patients and outpatients.
Offers a course in P.G. Diploma in dietetics and M.Sc in Clinical Nutrition
Holding lectures on nutrition and dietetics for doctors, nurses, medical and nursing
students.
Undertaking research projects in collaboration with other medical and nursing and
allied health units
Offers dietetic internship for student of various colleges/universities for 4/6 weeks and
6 months internship for post graduate students.
Conducting Nutrition Education and Nutrition Awareness programs for the public as a
team with other health care personnel.

2
Responsibilities of Chief Dietitian
To oversee the function of the department and to carry out the operation.
Directs activities of the department providing quality food service and nutritional care.
Inspect food preparation and food service for conformance with the prescribed diets
and standard.
Establishes policies and procedures, and provides administrative direction for menu
formulation, food preparation and service, purchasing, sanitation standards, safety
practices, and personnel utilization.
Coordinates interdepartmental professional activities, and serves as consultant to
management on matters pertaining to dietetics.
Directs departmental educational programs.

Role of a dietitian
Dietitian shall be the head of dietary department
Dieticians in the hospital are the nutritional experts who outline a customized diet plan
for each patient based on the medical condition and the diet prescription recommended
by the treating doctor.

Meal planning
The prime objective of meal planning is to achieve nutritional adequacy.
The diets are planned in such a way it meets the nutritional needs of the individuals
getting hospitalized.
Since no single food can meet all the nutritional requirements and hence it becomes
extremely important to achieve a balance of nutrients through a combination of different
foods included in the hospital diet.
The diets in the hospitals are usually planned by including foods from the five food
groups.

Principles and objectives of therapeutic Diet

To maintain good nutritional status.
To correct nutrient deficiencies which may have occurred due to the disease
To afford rest to the whole body or to the specific organ affected by the disease.

3
To adjust the food intake to the body’s ability to metabolize the nutrients during the
disease.
To bring about changes in body weight whenever necessary.
To reduce the complication and severity of the disease.

NUTRITIONAL CARE FOR PATIENTS

1. Provision of Nutritional care
a. Assessment of the nutritional requirement
b. Plan diet appropriate according to the disease condition and nutritional
requirements and provide counseling if required.
2. Dietitians visit the allotted wards and they are responsible for inpatient nutritional
care.
3. Visit the patient within 24-48 hrs. Of diet order except on Saturday & Sunday &
institutional holidays.
4. Check and document the following details in patient’s medical chart
i. Name, Hospital number, Bed number,
ii. Diagnosis
iii. Reason for admission,
iv. Biochemical tests results,
v. Gender, Age, Height, Weight,
vi. Appropriateness of Diet ordered
5. If not appropriate, inform the nursing staff/Clinician and the patient.
6. Necessary corrections are made and documented in the memo card.
7. Nutrition re-assessment for patients on therapeutic diets will be done after 4th day of
Initial Assessment. Re-assessment will vary depending upon patients’ health conditions.

IMPORTANCE OF DIET COUNSELLING AND PATIENT EDUCATION

The major objective of dietary counseling is to educate the patient regarding the nature
of the disease, its hazards, how a disease can be recognized and prevented.
It is essential to advice the patient on personal hygiene, individual instructions on diet
and any specific therapy needed.
Diet counseling makes the patient aware of the fact that diet plays an important role in
the treatment of the disease.

4
With today’s emphasis on prevention of disease, diet counseling helps to reduce the
risk of some illness by appropriate counseling.
Diet counseling is effective when the counselor assists the patient in setting realistic
goals and provides the necessary guidance in menu planning, food purchasing and
preparation.

Food service
Delivering right diet to the right patient every time is a carefully orchestrated team
effort when it comes to patient food service.
Food is prepared according to standardized recipes and according to conventional or
automated preparation methods.
Food is freshly prepared for each meal and is directly portioned, dished up, garnished
and served after the cooking process/preparation process which can also take place in
batches.

Role and Importance of Health, Safety, Environment& Quality (HSEQ) Executive

HSEQ is a safety programme which promotes a proactive safety culture in the working
place.
This is to ensure that every employee is accountable for safety practices in their
respective working areas to achieve excellent health and safety and food safety
performance.
The executive carries out internal audits on a regular basis to measure the performance
of the food service kitchen.
The executive very critically monitors the movements of the kitchen to ensure that
there no deviations.
In case of any deviations, the same is escalated and documented and ensures that the
deviations are rectified.

The routine of a HSEQ Executive in the hospital kitchen

1. Employee grooming & Personal Hygiene
2. Availability of Personal Protective Equipment’s (PPE)
3. Ensures that the walkthrough is hazard free.
4. Identifying any unhygienic practice

5
 5. Ensures that the emergency exits are clear
6. Availability of all the Standard Operating Procedures (SOP)
7. Availability of JSA –Job Safety Analysis posters
8. Availability of Food Safety Policy
9. Availability of Health and Safety Policy
10. Availability of Environment Safety Policy
11. Training –HSE Induction for new employees
12. Daily Staff Training according to Tool Box Topic
13. Ensures availability of calibrated thermometers wherever required
14. Checks on the receiving records
15. Checks on the storage records
16. Checks on the Sanitization records
17. Checks on cooking, reheating and cooling and food transfer records
18. Checks on Wastage and Scrap oil record

Risk Assessment by HSEQ Executive

The HSEQ executive frequently performs risk assessment at the unit level.
A risk assessment is a vital element for health and safety management and its main
objective is to determine the measures required to comply with the HSE requirements to
reduce the level of incidents / accidents.
The HSEQ executive follows the 5 step risk assessment guide.
1. Identifies the Hazards
2. Decides who might be harmed and how
3. Evaluates the risk and decides on control measures
4. Records the findings and implements them
5. Reviews the assessment and updates if Necessary

Guest Relation Executives in Hospital Food Service

Guest Relation Executive (GRE) plays a very important role of customer service in
any industry.
GRE’s are the recent trends in hospital industry.
GRE use their skills and experience to ensure that patients are delivered with highest
standards of services during their course of hospitalization.
The Strategy of the GRE is to get closer to the patient to try and understand the
requirements better and try to help patients during their course of hospitalization to a
possible extent.
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This strategy was adopted to build in confidence to the patients that there is a
committed team of members to look after their needs.

TYPES OF CATERING SERVICES

Conventional food system

 Food is freshly prepared each meal, cooked and served
 Food is prepared according to standardized recipes
 Directly portioned dished up, garnished and served
 Dishing up and garnishing of complete meals in suitable crockery and transported
on trays in suitable trolleys
 Decentralized

Cyclic Menu
To set a very good menu option; cyclic menu is the best way to prevent dissatisfaction
resulting from monotony.
The ‘MENU’ is the blueprint of operation in any catering establishment.
A hospital food service usually has a minimum of 2-5 weeks cyclic menu.
Nutritional concerns with respect to sugar, salt and complex carbohydrate content of
the diet is addressed in the menu planning by the nutritional experts making it as a
pleasant dining experience to the patients without compromising on the nutritional
quotient.

FOOD EVALUATION
Half an hour before the meal setting all main items are evaluated by
the dietitian on duty and recorded in the Food Evaluation Register.
The dietitian will taste the food.
Dietitians look for taste, flavour, and texture.
If any modifications are required the dietitian will intimate After
making necessary corrections the food is evaluated again, If not
satisfactory the food item is rejected and fresh item is prepared by
consulting HOD.
The dietitian records the quality of food item after evaluation in
Taste Evaluation Record.

7
Food safety
The term “food safety” refers to the manner of handling, preparation and storage of
foodstuffs with the aim of preventing contamination of the product and subsequent food
borne illness (or injury) of the consumer.
Food safety is relevant to everyone, but vulnerable people are more likely to be affected
even by low-level pathogens and, therefore, more likely to be infected.
This puts even greater responsibility on medical institutions to do everything possible to
ensure that safe food is always prepared and served.
Safety must be the top priority when it comes to hospital food which is used for
nutritional therapy and not just for taste.
The food must be free of hazardous chemical compounds and pathogenic
microorganisms.

Do Bacteria enter the Food Supply?

The hospital itself is the source of infection.
Without rigorous procedures and protocols,
dangerous microorganisms like pathogens,
viruses, etc., can disseminate among patients
and staff

Food poisoning bacteria can come from four

main sources:
Food handlers
Raw foods like Raw meat, poultry, shellfish and
vegetables
Pests and animals
Air, dust, dirt and food waste.

Contributing Factors for Outbreaks

CDC estimates that approximately 18-20% of foodborne outbreaks are associated with
an infected food worker
Thetop contributing factors for outbreaks from the Centers for Disease Control and
Prevention (CDC):

8
Food handlers contaminating ready-to-eat food through bare-hand contact
Food handlers contaminating food through a method other than hand contact (such as
with a utensil they contaminated)
Food handlers contaminating ready-to-eat food through gloved-hand contact
Food handling practices leading to growth of pathogens (such as food not kept cold
enough)

Food Safety Management System

Receiving Area
It is imperative to have a designated clean area for receiving and storing the food
materials.
In the receiving area, temperature control and quality inspections must be maintained.
These inspections should encompass specifications, brand names, condition of the
packaging and labeling.
Vegetables need to be disinfected right at the point of receiving them.

Sorting for physical hazards

Preliminary washing in cold running water and

soaking in 100 ppm chlorine solution for 5
minutes

9
Storage Area

Storage area: it is divided into:

Dry storage: for food items like sugar, dal, rice, fruits, vegetable salt and other
dry items.
Wet storage: for items like milk curd ghee juices etc.
FIFO/FEFO: date marking and FIFO are some of the most impactful methods to cut
down on food waste and helps to use before it goes bad.
Digital Thermometer: to be installed

Wet Storage

Dry Storage

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Are we storing foods at the right temperature?

Food Preparation Area

11
Time/temperature Control for Safety or TCS Food

Involved in most food borne illnesses

Generally high protein foods
Meat and meat products

Cut leafy vegetables

Sliced fruits

Cooked vegetables

Eggs and milk

Calibrated probe thermometer

Use proper methods to thaw frozen foods
Keeping under running water

Leave at refrigerator

Bacteria that grow on these foods thrive when the temperature is warm, usually between
about 41°F (5°C) and 135°F (63°C).
This temperature range is usually referred as temperature danger zone.
Keeping hot foods hot (above 135°F) and cold foods cold (below 41°F) can keep these
bacteria from growing.

12
Safe Plastics for Packing Foods

Food Service
Food hygiene, which refers to the many practices needed to safeguard the quality of food
from production to consumption.
Food hygiene is vital for creating and maintaining hygienic and healthy conditions for
the production and consumption of the food that we eat.
Meticulous cleaning of kitchen
Preheating the bain-marie
Holding food at 65°C or above
Packing and serving food in clean hot cases along with appropriate cutlery.

Wash Hands

13
Wash hands regularly and properly to
prevent cross contamination.

SANITIZATION TUB

Disinfection Carried Out For Perishable Items

14
Food Sampling
Why is it important ?
Is a process used to ensure the quality and safety of any food products

Hospital cafeteria serves food that is nutritionally and medically appropriate; a sample
must be taken and preserved.
If there is any suspension of food poisoning or if a patient complains, the food will be
tested to determine the source of contamination, whether it occurred during preparation,
transportation, or due to a lack of a Food Safety Management System (FSMS)
Regardless of the cause, this issue is punishable and compensation must be provided to
the affected patient or consumer.
Minimum 250 g of sample must be stored
The bags/Containers should be sealed properly with appropriate labeling-date
and time/ service of preparation (Breakfast, Lunch, Snacks, Dinner & Feed etc.).
The food samples to be retained/ kept in a freezer for 72 hrs.

Pest control Methods

15
Pest control measures are taken every week
After this procedure, entire area is cleaned thoroughly and ready for the next day
operations
Effectiveness of the pest-control program should be verified on a regular frequency

PPE : Why is it mandate ?

What happens when head gear is not used?

According FDA food code : “A hair restraint keeps away hair from ending up in the
food and may deter employees from touching their hair." This is crucial to prevent cross
contamination.
Staphylococcus aureus is an example of a common pathogen that is found on skin and hair.
If enough of the bacteria is ingested, it could cause illness. Common symptoms of this
illness include vomiting, nausea, and stomach cramps.

What happens when gloves is not used?

It is important to understand why avoiding bare-hand contact is crucial to food safety.
Even after washing your hands, they can still have pathogens on them.
Norovirus, for example, can easily be spread through person-to-food contact. In addition
to bacteria and viruses, dirt and grime can get stuck on your hands and pass to the food.
Bare hand contact with ready to eat food causes 30% of food borne illness outbreak

Taking Responsibility for Personal Hygiene and Hand Washing

16
25% of all food borne illness is due to improper employee practices
Anyone working with food must wash their hands
Employees who are ill with colds or employees with cuts or burns are at high risk for
transmitting illness
No smoking/eating/drinking
Avoid touching face, sneezing or coughing over the food
Single-use gloves should be used for only one task
Cuts to be covered with water proof dressing

Practicing good sanitization methods to prevent cross contamination

Cleaning Utensils
Cross contamination is the transfer of harmful bacteria from one food to another
Utensils, equipment, human hands
Use proper sanitizing solution to minimize and prevent cross contamination.
Disinfect boards and knives and food contact surfaces between different food types
Hand contact surfaces need to be disinfected.
Remember to change washing water once it is dirty.

There are five steps to utilize correctly in a three compartment sink

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Medical Check up

Medical check up is done once in a year

Blood and urine and stool
Skin
Eye
Deworming is done once in six month

Vaccine is given once in three years for enteric group of diseases

18
Food Safety Training and Re-Education
It's important to educate those handling food on the
importance of maintaining cleanliness, and to conduct
regular inspections to ensure they are following proper
hygiene protocols.
The nutrient content and density of the food is the
responsibility of dietitians, however we must closely
monitor and manage food safety and hygiene aspects as
well to deliver safe clean nutritious food.
Making food safety a priority will not only help prevent
food borne illness, it will also help provide excellent
and trustworthy service to our patients!

Importance of Plate Waste Assessment in a Hospital Kitchen

Plate waste is a methodology used in the hospital inpatient’s kitchen to find out the
amount of food that remains uneaten on the patients’ plate after a meal.

WHY CONDUCT PLATE WASTE AUDITS IN HOSPITALS?

No matters how well a diet has been planned, it matters the most only when the patient
consumes the food completely.
Only then the nutrition goals of the patients are achieved.
Plate waste assessment is one of the effective determinants of the level of acceptance of
food by the patients.

HOW TO CONDUCT PLATE WASTE AUDITS IN HOSPITALS?

To decide on the meals to be surveyed
Determination of the method of plate waste assessment

Two methods of plate waste assessments are

19
Weighing Estimation -Accurate and exact assessment of the plate waste generated.
Visual Estimation -Greater convenience and time-saving assessment.
Taking Pictures
Taking pictures of the trays which have not been touched by the patients at all.
This will give an immediate idea as to what has gone to the patient so that when
interacting with the patient, the dietitian will have a clear idea what has been served to
the patient and will facilitate to make appropriate changes to the patient meal keeping in
mind the items which the patient did not like.

Regular Monitoring and Recording

Record Keeping is very much essential to keep a track on the FMS
Cleaning Schedules
Temperature log of equipment
Food sampling
Garbage disposal
Pest control
Grooming

LICENSES
Labourand FSSAI licenses are obtained every year
Calibration-Protocols and calibration methods must be established for all equipment that
could impact on food safety. These include:
Thermometers

Refrigeration controls

Golden rules for safe food preparation

Cook raw foods thoroughly.

Thorough cooking will kill the pathogens, which means the temperature of all parts of
the food must reach at least 70°C.
Avoid contact between rawfoods and cooked foods.
Safely cooked food can become contaminated through even the slightest contact with
raw food.

20
Wash hands repeatedly.
Hands should be washed thoroughly before preparing, serving or eating food and after
every interruption, especially after use of rest rooms
Keep all food preparation premises meticulously clean.
Since foods are so easily contaminated; any surface used for food preparation must be
kept absolutely clean
Use safe water
Safe water is just as important for food preparation as for drinking

How clean is our kitchen?

Effective cleaning and disinfection is essential to

get rid of harmful bacteria and stop them
spreading to food..
The proper cleaning and disinfection of food
premises can contribute significantly to
controlling food safety hazards and risks
associated with cross-contamination and
inadequate cleaning.
Cross-contamination is one of the most common risk
factors reported in outbreaks of food poisoning

21
 Hospital Operations Management HHSM ZG614

Water & Waste Water Treatment in Health Care Facility

Mr. JOEL SABASTIN

BTech (chem.) MBA
NEERING
What is Water Supply Engineering?
Deals with supply of water from:
SOURCE OF WATER
Collection
Treatment
Storage
Distribution
Consumer
Water demand…per capita consumption
Involves design of a water supply scheme with the amount of water available and amount of
water demanded by the public
1. Domestic
a. Flushing: 45 litres / day / person
b. Other purposes: 90 litres/day/person
c. Total Consumption: 135 litres/day/person
2. Industrial
3. Public Use
4. Fire Demand
5. Losses such as waste, theft
Water requirement for buildings…

Recommended Standards Of Drinking Water

Specific Parameter of Drinking water

1. Total Hardness:
•Mineral content in a water sample
•Total hardness = total calcium + magnesium hardness.
2. Total Dissolved Solids (TDS)
•TDS -total of organic and Inorganic substances present in a liquid(Water).
•minerals, salts and organic matter -general indicator of water quality.
The Previous slide has important parameter, which are monitored for portable water

LICENSES FOR WATER SUPPLY

No objection certificate –obtained from the local competent authority
Ground water clearance certificate from the Executive Engineer, Ground Water
Division

Treatment of Drinking Water

1. Chlorination/Disinfection:
The Drinking water is primarily treated with 5% Sodium Hypo chlorite, a disinfectant used
to resist the Microbial Growth.
2. Chlorine di oxide:
Chlorine dioxide –is a bleach in liquid form. Effective at low concentrations.
Chlorine dioxide is a very strong oxidizer. Effectively kills pathogenic microorganisms such
as fungi, bacteria and viruses.
Chlorine dioxide is a powerful disinfectant for bacteria and viruses. Chlorine dioxide
prevents the growth of bacteria in the drinking water distribution network. chlorine dioxide
is active for at least 48 hours, its activity probably outranges that of chlorine.

In case of Hard water –water to be undergone with chemical treatment

1.Temporary Hardness
-Dissolved salts such as Calcium or Magnesium bicarbonate
-Ways to remove are Boiling.
2.Permanent Hardness
-Calcium and Magnesium chlorides /Sulphides
-Removed by Addition of Ion exchange process (Softening plant)

3. Chemical treatment
Softening plant:
Ion exchange softening, also known as zeolite softening, passes water through a filter
containing resin granules.
In the filter, known as a softener, Calcium and magnesium in the water are exchanged for
sodium from the resin granules.
The resulting water has a hardness of 0 mg / Land must be mixed with hard water to
prevent softness problems in the distributed water.
Application:
•Ion exchange softening is effective at removing both carbonate and noncarbonated
hardness. •It is used for waters high in noncarbonated hardness and with a total hardness
more than 350mg/L.

Storage & distribution of Drinking Water

Storage of Drinking water:
Storage of clear water in underground Sump and over head tanks in respective Blocks.
Distribution of water through pipelines.
The Water is distributed to the respective over head tanks from the Drinking water sumps
through channelized pipeline with a scheduled operational time.

SEWAGE & WASTE WATER TREATMENT

DEFINITION
•Maintenance of the environment such that it will not affect the public health in general.

•Preventive measure for the preservation of health of the community and individual
‘Health’: Physical and mental soundness of the human body so that it is in a position to
discharge daily routine functions
WHY TREAT WATER ???

Water Contains A Number Of Dissolved & Suspended

Impurities Which Need To Be Removed Before consuming The Water.
Water Contains
• Cations, • Anions, • Turbidity, • Collidal Particles, • Organic Matter, • Alkalinity,
•Silica, • Heavy Metals Etc.
Different Methods Of Treatment Have To Be Applied To Remove Different Impurities
Steps involved in Sanitation

Treatment Stages
TYPICAL SEWAGE TREATMENT SYSTEM
SEWAGE TREATMENT PLANT
Biological processes
A. Aerobic Process
1. Suspended growth process
eg., Activated Sludge process(ASP)
2.Attached growth process
eg., Fluidised Aerobic Bioreactor (FAB)

B. Anaerobic Process
1.Suspended growth process
2.Attached growth process

TECHNOLOGY INCORPORATED IN CMC, VELLORE

1. Stabilization Ponds –Aerobic & Anaerobic Systems (UASB/AF etc.)

2. Conventional Method-(ASP)
3. Submerged Aerated Fixed Film (SAFF)
4. Fluidized Aerobic Bio Reactor (FABR)
5. Sequential Batch reactor (SBR)
6. Membrane based treatment system
7. DEWAT SYSTEM
Integrated water supply system in CMC
FAB REACTOR – The New Generation Sewage Treatment Plants
Fluidized
Aerobic
Bio
Reactor
FAB –REACTORS
Works on the principles of Attached Growth Process.
Media will be in suspension -Specific gravity less than water.
Media fluidization -by virtue of hydraulic currents set by Aeration.
High SRT

DETAILS OF THE PLANT

Inlet Characteristics
•BOD : 500

•COD : 1000

•TSS : 400

•pH : ~ 7
PRIMARY TREATMENT – SCREENING
BAR SCREEN
* The arrested material like plastics, papers, floatable particles etc. to be removed on a
regular basis .
* Regular cleaning of screens will avoid the problems of pump choking, overflowing of
chambers etc.

OIL & GREASE TRAP

•Removes free floating oil & grease

•Oil removal will ensure the smooth operation of biological system [ FAB Reactors]

RECEIVING SUMP
EQUILIZATION TANK
•Dampens / absorbs fluctuations.
•Homogenizes effluent.
•Uniform feed to biological system
•Continuous air supply in the sump will not allow the solids to settle in the tank

Essential Components of FAB Reactor

CARRIER MEDIA
FAB BASED TREATMENT SYSTEM

FEATURES
TUBE SETTLER

TUBE SETTLER OBJECTIVE & OPERATION

• Removes biological dead mass /sludge generated in FAB reactors.
• The settled sludge from tube settler can be dewatered and / dried.
• Sludge from tube settler to be drained every 4hrs for approx.1-2 minutes based on visual
observation till total sludge is drained.

CHLORINE CONTACT TANK [CCT]

•Sodium hypochlorite [NaOCl] is to be added in CCT for dis-infection /killing of the

bacteria.
•The dose of free chlorine to be maintained @ 3.0ppm for disinfection.
•Sodium hypochlorite contains free approx. 8 to 10 % free chlorine
•The mixing of chlorine in CCT is achieved by zig-zag / upflow-down flow passing of
treated sewage with chlorine in CCT.

DMF/ACF FILTER
DMF : Removal of SS escaping from TS
ACF : Removal of trace organics , Color and odor in the treated effluent
Both filters need periodic backwashing (Typically once every 8hrs.)
Sludge Handling System
Following are the options available :
A. Sludge drying beds
B. Filter press
C. Centrifuge
D. Sludge digester etc.
Advanced Tertiary Treatment:
It involves filtration and disinfection mechanisms
• The Treated water is filtered using a Ultra filtration membrane to produce an ultra clear
water for Flushing.
• chlorination –adding chlorine( 5% Sodium Hypo chloride solution) as an disinfectant to
make it safe from microbial growth.

Disposal of treated water

•Toilet flushing
•Gardening
•Laundry pre wash water
•Chiller/cooling towers

View of GARDENS using Treated Water

 Hospital Operations Management HHSM ZG614

CSSD and its function

HISTORY

1928 –American College of Surgeons –CSSD

•1942 –World War II. Cairo, British SDS Unit.
•1955 –Cambridge Military Hospital –Regular
CSSD in UK
•1965 –First CSSD in India –Safdarjung Hospital
in New Delhi
•1972 –CMC CSSD in Vellore

DEFINITION

A Central Sterile Supply Department (CSSD) is a hospital support service, which is

entrusted with processing and issue of supplies including sterile instruments and
equipment used in various departments of a hospital. In certain hospitals, especially in
the developed countries, this department is called the central service department and
encompasses many other functions in addition to sterilization such as the purchasing,
stocking and distribution of supplies.
“As that service, with in the hospital, catering for the sterile supplies to all departments,
both to specialized unit as well as general wards and OPDs.”

OBJECTIVES

The objectives of establishing a CSSD are to:

To provide reprocess the and provide Sterile materials required within the health care
facility.
To take some of the work of the Nursing Staff so that they can devote more time to
their patients.
To avoid duplication of costly equipment’s which may be infrequently used. To
maintain record of effectiveness of cleaning, disinfections and sterilization process.
1
To monitor and enforce controls necessary to prevent cross infection according to
infection control policy.
To maintain an inventory of supplies and equipment.

PLANNING A CSSD DEPARTMENT

1. Physical Planning

2. Functional Planning

3. Personnel Planning

4. Equipment Planning

5. Financial Planning

6. Quality Control

7. Preventive Maintenance

LOCATION

It should be centrally located with proximity to the major departments to which it
supplies its material, preferably in the same building.

It should have easy access to the stores, from where it gets its raw material and also to
the laundry for a clean supply of linen,

LAYOUT DESIGNING PRINCIPLE

• There is no back tracking of sterile goods.

• One way movement from receiving counter to issue counter.
• Sterile area should be prior to sterile storage and issue.
• The receiving counter must be away from the issue counter.
• Separate receiving and issuing counter
• There should minimum six basic division in CSSD

2
ZONING
Department is typically divided into four zones:
•Zone I : Reception, inspection and decontamination (removal of bio-burden).

•Zone II : Assembly and packing.

•Zone III : Sterilizing.

•Zone IV : Storage and distribution

In the first zone, used items are received, disassembled, cleaned and decontaminated
by means of manual or mechanical processes.
In the second zone, cleaned items are received and then inspected, replaced if
necessary, assembled, packed and labeled for further processing like sterilization.
In the third zone sterilized items are received and stored until it is time for them to be
issued.

CSSD Design Concept 3 Zones and 2 Barriers

•Physical separation between soiled, clean and sterile zone

•The first barrier avoids cross-contamination of goods spread by staff

•The second barrier avoids mixing up clean and sterile goods

•Good building design will contribute to correct staff working routines and avoid wrong
human behavior

CSSD Design Concept Goods Work Flow

•Separated entries and exits for soiled, clean and sterile goods

•Strict separation of the staff working in the 3 different areas

•Controlled room ventilation -for good production conditions:

3
 -Soiled zone –negative pressure vs. adjoining areas
-Clean zone –positive pressure vs. to all adjoining areas
-Sterile zone –positive pressure
•Straight workflows -for simple, reliable working routines

Functional Areas required for a CSSD.

Accepted Practice Guidelines

•CSA-Canadian Standards Association International

•AAMI-Association for the Advancement of Medical
Instrumentation
•ASHCSP-American Society for Healthcare Central Service Professionals
•AORN -Association of Operating Room Nurses
•ORNAC -Operating Room Nurses Association of Canada
•CDC -Centers for Disease Control and Prevention
•HISI -Hospital infection society of India

4
FUNCTIONS OF CSSD

5
RECEIVING

The Personnel involved in receiving

must be properly attired in protection
gown or plastic Apron, cap, mask and
should wear gloves.
At CSSD, the instruments must be
checked for proper count and
disassembled for manual or machine
cleaning.

CLEANING AND DRYING

Cleaning is the first and most important step in the sterilization process.
Sterilization alone will not be sufficient to get free from potential health hazards.

ANNING A CSS DEPT

METHODS OF CLEANING

6
SELECTING PACKAGING MATERIAL
•Various packaging materials are used for sterilization
methods
•Depends on contents of pack

7
•Designed for need of storage
•Two types of sterile packaging
•Reusable
•Disposable

8
 Reuse of flexible pouches / Reels not permitted
 Fill only ¾ of pouches / Reel (Leave 25%)
 Pack must be dry after sterilization
 Never peel against peel direction to avoid tear off of paper fibre.
 Put labels or marking on film side only or out of seal area
 Use blunt pen to avoid pin holes
 May use Single wrap/ double wrap.

9
LABELING

It should identify the contents of the product.

Other information such as expiry date and

identification regarding where, when and how the
product was sterilized may also be incorporated.

This could be identified by a discrete number

which tells us about the sterilizer cycle, date and operator.

An indicator could also be attached to the label to differentiate between processed and
unprocessed goods.

• On film side only

• date of manufacturing to calculate the shelf life.
• no printing at filling area as medical item is not allowed to get in touch to printing
color.
• printing report on reel
• lot no manufacturer name or brand-indicator
• size code
• peel direction for pouches.

STERILIZATION

It is a process of freeing an article from all microbes including spores.

A material is pronounced sterile if it achieves 100% (99.99%) free from spores
Methods of sterilization is chosen based on the type of material

10
STEAM STERILIZATION

11
1. START –door seals, jacket warms chamber

2. PURGE–steam enters chamber, while air is purged through the chamber drain

3. CONDITIONING –positive pressure and negative vacuum pulses continue to heat

load and purge air

4. HEAT UP–steam pressure builds to selected exposure temperature and pressure

5. EXPOSURE –timing begins for selected exposure time and temperature

6. EXHAUST–chamber drain opens and ejector water creates vacuum in chamber to

exhaust steam

7. DRYING –ejector water controls vacuum in chamber for selected dry time

8. AIR-IN –chamber returns to atmospheric pressure

9. CYCLE COMPLETE –door can be opened

ITEMS STERILIZED BY STREAM

Methods of sterilization is chosen based on the type of material.

Advantages of Steam Sterilization

Ideal method for sterilizing Fabrics & Surgical Instruments.

• Short Process Time compared to EO Sterilization and Dry Heat Sterilization.
• Requires less temperature 1210c & 1340c than dry heat sterilization 160 0c.
• It is a reliable method of sterilization.
• Economical
• Most preferred method of Sterilization.

12
Disadvantages of Steam Sterilization

•Take 10 to 15 minute to dry a load.

•Steam is not effective in the sterilization of unhydrous substances such a soil, powder
and grease.
•Steam is not suitable for heat sensitive items such as plastic materials lighted
instruments (endoscopes) etc.,

ROUTINE MONITORING

DAILY
Bowie-Dick (EU Standard)

WEEKLY
All Daily Tests
Safety Checks (door seal, door safety checks, and safety valves/devices)
Leak Rate Testing

QUARTERLY
All Weekly Tests

YEARLY
All Quarterly Tests
Steam Quality
Requalification

BOWIE AND DICK TEST

The test devices its name from J.H.Bowie and J.Dick Department of Microbiology.
Edinburgh Scotland. It was developed to expose the pattern of residual air within the
load consisting of a single pack in a high vacuum sterilizer and it helps in detecting the
proper stream penetration

Uneven color changes indicates incomplete sterilization.

Even color changes indicate that it is sterile.

13
 Equipment Control

PLACEMENT OF BD TEST

14
BACTERIOLOGICAL OR BIOLOGICAL INDICATORS

A biologic indicator is a preparation of living spores resistant to the sterilizing agent.

These may be supplied in a self-contained system, in dry spore strips or discs in
envelopes, or in sealed vials or ampuls of spores in suspension.
Moist heat–BACILLUS STEAROTHERMOPHILUS.
Dry heat –BACILLUS ATROPHEUS
Ethylene Oxide Gas–BACILLUS ATROPHEUS

ETHYLENE OXIDE GAS STERILIZATION

Heat sensitive Hospital use article can be effectively sterilized by this method because
of high penetration.
Low grade temperature 500c .

15
Type of Articles sterilized by ETO

Rubber Goods
Catheters
Delicate surgical instruments
Electrical Equipment
Plastic Materials
Lenses instruments

MONITORING SYSTEMS – ETO

•Monitors available
•Chemical
•Biological
•Integrators
•Chemical –Tapes. These indicate that items have undergone a process & is not a check
for sterilization
•Biological indicators–kill factor test

•Integrators –advanced forms to indicate whether all critical parameters have been met,
indicates status of sterilization

•Integrator (Dosimeter)-Indicates completeness of process

DRY HEAT STERILIZATION - HOT AIR OVEN

Temperature should be closely regulated.

Sterilizer should not be overloaded.
Some space should be allowed between
articles in the sterilizer to promote
penetration permit free circulation of air
All articles exposed to dry heat sterilization
must be clean of all organic materials and
must be free from traces of oil or grease.
Temperature:1600ctime1hour

16
ADVANTAGES

Dry heat does not corrode ground glass surface. Hence good for sterilizing glass ware.

Dry heat sterilization is satisfactory for anhydrous oils, grease powder etc.

DISADVANTAGES

Deterioration of materials due to excess heat.

Heat penetration is slow and difficult
Longer exposure period.
Decomposition and discoloration of grease, powder or oil sterilized.
Temperature is likely to vary with in the load.

STERILE STORAGE

STORAGE CONDITIONS

• Should meet EN standards.

• Room should be dry, air conditioned and clean no direct
light.
• Maintain room temp 15-25°c
• Relative humidity 30 - 60%
• Pest free area.
• RESTRICTED ENTRY OF PEOPLE.
• KEEP AWAY FROM DISINFECTANTS AND
SOLVENTS

17
STORAGE

Sterile goods should be stored in the order of their date of expire.

Personnel working here must follow proper hygienic practices.
Sterile material should be stored on wire mesh (non soled) open shelves.
Shelves should be at least 8 to 10 inches from the floor, at least 18 inches from the
ceiling and at least 2 inches from the wall.
At sterile store room no dry sweeping must be done.

IDENTIFICATION AND TRACEABILITY RECALL

Instrument Recall
Procedure followed
•RCA
•CAPA
•Mock drill (annual)

Incident Reports
•RCA
•CAPA

•Identification number or code, and the cycle number, the date of sterilization
•Specific contents of the lot or load including quantity, department, and a specific
description of the items
•Name or initials of the operator;
•Results of biological testing, if applicable
•Results of bowie-dick testing, if applicable
•Tracking
(Details of the used set in log register & Patient file)

POLICIES AND PROCEDURES – DOCUMENTED MANUAL

Organogram

Departmental Structure

Job Description & Responsibilities

Area Layout and Zoning

Operational Procedures

18
Validation for various Sterilizers

Recall Procedure

Reuse of SUMD

DOCUMENTATION

Policies and Procedures-Documented Manual

Validation Documents
Log Book/Registers
Training Documents
Staff Health Check-Vaccination Status
Instrument Recall
Incident Reports
Chemical Register
Checklists

VALIDATION DOCUMENTS

Installation Qualification

Operational Qualification

Performance Qualification

Bowie Dick Test

Leak Rate Test

Biological Indicator Test

Chemical Indicators

Revalidation after PPM

PERFORMANCE QUALIFICATION / BATCH PROCESS RECORD

•Sterilizer identification;

•Cycle number

•Batch number

•Date of sterilization

•Reference number of the master process record

•Temperature (chamber temperature)

19
•The pressure (chamber pressure)

•A signature confirming whether cycle was satisfactory

20
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26
 Hospital Operations Management HHSM ZG614

Hospital Information System

Godwin Jebakumar C V
Senior Programmer
Department of Medical IT (CHIPS)
Christian Medical College Vellore

Agenda

•What is Hospital Management System (HMS)

•Application of HIS

•Benefits of a Hospital Management System

•Security Levels

What is Hospital Information System

Several components work together to add value to an organization:

1.Hardware –physical components

2.Software
1.-instructions that tell the physical components what to do
Operating systems –interacts with the hardware

Application software –interacts with the user

3.Data -collection of facts
1
4.People –Doctors, Nurses, Technicians (Medical and Non Medical)

5.Process -Series of steps to achieve a desired outcome

A system enabling Hospitals to manage information and data, related to all aspects of
healthcare –
-Processes, -Providers, -Patients, and more, which in turn ensures that processes
are completed swiftly and effectively.

Applications of HIS

1.Patient Information System (PIS)

2.Nursing Workstation System (NWS)
3.Laboratory Information System (LIS)
4.Picture Archiving Communication
System (PACS)
5.Stores Information System (SIS)
6.Financial Information System (FIS)
7.Administration / Management
Information System

2
Core Modules

Architecure Modules

Add on Modules

Third Party Solutions

3
Patient Management

Patient Info OPD IPD Admission Emergency

Registration Registration
Patient Search Rooms Availability Appointment Basic Patient
Accounts
Basic Patient Patients’ All Details Registration Report Occupancy Report
Accounts

Nursing

Staff Scheduling Dispensing of Blood Bank Requisition Req –

Medicine Pharmacy
Requisition Req – Medical Internal Posting Nursing Assessment
Store Req. to pharmacy Rec.
Inpatient Room Status Emergency Call Alert System to Doc
Monitoring & Monitoring Logging
Logging
Nursing Assessment Medical Nurse Note Progress Note
Rec. Observation

Lab Management

Test Wise Group wise Patient Wise Sample Acceptance

Worksheet Worksheet Worksheet
Report Entry & Culture Reporting Histopathology Interfacing with Lab
Printing Reporting Equipments
Remote Reg. of Test Reports Export PDF, XML, Word,
Tests to RTF

Radiology & Imaging

Report Master X-Ray 2D – Echo Ultrasound

Cathlab CT Scan MRI ECG

Stores Management

Master Voucher Reports Utility Management

Management Management
Search
Equipment Management

Equipment Master Equipment Equipment Status Current Stock

Maintenance Entry Report Report
Item Location AMC Master Service Report Warranty Expiry
Report Entry Report
AMC & Date Work Order Work Request Renewal of
Report Agreements
Preventive Safety Inst. Master Work Type Master Work Trade Master
Maintenance

4
Transaction / Billing Management

Order to Supplier Purchase Voucher Claim Memo Claim Received

Cash Payment Cheq. Payment Stock In & Out Sale Voucher
made to Supplier made to Supplier
Cash Collection of Cheque Collection Daybook Patient Wise Cash
patient of Patient collection
Supplier Wise Cash Daily Order Requisition
Payment Generation

General Setup

Organization / Collection Centre Doctor Donor

Company
Employee Vendor Medicine Surgery
Account Head Disease Department Bank
Privilege Card General Setup Other Setup OPD Reg. Setup

Reports

MIS Reports MRD Reports Accounts Reports Forms &

Certificates
Report Gallery

Advantages of HIS

1.Improved quality of patient care

2.Improved communications within the hospital
3.Increased productivity
4.Reduced chances of errors
5.Reduced costs.

Security Levels


Authentication
Access control
Audit trails
Physical security of communications, computer, and display systems
Control of external communications links and access
Exercise of software discipline across the organization
System backup and disaster recovery procedures
System self-assessment and maintenance of technological awareness.

5
 Hospital Operations Management HHSM ZG614
Supply Chain Management

Topics to be covered
•SCM –Theory
•What do we do in CMC Vellore?
•Sections under Materials Department
•Materials cycle in CMC
•Purchase Procedure
•Purchase Section
•Coding
•Ordering
•Follow up
•Imports
•Tenders and Enquiries

Supply Chain Management –Theory

•Supply chain management is the management of the flow of goods and services and
includes all processes that transform raw materials into final products.
•The five most critical elements of SCM are developing a strategy, sourcing raw
materials, production, distribution, and returns.
•A supply chain manager is tasked with controlling and reducing costs and avoiding
supply shortages.

Some stalwarts in the field

•Apple
•Relationship
•Flexibility
•Cost
•Walmart
•Responsive to customer demand–through company inventory system
•Amazon
•Strong supplier chain network – multiple ware housing–aggressive
negotiation tactics
1
What do we do in CMC Vellore?

Materials Department

Materials Department –Purchase Cycle in CMC

2
Purchase Procedure at CMC Vellore

Procedure for equipment

•For value below Rs. 50,000/-and consumables –chemicals, kits and reagents –Purchase
Committee
•For value above Rs. 50,000 –Biomedical equipment –GAAT A
•For value above Rs. 50,000 –Non-Biomedical equipment –GAAT B
•Administrative Committee (Apex Body)

Purchase Committee
•The Chairman

•The General Superintendent

•Deputy General Superintendent (Materials) Convener

•Biomedical Engineer

•Mechanical Engineer

•Stores In Charge

•CRS In Charge

•CSSD In Charge

•Add. Dy. Nursing Superintendent

•Treasurer
3
Committee

GAAT A (Medical)
Assoc. Director (Admin)
Medical Superintendent
Treasurer
Dy. Nursing Superintendent
Dy. General Superintendent
Senior Biomedical Engineer
Legal Officer
Clinicians

4
GAAT B (Non Medical)
Assoc. Director (Finance)
General Superintendent
Treasurer
Dy. General Superintendent (Materials)
Dy. Nursing Superintendent (Materials)
Senior Biomedical Engineer
Other members

Administrative Committee (AC)

Director
Principal
General Superintendent
Medical Superintendent
Nursing Superintendent
Dean, CON
Treasurer
Assoc. Directors
AC members

5
Purchase Section
Objectives
•Ensuring continuous supply of quality materials at competitive pricing to the Hospital &
College
•Executing control over the procurement process
•Controlling the inventory and maintaining optimum stock
•Acting as an interface between the end users and suppliers

Process flow for raising Purchase Order

6
Sections of Purchase Department
MMM Section
Ordering Section
Follow Up Section
Imports & Advances Section
Tenders
Committees

7
MMM Section
●Method of Material Management in which symbols, numbers and alphabets are used
(either individually or in combination) to represent materials.
●Materials may include raw materials, consumables, spares or even equipment
●Eg.RM00001A

Why Material Coding?

●Material Coding is done to
○Digitalize materials
○Classify/group materials
○Aid in the procurement, storage, usage and disposal of materials.
●Material Codes should be
○Simple and Easy to Understand
○Unique
○Consistent
○Flexible

Material Coding in CMC

● Material Code: Code for a Material

Format Used: Material Name and Relevant Specs
Eg. BULB -LED -15W

● Item Code: Code for a Specific Material

Format Used: Brand Name Material Name -Relevant Specs –CAT NO (Make)
Eg. Stellar BULB -LED –15W –1001 (Philips)
The Brand, Make, CAT No, relevant specs of the items are pertinent for item code
creation.

8
Ordering section
•Approved ePRsare allotted based on round-robin method to staff

•Staff check the ePRson pricing, negotiate if the rates have changed etc.,

•Orders are placed to the supplier

•Following are the types of orders placed

•Regular
•Confirmatory
•Import
•Standing

9
 Follow up section
•After placing order, a notification email within 7 days is sent to the supplier.
•After due date is over, 2 reminder emails are sent in 7 days interval and final reminder is
sent.

Imports

Tenders and Committees

In a day in Materials Department

No. of Purchase Orders raised in Purchase 240

No. of GRs processed in CRS 257

No. of issues handled in Stores 350

Value of PO and Invoice processed 2 crores

10
Materials Department –Statistics:
Purchase Statistics – 2022 - 23
NO. OF NO. NO. OF NO. OF TOTAL PO NO. OF NO. OF
PURCHASE PURCHASE IMPORT CASH VALUE ENQUIRIES MATERIAL
REQUESTS ORDERS ORDERS ORDERS SENT CODES
RECEIVED PLACED PLACED PLACED GENERATED

TOTAL 47,302 65,903 132 418 500 436 10,762

CRORES
APPROX.

Recent developments
•Machine Learning and Artificial Intelligence

•Medical Devices Rules / CDSCO

Class Type Licence required under
MDR
A Low risk Form 5
B Low moderate risk Form 5
C Moderate low risk Form 9
D High risk Form 9

Materials Department –Developments

Expansion to Ranipet and Chittoor Campus: Stores and CRS were established in the
Ranipet and Chittoor Campuses of the Institution.

11
Stores & CRS –Ranipet Campus

Stores & CRS –Chittoor Campus

12
Materials Department –Developments

•New Section – Material Master Management (MMM) Section: Started in the

Purchase Department in July 2021, with 3 project staff and as supervisor, the team
updated around 30,000 material codes (containing irrelevant, inadequate information)
within a year. Today the team ensures that new material codes are created as per the new
developed format.

•New Purchase Order Format: Replaced the old Purchase Order Format with a new
one containing multiple line items, revised PO terms and conditions.

13
•New Purchase Committee Module: Developed and implemented a new module, with
the provision for 1) Attaching invoices / documents 2) Viewing PR with history of the
item code 3) Option for tracking user information 4) Tool tip of material description
and 5) Option for viewing documents pertaining to PR/PO.

14
•Implementation of eGRN : An initiative that 1) Reduced the man hours spent in
sending and receiving manual GR, 2) Eliminated the time delay in getting signed GR
from the department 3) Reduced cost on Stationery.

Manual GR
eGRN

•Inventory Module in PCS: The inventory module which was a standalone software
by BME was migrated into the CRS module that 1) Enabled Automatic capturing of
PO Details for Equipment Purchases 2) Made inventory data available to users.

15
Inventory module

Inventory data made available for Depts

16
•New Vendor Portal : A new portal in which, the supplier will be able to view the PO,
enter consignment details, track invoice status and update their profile was developed
and implemented.

17
Vendor Portal

18
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20
•Concealed the exposed pipelines in CRS–Main Campus: The exposed pipe lines in CRS in
the main campus, which were not only as oretotheeye but also a safety hazard was
concealed.

•New Automated Shutters in CRS–Main Campus : Manual shutters were replaced with
automated shutters, which made opening and closing of the large shutters effortless.

Transition to the new campus: The Transition of 13 departments to the New Ranipet
campus was facilitated by CRS and Coordinated by the MSOffice. An external agency
(M/s Fidelis Global) was appointed for moving bio medical assets. Almost 160 trips
were taken to transfer 3000 assets to the new campus.

21
 Hospital Operations Management HHSM ZG614
Central Receiving Section (CRS)

Materials Department

Functions of CRS

Statistics in 2022-2023
NO. OF NO. OF GRN NO. OF NO. OF NO. OF NO. OF
ITEMS PROCESSED INVENTORY CYLINDERS INVOICES INVOICES
RECEIVED GENERATED DISTRIBUTED PROCESSED REGISTERED
TO
ACCOUNTS

TOTAL 17,300 80,436 35,800 15,689 75,000 7,800

Receiving

An administrative function that involves checking of the quality, quantity, and condition
of the incoming goods followed by their proper storage.

•One of the first things that should be considered when receiving and processing
incoming goods is that the receiving bay or loading dock is well organized and clean.
Also should have facilities for receiving and unloading of material.
1
Receipt of Material
Goods Receipt Note (GRN) is a written record that indicates the receiving details of
materials from a supplier to the inventory location.

Mode of Material Delivery

•Hand delivery
•Courier Delivery
•Transport Delivery
•Waybill clearance

Waybill & DC

Delivery checking

•Confirm delivery address

•Check number of package/s
•Condition of the package/s
•Any payment indication
•Any other special instruction
•Check tilt dog indication

2
Physical Verification

•Document -Invoice / Delivery Challan

•Check for
•Supplier name & Address
•Description of the material
•Quantity
•Rate
•Any other charges / Discounts
•GST number
•Appropriate GST rate
•Warranty period

•Material:
•Catalogue number
•Manufacturing date
•Expiry date
•Quantity
•Quality
•MRP
•Pack size

Certificates:
•Test Certificate
•Warranty Certificate
•Absorbent Certificate
•Calibration Certificate
•Weight & Measures Certificate
•User manual
•Certificate of Analysis
•Any other

Technical Checking
•Bio-medical •Mechanical •Electrical •Air Condition •Laboratory
•Other

3
Intimation to supplier

•Damage
•Receipt of material without proper cold chain
•Short receipt / missing of package
•Installation
•Any other discrepancy

Inventory

•Biomedical equipment
•Non-Biomedical equipment
•Computers
•Copiers
•Mobile phones / Tablets

4
•Data pertaining to equipment like
•Serial no.
•Supplier, User Department
•Date of purchase, Warranty details
•Service Department
•Image is captured
•Inventory label is affixed

Inventory module

Inventory label

5
Documentation

GRN Prepared by CRS

6
Queued for CRS In charge Approval

eGRN

7
acknowledged eGRN received in CRS

Acknowledged eGRN received in CRS

8
Invoice forwarded to accounts
Covering letter

CRS checklist

Discrepancy

•Discrepancy while receiving

•Invoice
•Rate
•Quantity
•GST
•HSN Code
•Supplier Address
•Description
•Catalogue no.,
•Goods
•Excess quantity
•Decreased quantity
•Quality issues
•Technical issues
•Damage
•Temperature
•Date of expiry

9
•Supplier, Purchase Department and User Department are informed of the discrepancy
by email.
•Discrepancy item is returned to Supplier through packing slip and replacement is
requested
•For invoice discrepancy, we request for revised invoice or credit note.
•Once discrepancy is sorted out, GRN is prepared and payment is settled

Payment process

•Once eGRN is approved by the concerned User Department.

•It is sent to Accounts Department for making payment.
•The Accounts Department check for three way match i.e. the invoice, GRN and the
Purchase Order should match.

•The invoice is checked for the following

•Supplier name & address
•Supplier GST and CMC GST no.
•Description
•Rate and Quantity
•Catalogue no. / model no.
•HSN (Harmonized System of Nomenclature) code and GST
•Packing and forwarding charges
•Discount
•Once everything is cleared, payment is made online.
•If there is any discrepancy, the discrepancy is amended through proper procedure and
payment is processed.

10
 Hospital Operations Management HHSM ZG614

STORES MANAGEMENT & INVENTORY CONTROL

Topics covered
Stores
Inventory
Inventory Control
Objectives
Types of Inventory System
Concepts
What do we do?

STORES
“Stores” is an area set aside into which all the items and materials required for
production and/or for sale/distribution are received, where they are housed for
safekeeping, and from which they will be issued as required.

INVENTORY
Are stock of materials of any kind stored for future use.

1
Need for Inventory / Stock Control

Balanced flow of material

Minimize stock out
Reduces the possibility of excess stock
Eliminates duplication in ordering
Inventory Control is a major Materials Management function, which requires
the reduction in materials cost without impairing operational efficiency also
known as stock control

Objectives
to minimize the total cost

to keep optimum inventory

uninterrupted supply of items

Types of Inventory System

Two-Bin System
Max and Min System
Periodic Review System
Barcode Inventory System
RFID Inventory System

TWO BIN SYSTEM

Materials are issued from the first bin.

When the first bin is empty materials are ordered.

Replenishment arrives just when the second bin is empty.

When delivery is received both the bins are again filled.

This method is appropriate when the consumption rate is constant

MAX MIN SYSTEM

Maximum level & Minimum level are fixed

Re-order is done after a period of review when the quantity touches a certain level i.e. re-
order level

2
Max Min Method

Re-order quantity (EOQ) 1,500 units

Lead Time 4 to 6 weeks

Maximum consumption 400 units per week

Average consumption 325 units per week

Minimum consumption 250 units per week

PERIODIC REVIEW SYSTEM

Time-bound system
Periodic reviews of stock levels of all items
Period of review is fixed either 3,6 or 12 months
When requirements of all items are worked out afresh, the levels are updated

Barcode Inventory
A barcode is an optical machine-readable representation of data, which shows data
about the object.
Linear Code
Q R Code
Mostly used in Retail Stores

RFID
Termed as RADIO FREQUENCY IDENTIFICATION

Consists of a tiny Silicon computer CHIP and an antenna

The remote reader scans this and sends it to the database.

The CHIP is known as the Spy CHIP

3
CONCEPTS

SAFETY STOCK

•A safety stock is a cushion to prevent against stock outs. A system that can absorb the
shocks of large fluctuations at the least possible cost
•

•Safety Stock = 100 box of mask per day * 15 days –50 box of mask per day * 10 days =
1500-500 = 1000 boxes

Lead Time

Time Period between PR raised and receipt made in Stores.

Factors influencing:
Administrative Lead Time
Delivery Lead time

Ordering Cost
Clerical Cost
Administrative cost.
No of orders * Cost per order

Inventory Carrying Cost

The costs of holding these goods in stock are
known as carrying costs, or inventory holding costs.

Obsolescence 10%

Interest in Invtry. investment pymt 6%

Physical deterioration/prevention cost 5%

Distribution, handling & transportation 3%

Tax, insurance, rent etc. for storage 1%

4
Economic Order Quantity

Most Economic purchase order quantity which keeps balance between Inventory
carrying cost and ordering cost.
For example, consider a retail clothing shop that carries a line of men’s shirts. The shop
sells 1,000 shirts each year. It costs the company Rs.100 per year to hold a single shirt in
inventory, and the fixed cost to place an order is Rs. 20.
The EOQ formula is the square root of (2 x 1,000 shirts x 20 order cost) / (100 holding
cost), or 28.3 with rounding. The ideal order size to minimize costs and meet customer
demand is slightly more than 20 shirts.

What do we do?

5
GOODS INWARD BOOKS
Register maintained in stores to record the
material directly received in stores without
necessary Document.
Information like Po number, Invoice no/DC
number & Description and date forwarded to
CRS for Proper Documentation.

Goods Received Note (GRN)

Mandatory Document for Payment process

Multiple levels of Approval .
To avoid double payment with original invoice and Accounts copy of GRN is required
for payment.
All the documents including Warranty and inventory numbers are captured in GRN.

Discrepancy note Register/Intimation slip

If there is any deviation in the product from the purchase order then discrepancy note is
made.

Information will be conveyed to CRS & Purchase for administrative decision .

Packing Slip
Slip generated for returning the
goods to the supplier .

Unique number is generated

along with suppliers documents .

Two copies generated one is for

supplier and other one is retained
in CRS.

6
Stores Receipt
Confirmation receipt generated by stores before
updating the stock .

Unique ID number is generated for a batch of

materials

Cannot be revoked .

Issue Slips
ID numbers generated
for issuing the materials
to the wards for better
accounting.

Captures Material Code

Bin details Account
number and other
valuable informations.

EMR Slips
Excessive Material Return slip .

Returning the material back to store if wrongly

indented or idle stocks .

Two copies generated one is for store record

keeping and other is for Accounts

Weekly / Annual Stock Register

Weekly Audit report is stored but stock is not updated .

Annual Stock take is done in the business year end Mar 31 .

Record of the update is maintained for future reference.

7
FUNCTIONS OF STORES

Receive the materials, Check them for quantity, co-ordinate for inspection and quality
checks.
Accept the passed materials, and prepare documents for the supply received. Reject the
materials failed in Quality checks.
Take into Stock the accepted materials, store them in respective locations.

Receive Indents from users, Issue the required materials to users, Issue Slips prepared,
Record and update the Stock registers/ledgers.

Periodic review of Stock levels, raising Purchase Requests when Reorder level reaches.

Keep the storage place clean for facilitating handling and movement and observe all
safety measures and security regulations.

Periodical physical verification of Stock and ensuring proper accounting.

TYPE OF STORES

Decision by Management.

Centralized Stores –ensure economy by reducing man power, economy in inventory &
effect better control. But difficult to cater the needs of various work centers scattered
in different locations.

Decentralized Stores –various stores kept near the production floors/work areas
ensure immediate supply. Waste of money by blocking up large capital in the same
material inventory by various stores of the institution.

CLASSIFICATION AND CODIFICATION

Classify materials to their permanent basic characteristics, and then proceeding from
the general to the particular, bring together all closely similar materials and parts
irrespective of their functions and assemblies for which they were originally designed.
Identification through proper codification resulted in elimination of the multiplication.
A rationalized system of codification would reduce the number substantially at the same
time make their identification an easier job, avoiding lengthy descriptions and
confusions.

Codification
1. Alphabetical system -first alphabet of the name of the material is the starting point of
codification
2. Numerical system –Based on simple numbers (One number is allotted against each
material) or block numbers ( Eg: raw materials 1-1000, packing materials 1001 –2000
etc.)
3. Decimal system -0-9 digits are used in this classification and each digit signifies some
characteristics of that material
Alpha Numerical system

8
MATERIALS ACCOUNTING

Bin Card–a record of movement of materials the daily transactions (daily receipts,
issues) and material codes, description, balance quantity on hand & Re-order levels. It
serves as a check on Stock Ledger and helps physical verification of stores.
Stores Ledger–PR details with quantity ordered, Stock levels, Material code number and
bin number, GR No., Supplier name & Quantity received, Issue details –user
department, indent number, quantity issued
Materials Returned Note(EMR)

PRICING/CHARGING
•FIFO
•LIFO
•AVERAGE COST METHOD

PHYSICAL VERIFICATION

Necessary to ensure against embezzlement, spoilage, damage, obsolescence and errors.

Discrepancy found the causes are investigated and records reconciled.
PERIODIC VERIFICATION
CONTINUOUS VERIFICATION
ANNUAL STOCK VERIFICATION

AUDIT CONTROL
Periodic or surprise audit may reveal some potential security problems. Audit may take
the role of a watch-dog, pointing out weak spots and then advising for remedial action.
It controls inaccurate record keeping and fraudulent practices.

Auditing – Internal

-External

Statistics 2022-2023

9
 Hospital Operations Management HHSM ZG614

EMERGENCY DEPARTMENT
Dr. Sandeep Nathanael David
MD, MEM (SEMI), MRCEM(UK)
Assistant Professor, Dept of Emergency Medicine
CMCH, Vellore

Introduction
•Emergency -a dangerous or serious situation that happens unexpectedly and needs fast
action in order to avoid harmful results.
•Emergency care starts in pre-hospital setting, usually provided by paramedic and
ambulance services.
•Continued at the hospital at the Emergency Department

What do we do?
•Casualty Emergency Department
•Stabilise critically ill patients from all ages groups, across all specialities
•Ensure that patients receive appropriate further care from concerned departments
•Training and Research

Scope of patient footfall

Expected patients
• Trauma and Accident victims
• Acute medical or surgical illness –MI, CVA, Acute Abdomen etc
• Poisoning and Deliberate Self Harm

Non emergent visits

• Patients with admission slips but lack of beds
• Patients who require admission from OPD but delay in arranging beds
• Patients with CLD, CKD, etc on routine follow up
• Patients referred to other departments for further management

1
CMC Emergency Department
• Started in the ground floor of OPD building and was managed by interns (Casualty)
• Moved to the current location in 1990’s and became an independent Emergency
department (A & E)
• 1 year fellowship course was started in 1997 which was extended to 2 year course in
2008.
• Currently it has evolved into Department of Emergency medicine with a recognized
MD program, and is further staffed by fellowship registrars and senior house officers

ED Personnel
• Consultants –MD/MS/FAEM/MRCEM
• Registrars –PG, Fellowship and Non PG trainees
• Staff nurses
• Emergency medicine technicians/Paramedics
• Attenders
• Housekeeping staff
• Radiology technicians
• Security

Emergency Department Layout

•Triage
•Resuscitation Room – Immediate threat to life and/or limb
-ABC Compromise
•Bays 1, 2, 3, Trauma bay -Incumbent threat to ABC
-Pain relief, Pregnant women
-Trauma patients without immediate ABC compromise
•Consultation room -Stable patients, no danger to life, limb or ABC

2
Flow of Patient-Care

Triage
•“Trier” –‘To sort’
•“The right patient gets the right treatment at the right time
•Different systems exist –1-3, 1-5, Colour systems, etc
•In CMCH, follow a 1-4 system
•Done by a trained Triage-Nurse, can also be done by a Doctor

3
Triage
Condition Time to be seen
Priority
-ABC compromise
I Immediately
-Immediate threat to life or limb

-Haemodynamically stable, needing

intervention/further care ½ hour to 1 hour, earlier if
II
-Potential ABC compromise feasible
-Severe pain
-Pregnancy
-Vitals stable, ambulant
>1-2hours depending on patient
III -Chronic complaints
flow
-No emergency care needed
IV -OPD referral required Usually sorted out at presentation

Priority I –Resuscitation Room

•Triage level 1, should be seen immediately
•Manned by 1-2 doctors, trained in advanced airway management, ACLS, Trauma
management
•Separate nursing and EMT team
•Blood gas analysis, NIV, mechanical ventilation if required
•Bedside Ultrasound –E-FAST, RUSH protocol
•Rapid handover and disposition

Priority II –Bays I, II, III, Trauma

•No immediate danger to life/limb ; No ABC compromise
•Bulk of ED patients, should be seen within ½ hour to 1 hour
•PI patients can be shifted here after stabilization
•2-4 doctors
•Focused history, examination, differential diagnoses. Relevant investigations and
interventions (analgesia, splintage, IV fluids, etc)
•Handover to concerned unit

Priority III and IV –Consultation room

•Stable, ambulant patients. Waiting time often longer than an hour
•1-4 doctors, depending on need/availability
•Usually referred to other specialty departments
•May be evaluated if needed, if no obvious acute intervention needed, sent to OPD
•Vigilance needed here as well

4
Core competencies required
•Good clinical skills, better decision-making skills
•Must have a basic knowledge of emergencies from all fields
•ACLS, Trauma care, advanced airway management, IV access, Intra-osseus access
•Basic Bedside Ultrasonography
•Anaesthesiology, Orthopedics, Pediatrics
•Diplomacy, good people-skills
Equipment required
• Trolley –mobile, tiltable
• Monitors with SpO2, ECG, NIBP and
ETCO2
• Wall Oxygen supply as well as
O2cylinders
• Defibrillators with pacing paddles
• Airway –Direct and Video Laryngoscope
• CPAP, BiPAP and Ventilators
• AMBU bag and Bain’s circuit
• Portable Ultrasound machine
• Blood gas analyzer
•Tiltable, mobile trolleys
•Uninterrupted Central Oxygen supply
•Oxygen cylinders, periodically checked
and maintained
•Biphasic Defibrillator(s)
•Monitors with continuous NIBP, pulse
oximetry, ECG monitoring
•Blood glucose/serum ketone strips
•Urine-dipstick tests
• Blood glucose and serum ketone analyzer
• Portable X-ray machine
• In-house Radiology suite
• Handheld Doppler
• Opthalmoscope and Otoscope
• Computers and Telephones
• Refrigerators for drugs
• Splints
•Refrigerators at strategic areas
•Drugs, including cardio-active and
anaesthetic agents
•Computer terminals and telephones at all
areas
•Blood Gas Analyzers
•Splints
•In-house radiology suite
•Portable X-Ray
•Bedside USG
5
Special Liaisons
1. Trauma services –Special Trauma pager, through the telephone exchange
-Trauma surgery, Orthopaedics, Neurosurgery, Radiology
2. Stroke Team -Within 4.5 hours of a clinically diagnosed stroke
-Stroke team manages the patient and decides on further
care
3. Obstetrics - Rapid transfer to Labour room/Scan room after initial stabilization
4. Cardiology – Shift for PCA/Thrombolysis once ECG diagnosis of STE-ACS is
made and initial management done

Services offered
•Procedural Sedation and Analgesia
•Code-blue rapid response team for certain areas of the hospital
•Stabilization of OPD patients
•Command centre in the event of a Mass-Casualty-Incident

Medico-legal duties
•Road Traffic Accidents –Incident Report,
detailed documentation of injuries, blood
alcohol levels
•Brought dead –Incident report if unnatural
death suspected/confirmed
•Deliberate Self Harm –Incident report
•Child Abuse/Sexual assault –Incident
report, inform senior paediatrician
/obstetrician

Training
•Structured training courses
•MD Emergency Medicine (3 years), Fellowship in Accident and Emergency Medicine
(2 years)
•Non-PG residency also offered
•EMTC, MSEED

6
Quality
•External: • NABH
• Internal:
• Audits
• Chart audit
• CPR audit
• Mortality audit
• DAMA/DAR audit
• 72 hr revisit audit
• Trauma audit (With Trauma Sx)

“No Trolleys!!!”
•Code grey declared, no more patients to be admitted in the ED
•Duty ED consultant directly speaks to the admitting unit consultant, involves in
admitting patients
•De-prioritize patients to priority III, or directly discharge patients to OPD
•Code-red can be lifted when trolleys are free

Conclusion
•Face of the hospital for the sickest patients, 24 x 7 x 365
•Ensure competency and compassion in patient care
•Proper acute management of sick patients can make the difference between life and
death
•Needs support of other departments to prevent overcrowding and optimal functioning

7
 Hospital Operations Management HHSM ZG614

ROLE OF ENGINEERING SERVICES IN

HOSPITAL OPERATIONS MANAGEMENT

JEYALIN VINO J V
M.E. STRUCTURAL ENGINEERING
Asst. Engineer
Department: Engineering Planning.
INTRODUCTION
•Engineering services have large contribution towards shaping the environment of
Hospitals.
•Engineering services are an integral part of hospital infrastructure
Hospital Engineering Services are considered as ‘Backbone of the hospital’

FUNCTIONS OF ENGINEERING SERVICES

•To provide safe & hazard free environment.

•Ensuring that the facilities /services under their scope are in compliance with the
relevant legal provisions and are in order.
•Ensuring optimum operational efficiency of engineering system.
•Preventive maintenance to avoid break down.
•Preparedness for break down to reduce down time.

ENGINEERING SERVICES
Hospital Engineering services are the life line
for a smooth functioning of the hospital.
Engineering services are broadly classified as

1
CIVIL ENGINEERING

ELECTRICAL ENGINEERING

2
ELECTRICAL ENGINEERING –Electricity supply

ELECTRICAL ENGINEERING –Power and Voltage

•Switchgears & Control panels are inside in a shaded / dust free environment
•Proper earthing should be provided
•Dual supply should be provided in emergency, OT, ICU etc
•Standby Noise free DG sets with SEB, SPCB approvals
•One electrical circuits for 10 lights / fan points and One power circuit for two 15 amps
sockets / 1800 watts
•Use of Appropriate MCB
•Steel conduits will be more than PVC tubes ensure more protection against fire.
•No Socket/Switches in anaesthetic store room
•Illumination standards to be different for different areas such as High illumination in
Admin offices, Nursing station, Dietary store, Examination rooms.

ELECTRICAL ENGINEERING –Lift

3
ELECTRICAL ENGINEERING –AC & REFRIGERATION

MECHANICAL ENGINEERING

BIO MEDICAL ENGINEERING

4
ENVIRONMENTAL ENGINEERING

ENVIRONMENTAL ENGINEERING –water supply

ENVIRONMENTAL ENGINEERING –Waste water disposal

5
CHIPS (Computerized Hospital Information Processing System)

Computer and Information Technology Engineers have emerged as an important

Engineering group, who cater to the Data Management needs of the hospital.

6
Telecommunication

7
The use of digital information and communication technologies to access health care
services.

STANDARDS FOLLOWED FOR CIVIL ENGINEERING DESIGNS

The Hospital being a specialized establishment for providing Patient care, its
infrastructure not only needs to satisfy all the statutory norms, but also needs to meet
some additional specialized requirements, which are closely linked to Patients care &
safety. Thus, by referring to Indian Standard & National Building Codes and various
guidelines, Facility Engineers can enhance the safety of the infrastructure and thus,
help in Enhancing Patient safety.

CIVIL ENGINEERING –Land development Standards

8
CIVIL ENGINEERING –Water Requirement Standards

MECHANICAL ENGINEERING –Air Ventilation Standards

In order to achieve air changes given above, we can plan the type of air ventilation need
for the respective spaces.

ORGANOGRAM OF ENGINEERING DEPARTMENTS

9
MAINTENANCE

•All Engineering Service Departments have their own maintenance Team for carrying
out various Maintenance Works.
•In order to prevent and to oversee the defects of each service, an maintenance team is
required.
Maintenance can be classified based on its requirement as

DAILY MAINTENANCE

•Daily / Routine maintenance refers to any maintenance task performed at regular, time-
based intervals that keep facilities operating smoothly.

•Routine maintenance can be as simple as making sure all bathrooms is stocked with
toilet paper at the end of every day or as complex as inspecting and adjusting heavy
machinery.

Examples:
janitorial tasks
Cleaning debris and excess lubricant from equipment

Emergency Maintenance
An emergency where immediate maintenance is essentially any repair that you need to
do immediately to keep people and assets safe. If left unattended, the damage could be
substantial and even hurt your bottom line and have reputational costs.
These situations have the possibility to cause a significant amount of loss, and it
sometimes is hard to get the emergency under control.

10
Examples:
•Fires
•A sewer line backing up into a unit or complex
•Air conditioning going out in extreme temperatures
•Elevators breaking down with people trapped inside
•Burst pipes
•Leaking roofs
•Gas Leaks etc

Planned Maintenance
Planned Maintenance covers any maintenance that is planned, scheduled, and
documented. It is specifically defined as preventive maintenance that is carried out
according to a set plan.

Break Down Maintenance

Breakdown maintenance is maintenance performed on equipment that has broken down
and is unusable.

Preventive Maintenance
Any break in any of the services may spell serious trouble of some or the other kind into
the Efficiency of the entire patient care delivery system of the hospital and that’s why we
have this Preventive Maintenance Program.

Preventive Maintenance is is defined as taking precautionary steps or actions to prevent

equipment failures before they actually occur. Preventive maintenance typically involves
routine inspections, upgrades, proper lubrication (where applicable), adjustments, and
replacement of outdated equipment or parts.

Advantages
 Increase Longevity of the system
 Ensures safety and Prevent hazards
 Prevent break in continuity of the system
 Prevent costly emergency repair

11
Preventive Measures against Safety Hazards –Common For all Branches

1. Prevention of Engineering Connected Safety Hazards:

This is achieved by following the steps below:

1. To manage the Engineering services, with full efficiency and effectiveness, the hospital
requires a full department of engineering services with adequate fully trained staff
including qualified Engineers.

2. The department should be headed by senior well qualified Engineers with vast
exposure in the relevant field of Engineering.

3. Adequate supervisory and other staff in all branches should be available to attend to
problems round the clock.

12
4. Availability of a documented Quality manual with clearly defined role and scope of
services of the engineering department and the policies and procedures covering every
aspect of their activities.
5. A procedure for detection/reporting of defects and their repair/maintenance with the
minimum possible downtime and fixed minimum time frame for restoring the facility to
operational state.
6. A check list of all the legal compliances and a mechanism for ensuring regular
updating of the Licenses/registrations/Certifications.
7. A comprehensive equipment management program and a system of equipment audit.
The records of proceedings including the audit points and corrective actions are to be
maintained.
8. An updated inventory of all the equipment and a comprehensive history sheet in
respect of each and every equipment unit.
9. A standardized system and format for registering complaints giving the details of:
i. Ward/ department
ii. Details of the equipment
iii. Details of the defects
iv. Urgency involved (routine/urgent/immediate)
v. Date and time of complaint
vi. Authentication by the complaint.
10. A record of breakdown complaints and the response time for attending to
complaints (restoration of operational status) is to be maintained and monitored.
11. Regular periodic Inspection and Re-Calibration of the Equipment by Authorized
Agencies.
12. Adequate potable water supply round the clock with 3 days reserve and a system of
regular periodic testing of water samples at the source as well as at the user end.
13. Planned periodic cleaning of AC ducting and cleaning/replacement of filters.
14. Availability of a Fire safety Manual with a check list of actions to be taken by the
staff during Fire/other emergencies.
15
a. It is to be ensured that Up to date floor plans along with the Escape routes
are available, the escape routes are kept free of any obstacles and there is a documented
plan for safe escape of Patients, Public and Staff during a Fire or other Emergencies.

13
 b. Operational readiness of the equipment is ensured by regular periodic
inspection and planned preventive (and breakdown) maintenance of all fire safety
equipment.
16. Hospital safety committee has to regularly inspect the facilities at least twice a year
and after a detailed exercise in Hazard Identification and Risk Analysis (HIRA)
Submit their findings and recommendations in writing. A record, including the actions
taken, is also to be maintained.
In CMC we have a Committee and inspection will be done once in every month
17. There should be a documented system of periodic inspection and Planned
Preventive (and breakdown) maintenance and risk reduction in respect of each of the
following facilities/services.
a. Buildings and environment for loose stones/ plaster/ slates, bricks.
b. Electric supply and distribution system including the diesel generator (DG)
sets UPS systems and stabilizers: No loose hanging wires or temporary
connections to be allowed.
c. Water supply and distribution system including the supply of hot, cold, potable,
ultra pure water and steam supply: - There should be no dripping taps, leaking
pipes or blocked sewage lines.
d. Air conditioning and refrigeration facilities.
e. Centralized gas and vacuum supply service.
f. Communication system.
g. Traction/transportation system.
h. Lightening Protection-Periodic testing of patency of Earthing.
i. Public health engineering system (waste storage/disposal, effluent treatment
plant).
j. Proper earthing of all electric equipments.
k. Periodic checking of all switches/ sockets to ensure their adequacy and hazard
free functioning.
2. Prevention of Hazards Related to Construction / Maintenance Activities:
 Construction and maintenance activities are activities that temporarily throw the
system out of gear and disrupt the normal functioning for a variable period.
 Any demolition/new construction may mean temporary change of entry/exit
routes, spread of debris or building materials here and there, disconnection of

14
 electric cabling, shutting down the power supply or water supply or
communication lines.
 It also has the hazards of accidental fall of construction materials on the patients,
public or staff nearby, leading to serious injuries.
 In order to prevent any disruption of normal functioning and its adverse effects on
the health and safety of people, the Management and the Engineering services
shall make the following arrangements.
1. Plan the activities in advance in a phased manner to ensure minimum
disturbance of the normal functioning of the services.
2. Put in place and test the alternate arrangements before actually starting the
activities.
3. Inform all concerned departments about the activities and their timings well in
advance and also the changes necessary in the system of functioning.
4. Ensure that the people are fully protected from any possible/accidental injurious
effects of demolition/construction activities by creating barriers to dust, noise, falling
materials.
5. Ensuring that the maintenance activities are started only after making all spares/
equipment/tools available, so that they can be completed as per the schedule.
6. Timings for such activities may be adjusted so that they have minimal disruptive effect
on the patient care activities.
7. If necessary, suspending some of the services or shifting locations/timings, as an
interim measure.
8. Placing warning signs and directional signs wherever indicated.
9. Any other measures necessary to ensure safety of patients and their
safe/uncompromised treatment.
Construction and maintenance activities do have an adverse impact on the Life Safety
Systems in the hospital.

CONCLUSION
Hence, it’s clear that the Role of Engineering Services plays an extremely vital service
on` the efficiency of the entire Patient care delivery system of the hospital’.
And it is also evident that the Facility Engineers are responsible for the Design,
Detailing, Inspection, repair and maintenance of all the facilities and services mentioned
above to ensure their optimum operational reliability and reduction / Elimination of any
risks associated with them

15
 Hospital Operations Management HHSM ZG614
NURSING SERVICES & WARD MANAGEMENT
Mrs.Lillian Percy Kujur
Deputy Nursing Superintendent

Nursing services
Nursing services refers to the department of the Christian Medical College managing the
Nursing task forceof the hospital.
The Office of the Nursing Superintendent, known as Nursing Service Office (NSO) is the
central hub for all nursing care activities.

Nursing Administration
Is the strategic management of nursing personnel, patient care, and facility resources
through the support of regulating policies.

Levels of nursing management

1
Elements of administration –POSDCORB

1. Planning
A plan is a future course of actions. Planning involves selecting objectives, policies,
strategies, programmes for the nursing services.

Role of nursing administrator in planning

•Laying down the vision and mission of Nursing Service and the Institution
•Representation on committees such as Administrative committee, executive committee,
quality steering committee, safety steering committee, budget management etc.
•Planning of human resources, equipment, infrastructure etc.

2
VISION
‘Christian Medical College seeks to be a witness to the healing ministry of Christ through
excellence in education, service and research.’
MISSION
‘The primary concern of the CMC, Vellore is to develop through education and training,
compassionate, professionally excellent, ethically sound individuals who will go out as
servant-leaders of health teams and healing communities’.

VISION:
The Nursing Service of the CMC, Vellore seeks to provide Christ Centred,
Compassionate, holistic state of the art quality patient care through nurses excelling
professionally in practice, education, management and research

MISSION:

 Committed to care for patients and their families in the physical, psychological,
social and spiritual dimensions maximizing the potential for health and
productivity or maintaining the patient's comfort and dignity until death.
 Strives to develop Nurses personally and professionally to be of sound faith,
integrity, ethical conduct and responsible to our society
 Advocates the mandate of Christ to excel by developing nurse leaders who will
impact nursing practice through diligent management, education and research

OBJECTIVES
•To practice the art and science of Nursing in the spirit of Christ
•To provide promotive, preventive and curative care to patients irrespective of their
caste, creed and socioeconomic status with compassion
•To equip the practising Nurses with the knowledge, guidance and resources required to
provide holistic, evidence based care

3
2. Organization

•Process of developing physical, informational, and human resources as per plan.

Organizing involves the grouping of activities necessary to accomplish goals and plans,
the assignment of these activities to appropriate departments and provision of authority,
delegation and coordination.

PRINCIPLES OF ORGANIZING

4
•Hierarchy or chain of command –it means the rule or control of higher
over the lower.
•Span of control –refers to the number of subordinates a manager can effectively
manage.
•Integration (unification) vs disintegration (diversification)

•Centralization and decentralisation

Centralisation refers to the concentration of

authority and decision making in one single
position in the organization
Decentralisation – is one in which the lower
levels are allowed the discretion to decide
most of the matter

•Unity of command –An employee must get orders from one superior only.

5
•Delegation–assignment of the work to subordinates

Delegation of activities

•Centralization: Activities such as recruitment, human resource planning, disciplinary

action are centralized and acted upon by the Nursing Superintendent

6
•Decentralization: Day to day activity planning, staff development and training are
handled by the Department Heads and the Nurse Managers

Nursing Superintendent in the Organization

NSO ORGANOGRAM

7
The Nursing Superintendent is also assisted by the following administrative members:

Associate Nursing Superintendent 1-Human Resource management

Associate Nursing Superintendent 2-Peripheral area management

Deputy Nursing Superintendent 1-Quality management

Deputy Nursing Superintendent 2 -Material management

Deputy Nursing Superintendent 3 -In-service education

CATEGORIES OF Nursing personnel

3. Staffing
It involves manning the organizational structure through proper and effective selection,
appraisal and development of nursing personnel.

8
The staffing process includes:

Recruitment and placement

• Competency based training program

• Placement based on appropriate

experience

• Induction training

Education and training

9
Performance appraisal

•Every 3 months-2 yrs

•Every 6 mo-1 yr

•Every year-confirmed staff

10
Staff welfare

•Organize welfare activities of staff –curricular and extracurricular activities

•Protecting the rights of staff
•Advocating for Nursing Staff
•Formulate policies related to staff welfare

1. Communication–It is the process of sharing and transferring the information

between nurse managers and their subordinates
2. Supervision–involves guiding the efforts of others to achieve stated work output
3. Motivation–is the desire to act and move toward a goal
4. Leadership –it is a continuous process of influencing and supporting subordinates
to work enthusiastically towards achieving goals

11
5. Co-ordination
It is the act of synchronizing and unifying individual staff efforts for better action to
achieve organizational objectives.

Types of coordination

12
6. Controlling
It is the measuring and correcting the performance or the activities of staff as per
expected performance.
Steps of control
Standards are determined
Actual performance is measured
Actual performance is compared with standards
Appropriate corrective actions are taken

Standards of care

Capturing of quality indicators

•Pressure sore
•Medication error
•Falls
•Extravasation
•Accidental de-lining
•Skin tear –Medical Adhesive Related Skin Injuries, Cautery burn
•Needle stick injury

13
7. Reporting and Recording
Reports are oral or written exchanges of information shared between caregivers or
workers in a number of ways.
A report summarizes the services of the person, personnel and of the agency
Reports are written usually daily, weekly, monthly or yearly.

8. Budgeting
Budgeting process is a systematic activity that develops a plan for the expenditure of a
usually fixed resource during a given period to achieve a desired result.

Budgeting is the allocation of resources (human, material and financial) to best assure
the accomplishment of nursing organizational goals.
Operating budget –daily activities and services including patient care revenues, labour
costs, outside purchase services, supplies etc.
Capital budget –money earmarked for the purchase of permanent equipment or major
renovation, construction projects

14
Florence Nightingale
To be in charge is certainly not only to carry out the proper measures yourself but to see
that everyone else does so too.

•Ward management is a process whereby the ward manager through people and with
people makes use of ward resources to achieve ward objective. Kozier, Erband Burk
(2011)
•Ward manager -a person responsible for the management of a hospital ward.

Objectives of Ward Management

 To foster team spirit in the ward that will provide highest quality healthcare
services.
 To provide a clean, well ventilated environment, free from infection, accidents
and hazards for patients.
 To provide facilities that meet the needs of patient and their attendants.
 To optimally utilize ward resources for maximum output.
 To encourage personnel training, job satisfaction and advancement for
patient care.

15
Factors influencing ward management
Ward management is one of the prerequisites for good nursing care. Nurse
Manager/Supervisor should understand the following thoroughly for good ward
management:
(1) Knowledge of the ward –duties and activities performed
(2) Planning the schedule of the ward –to save time
(3) Starting the work on time
(4) Preventing interruptions
(5) Establishment of ward routines for delegation of work
(6) Use of democratic method in establishing ward policy –to encourage staff
participation as it will enhance the cooperation
(7) Orientation of new personnel to hospital and unit –induction training is a must for
new staff
(8) Maintenance of suitable environment

MANAGEMENT OF ENVIRONMENT
1. Adequate Lighting
2. Prevention of Noise
3. Elimination of unpleasant odors (Bad Smell)
4. Dust control
5. Safe water supply
6. Safe disposal of waste

16
 7. Freedom from insects
8. Provision of adequate privacy
9. Prevention of cross infection
10. Control of visitors

(9) Providing supplies and equipments

For good management, all materials (supplies and equipment) should be:
 Free from repair
 Accessible
 Conveniently located
 Maintaining standard
 Maintaining good exchange system
 Maintaining good inventory and requisition

17
10. Clear cut and specific orders for medical therapy and
nursing
Clear cut doctors orders and nursing orders
help to :

11. Record keeping

 Maintain accurate records –has legal and scientific value

 Eg. Patient clinical records
 Administrative records
 Equipment records
 Personnel performance records

12. Reporting

18
 13. Morale
Refers to the confidence, enthusiasm, and discipline of a person or group at a
particular time. Maintenance of high morale among all members of the staff.

14. Establishment of good relationship

Establishing good working relationship within the ward and with other associates is an
essential factor in good work management.

15. Delegating responsibility

Delegation is the process in which a nurse directs another person to perform nursing
tasks and activities

19
 16. Assigning duties and responsibility
Methods of assignments

Patient method –a nurse is expected to give complete nursing care to one or more
patients.

Team method –several staff members under the leadership of a professional nurse are
assigned to a group of patients. Ideally the team cares for the patients throughout
their entire hospitalization

17. Time planning

The objectives are:
To provide adequate staff for good nursing care for 24 hours
To provide the best possible experience for nursing students
To comply with good personnel policies and keep nurses happy and contented

20
 18. Good teaching
For both the students and staff should be
ensured.
Incidental teaching
Clinical demonstration
Individual conference
Group conference

19. Good supervision

•Supervision is a cooperative relationship between a leader and one or more persons

to accomplish a particular purpose. -Lambertson
•It is a teaching learning process.
•Good supervision helps the individual nurse to set up objectives and attain it.

Espirit de Corps (union is strength)

States that an organization must make every effort to maintain group cohesion in the
organization.

21
 CMC
Vellore
Biomedical Equipment
Management in Hospitals
Please
Insert your
Photo Here
Arul Prakash
BE, MBA
Head of Biomedical Engineering

Christian Medical College Vellore

Serving the nation since 1900

 Learning objectives
CMC
Vellore

• In this session you will learn

• What is Biomedical Equipment Management?
• As a manager what you should know about Biomedical
Equipment Management program?
• What is the importance of such a program?
• What are the components of such a program?
• Importance of Inventory, Maintenance and Calibration
• Monitoring and improving such a program with quality
indicators
• Terms used in Medical Equipment Management like PPM,
Breakdown, Inventory, Calibration, AMC, , KPI, MDR, MDIR etc.,
 Biomedical Equipment
CMC
Vellore

• Biomedical Equipment or Medical Equipment or Medical Device plays a

vital role in hospitals as they directly impact patient care
• Biomedical Equipment are used for diagnosis, monitoring, life support,
treatment and therapeutic purposes
• Healthcare practitioner decides on the course of action based on the
results/outputs obtained from Medical Equipment
• Medical Equipment forms a combination from handheld devices such as
Glucometers, Pulse oximeters, Monitors etc, to major hi-end equipment
like Xray, CT, MRI, CATH Labs etc
 Life cycle of Biomedical Equipment
CMC
Vellore

Operation
 Biomedical Equipment Management Program
CMC
Vellore

• A Biomedical Equipment Management Program (BEMP) is a well

defined and structured plan of activities that covers the entire life
cycle of Medical Equipment from planning till disposal
• Medical Equipment are valuable assets to a hospital and hence needs
proper management and maintenance
• BEMP is an essential tool for efficient management of Medical
Equipment

World Health Organization:

Medical Equipment maintenance, when well planned, managed and
implemented, allows for all the equipment in a healthcare institution to be
reliable, safe and available for use when it is needed for diagnostic procedures,
therapy, treatments and monitoring of patients. It also has the ability to
prolong the useful life of equipment and minimize the cost of ownership
Ref: Medical equipment maintenance programme overview - WHO Medical device technical series
 Importance of Biomedical Equipment Management Program
CMC
Vellore

• Proper selection of Medical Technology

• Equipment reliability
• Equipment safety
• Equipment availability
• Minimize breakdowns
• Minimize maintenance cost
• Improves life of Equipment
• Improves efficiency
• Improves quality of care
 Hospital Biomedical Engineering
CMC
Vellore

• In order to implement such a program, you will require an in-house Biomedical Engineering
department (for large hospitals) comprising of Biomedical Engineers and Technicians with proper
testing equipment and tools
• For small hospitals and nursing homes with less number of Medical Equipment, the maintenance can
be outsourced or managed with 1 or 2 in-house Engineers/Technicians

Director / Head of Facilities

/ Chief Engineer

Head / Manager - Biomedical

Dy. Head / Dy. Manager

Section 1 Section 2 Section 3 Section 4

Engineer / Engineer / Engineer / Engineer /
Supervisor Supervisor Supervisor Supervisor

Junior Engineers Junior Engineers Junior Engineers Junior Engineers

and Technicians and Technicians and Technicians and Technicians
 BEMP - Committees
CMC
Vellore

Biomedical Engineer will serve the following committees to implement BEMP or

in other words the following committees are part of BEMP
• Purchase committee
• Capital Budget committee
• Technology acquisition committee
• Quality & Safety committees
• Condemnation committee
 Components of Biomedical Equipment Management Program
CMC
Vellore

Selection of Medical Equipment /

Technology

New Equipment Acceptance process

Inventory Management

Maintenance Management
Biomedical Equipment
Management Program Calibration and Testing

Annual Maintenance Contract

Management

Stock Management

Training & skill development

Condemnation - Disposal
 Components of BEMP
CMC 1. Selection of Medical Equipment / Technology
Vellore

• Selection process should be done collectively by a committee or team comprising of

• Admin / Representative
• Purchase Manager
• Finance Manager
• Biomedical Manager
• Clinicians / Surgeons / Nursing
• Policy and procedures for Equipment procurement / Replacement
• End user requirements / specifications
• Available technologies / choices / vendors
• Tendering / quotations / technical / commercial comparisons
• Short listing & negotiations - commercial, warranty, terms & conditions
• After sale service and Annual Maintenance contracts
• Maintenance and operational cost / spares cost
• Availability of other support services (Space, Electrical, UPS, AC etc.,)
• Statutory & Legal requirements (Licenses, Approvals, PNDT, AERB etc.,)
• Final approvals – procurement & logistics
 Components of BEMP
CMC 2. New equipment inspection, installation, acceptance & testing
Vellore

• Pre-installation testing : All new equipment should be inspected and tested for
acceptance
• Equipment should be installed / tested in the presence of Biomedical Engineer
• Electrical safety testing & Functional testing to be done and recorded
• Service and Technical manuals
• Factory calibration & testing certificates
• Trainings for End user / Operator / Biomedical Engineer
• Inspection report format
• Records and documentation (File / Software)
• Equipment hand over for patient use after inventory
 Components of BEMP
3. Inventory Management
CMC
Vellore

• As an Administrator / Manager you should know how many Medical Equipment are in use,
how many should be replaced, what is the maintenance cost for an equipment etc.,
• Hence all Medical Equipment should be inventoried
• An unique ID number can be provided to each Medical Equipment
• This inventory system will be of immense help to
• Identify and track each equipment
• Purchase details
• Maintenance history
• Cost of ownership
• Spares replaced details
• Analyze breakdowns
• Age of equipment
• Capital budgeting
• Asset control
 Components of BEMP
4. Maintenance Management
CMC
Vellore

• There are two types of maintenance

• Planned Preventive Maintenance (PPM)
• Breakdown or Corrective Maintenance (BM / CM)
• PPM should be scheduled for each piece of equipment based on its inventory and location
• PPM should be carried out as per manufacturer’s recommendations
• PPM helps to reduce breakdowns
• Helps to plan for spares or kits replacement in advance
• Regular PPM ensures safety and reliability
• Improves efficiency and life of equipment
• BM or CM is unexpected or sudden failure of equipment which requires corrective action in order to
get it functional
• Proper stock of spares should be maintained
• Should have service/technical manuals
• Staff should have been trained on servicing
• For AMC equipment, the service provider should respond within response time
• For both PPM and BM, proper records should be maintained. All activities should be recorded
• In CMC we have online reporting system for breakdowns that captures events with time
• CMMS software records all maintenance activities and details can be retrieved anytime
• PPM and BM month reports should be sent to Management every month
 Components of BEMP
5. Calibration and Testing
CMC
Vellore

• Calibration in its simplest terms, is a process in which an equipment’s (DUT) accuracy is compared with
a known and proven standard (Master device)
• Calibration and testing is part of maintenance and should be performed at regular intervals
• Calibration is mandatory and should be performed as per manufacturer’s recommendations /
standards
• Calibration can be performed in-house or can be performed by authorized agencies
• Calibration is essential for accreditation processes (NABH/NABL/JCI)
• Testing includes functional testing and electrical safety testing
• Equipment should be tested and calibrated after repair or spare replacement
• Calibrated equipment can be labelled with details of due date etc.
• Calibration and test reports should be stored in CMMS against inventory number
 Components of BEMP
CMC
6. Stock Management - Spare & Accessories
Vellore

• Stock of spares / accessories required for PPM/BM should be maintained

in central stores or biomedical stores
• Inventory of stock should be monitored
• Stock inventory should be updated during receipt and issue
• Spares should be issued against inventory number and work order
• Standardization of equipment models will help to reduce the investment
on spares
• Standardization will also help to optimize spares utilization and better
control over stock management
• Standardization will help to salvage spare from similar condemned
equipment
 Components of BEMP
CMC
7. Annual Maintenance Contract Management
Vellore

• There are 2 types of maintenance contracts

• Comprehensive Annual Maintenance contract
• Labour Annual Maintenance Contract
• AMC should be negotiated along with equipment purchase
• AMC will start after expiry of warranty
• AMC agreement should have PPM/BM visits
• Response time for BM calls should be defined
• End user / BME should ensure that the scheduled PPM are carried out
• End user / BME should ensure that BM calls are attended within
response time
• All AMC related activities should be recorded in CMMS to find the
compliance of services provided during the period
 Components of BEMP
CMC
8. Training and skills development
Vellore

• Periodical training is essential for end user as well as biomedical engineer

• There are 2 types of training
• Application training
• Technical or service training
• End user or operator should be given application training during new installation and
upgrades on how to operate the equipment
• Technical or service training should be given to biomedical engineering staff
• Only trained personnel should operate or service an equipment
• Training ensures error free operation, gives confidence to operate equipment and helps
to save time
 Components of BEMP
CMC 9. Condemnation and Disposal
Vellore

• Equipment can be condemned or removed from service if

• Unrepairable or non functional
• Beyond economical repair, Service and spare cost is more
• Clinically obsolete
• Technically obsolete
• Manufacturer has given end of life or support
• Condemnation check to be performed and certified by Biomedical Engineer /
Vendor
• Necessary support documents to be obtained
• Condemnation committee should assess all factors, equipment history and
then approve for condemnation/disposal
• Condemned equipment should be removed from inventory or in-use list
• Condemned equipment should be disposed properly as per guidelines
• If similar models are still in use, then condemned equipment can be retained
for spares salvaging
 Medical Device Recall
CMC
Vellore

What is Medical Device Recall (MDR)?

When a company learns that there is a problem with one of their medical devices, it proposes a correction or
a removal depending on where the action takes place
FDA uses the term “recall” when a manufacturer takes a correction or removal action to address a problem with
a medical device or group of device that violates FDA law. Recalls occur when a medical device is defective, when
it could be a risk to health, or when it is both defective and a risk to health.
A medical device recall does not always mean that you must stop using the product or return it to the company.
A recall sometimes means that the medical device needs to be checked, adjusted, or fixed
Who recalls medical devices?
Manufacturer, distributor, or other responsible party
What does the FDA Do about Medical Device Recalls?
FDA classifies and monitors the recall to ensure that the recall strategy has been effective. Only after the FDA is
assured that a product no longer violates the law and no longer presents a health hazard, does the FDA
terminate the recall
How does the FDA Notify the Public about Medical Device Recalls?
FDA posts information about the action in the Medical Device Recall Database.
FDA may post company press releases or other public notices about recalls, market withdrawals, and safety
alerts
FDA notifies the public in the weekly Enforcement Report
For more information visit: US Food and Drug Administration website
 Medical Device Incident Reporting
CMC
Vellore

What is Medical Device Incident Reporting (MDIR)?

Medical Device related adverse events, injuries or deaths are reported to regulatory authorities in
order to monitor and take corrective actions for the affected device or to alert the potential hazard
in using the device
• Each county will have its own MDIR system (online reporting)
• India - Drugs Controller General India launched Materiovigilance Program of India (MvPI) at
Indian Pharmacopeia Commission (IPC), Ghaziabad on July 6, 2015. The fundamental aim of this
program is to monitor medical device-associated adverse events (MDAE), create awareness
among health-care professionals about the importance of MDAE reporting and generate
independent credible evidence-based safety data of medical devices and to share it with the
stakeholders
• The MvPI aims to enable data collection and evaluation in a systematic manner so that
regulatory decisions and recommendations on the safe use of medical devices in India can be
evidence-based

For more information visit: Central Drugs Standard Control Organization

 Quality Indicators and Reports
CMC
Vellore

• Biomedical Equipment Management program should be reviewed periodically

• The performance of BEMP can be measured by having proper Quality Indicators or Key
Performance Indicators like
• Ratio of PPM
• Ratio of BM
• Response Time Monitoring
• Trend Analysis of Breakdowns
• Fault Index Analysis of Critical Equipment
• Quarterly reports of Quality Indicators, MDR, MDIR etc., should be submitted to
Management, Quality and Safety departments
• Monitoring, Reporting and Periodical review of BEMP will help to improve the program
 CMC
Vellore
 Hospital Operations Management HHSM ZG614

ICU Management

Dr. K. Subramani MD DA FRCA CST FANZCA EDIC FICCM

Senior Professor and Head
Surgical ICU
Christian Medical College
Vellore

FLORENCE NIGHTINGALE

Crimean War 1854

Reduced mortality from 20% to 2%

Challenging status Quo

Improving patient experience.

Improving patient outcomes

Evidence based practice

Teaching and Mentoring

PETER SAFAR

Advanced life support

1950

First Intensivist

First ICU in 1958 in the USA

1
MORE HISTORY

Bjorn Ibsen
Polio pandemic 1953
Monitoring for cardiac arrhythmias1960’s
Critical care nurses 1960’s
Intensivists1970’s
India moves forward 2010

CMC
Surgical ICU and Surgical HDU
Medical ICU and Medical HDU
NeuroICU
Cardiothoracic ICU
PaediatricICU
Neonatal ICU
Coronary Care Unit
Private block ICU (AICU)
ST ICU
Ranipet: Trauma / Medical / Neuro and CTVS ICU

CMC ICU’S

2
OVERVIEW

Structure
Equipment
Personnel
Function
Legal & ethical issues

STRUCTURE
Location
Size
Internal Structure
Non-patient areas
Utilities

Location
-Access
From the Casualty
From the operation theatre
To Radiology department
To lifts

Existing structure or new structure

Number of beds and size

10% of the hospital beds

Optimum number of beds: 6-12 per unit
General about 4%
Specialty up to 10%
Size
Patient care area 100 –125 sq feet / bed
Equal non-patient care area

3
Statistics

4
Internal structure
Patient Areas
Open vs cubicles
Isolation areas
Lighting

BED SPACE

5
SPACE

Space Behind The Beds

6
Isolation Areas

Too Crowded

Lighting

7
Location, Size, Internal structure
Non patient areas
Nursing Station
Visibility
Computers
Central monitoring
Desk space
Medication preparation

8
WORKING SPACE

Non patient areas

Storage area
•Linen

•Disposables

•Medications

•Equipment

9
10
Non –clinical areas

•Lounge / library / conference room / dining

•Changing room

•Toilet facilities

Location, Size, Internal structure

Non patient areas

Non –clinical areas

Utility area

Visitor area
Adequate area –Indian Culture
Toilet facilities
Telephone (?)
Counseling room

11
Therapeutic Equipment

Ventilators
Infusion and syringe pumps
Defibrillator
Dialysis equipment, balloon pump, etc

12
Bronchoscope
ECMO
Diagnostic –point of care equipments
ECG
Blood gas analyser
Echo cardiogram and Ultrasound

Utilities
Electricity
Mains
UPS backup
Medical gases
Water
Adequate quantity

POWER

EQUIPMENTS

13
OVERVIEW

Structure
Equipment
Personnel
Function
Legal & ethical issues

PERSONNEL

Medical
Non-Medical
Nurses
Allied Health
Respiratory therapists
Physiotherapists
Nutritionist
Pharmacist
Dialysis therapists
Counselors
Biomedical Engineer
Clerical
Attenders, Sweepers etc

PERSONNEL

Medical
Medical Director

Senior Medical Personnel

Junior consultant

Trainee Medical Officers

Medical Director
Coordination of medical care
Administrative responsibilities

14
PERSONNEL ISSUES
Discipline
Conflict
Retention
Motivation

OVERVIEW
Structure
Equipment
Personnel
Function
Legal & ethical issues

15
DIFFERENT ASPECTS OF FUNCTION
Type of Medical care
Gate keeping
Infection control
Protocols
Records & audit
Research & education

TYPE OF ICU
Open
Closed
Transitional

LEVELS OF CARE
Level 1
Level 2
Level 3

ADMISSION AND DISCHARGE CRITERIA

Necessary for an ICU running at or near capacity

Clear Written

GATEKEEPING IMPERATIVES
Give all salvageable patients a chance
Keep theatre schedules going
Keep Casualty open
Maintain quality of care
Pacify fellow physicians

INFECTION CONTROL
All personnel all the time
Training, monitoring
Good microbiology support
Good sterile supply

16
ACCESS CONTROL

ROUTINE CARE

All regularly carried out interventions should have written protocols
-Minimize error
-Junior / new personnel
-Breaking protocol justification
-Regularly reviewed and revised

CHECK LIST 1

17
ACADEMIC ACTIVITIES
Teaching

-Improve patient care

-Improve personnel
-Improve morale
Research

TRAINING

18
RESEARCH

DIFFICULTIES IN MANAGEMENT

Physicians preferences
-Treatment
-Admission / discharge

DIFFICULTIES IN FUNCTION

Maintaining standards
Treatment standards
Antibiotic stewardship
Infection control

Administrative pressure
-Financial
-Bed availability

ANTIBIOTIC STEWARDSHIP

19
ECONOMICS

20
 OXYGEN CHARG

(A) TYPICAL BILL

TRAUMA POST-OP

21
TRAUMA, NO SURGERY / VENTILATION

ROLE DURING EMERGENCIES

Mass casualty
Pandemics
Case load
Triaging
Treatment area
The increased case load
Existing load
Manpower
Existing
Secondment
Training
Support
Equipments
Disposables and drugs
Oxygen …..
Sedatives etc

22
COST REDUCTION & MAINTENANCE OF QUALITY

Sampling and Flushing

23
Sampling – The VAMP System

Commercial Custom Designed

Closing The System

24
Closed System

Closed System Sampling

Local Initiatives

25
Covered Probe

Custom Designed Drape

26
Full Drape – Double Procedure

Equipments

Ethical Issues

Primarily
Lack of Physical Resources
Financial Constraints
Lack of awareness

Quality

Mortality:
Standard Mortality Rate
Actual mortality / Expected mortality
>1, 1, <1
0.8 for SICU
0.3 for trauma ICU
27
Morbidity
Pneumothorax
Acute Kidney injury
Bed sore

Operational procedure:
Length of stay
Compliance
ICU readmission

Errors and patient safety:

Medication errors,
Adverse events,
Fall
Re-intubation rate
Needle stick injury Infection control:
Ventilator Associated Pneumonia, Blood Stream infection, Urinary Tract
Infection
Employee satisfaction
Patient / Family satisfaction

Medical Awareness

Duty to family
-Explanation, Prognosis
Capacity to understand

CONCLUSION

Intensive Care is a very complex environment
Deals with the sickest patients
Outcome may not always be favorable
High costs
Ethical considerations
Highly skilled personnel
Burnout

28
 Hospital Operations Management HHSM ZG614
Operation Theater MANAGEMENT
Pranay Gaikwad
DNB, MNAMS, DMAS, FMAS
Professor & Head
Department of Surgery Unit 1 – General and Head & Neck

Outline
Background
• Aim
• Components
• Structure
• Environment

Background
Theatre: a place for dramatic performances

1
Historical Surgical Operating Theatre

Aim
Provision of an environment that is:
• Safe
• Efficient
• User-friendly
• Free from bacterial contamination

Components
• Structure
• Environment
• Organizational responsibilities

Structure
Location and relationship to other facilities
• On the 1st floor
• Close to ICU on the same floor
• A&E on the ground floor
• Radiology on the ground floor
• Single suite
• Multiple separate units

2
Plan of the Suite
• Concrete with metal frames
• Jointless floors and walls
• Easy to clean mellow plastic paint, 3 m height
• PVC terrazo anti-static waterproof floor
• Space
• free floor space 50 m2
• Supporting facilities 150 m2

Supporting Facilities
• Office administration
• Reception
• Changing room with lockers
• Toilets
• Conference/ classrooms
• Lounge
• Scrub room
• Anesthesia room
• Recovery room
• Optional
• X-ray and Dark room
• Laboratory
• Pharmacy

3
4
5
 Outer Protective Zone

Intermediate Zone
Between reception and suites approached by inside and outside staff
 Counter
 Storage areas
 Facility to handle waste, linen
 Pharmacy, lounge, class room, sterile supplies
 Recovery room

6
 Inner/ Restricted Zone
Anesthesia room (induction)

• Advantages
• Patient comfort
• Free from disturbance
• Quick turnover
• Immediate recovery

• Disadvantages
• Duplication of equipment
• Transfer of unconscious patient
• Scrub room
• Operating room
• (X-ray & Dark room)

Scrub room
• A section of OR
• Antiseptic hand wash (wall mounted, no-touch)
• Water sinks, drainage

Changing area
• 10 m2
• Close to scrub area

Operating Room
• 50 m2
• Sliding doors
• Waterproof Electrical Supply
• Central supplies with piping
• Scavenging of gases
• Light
•400 lux (general)
•40,000 -50,000 lux (focus)
•8,000 - 10,000 lux (depth)
• AdjusTable
• Electrocautery - 400 MHz

Recovery Room

Environment

7
Cleanliness with periodic surveillance

• Volume of work
• Number of personnel
• Duration & magnitude of cases
• Ventilation

Microbiologically
• Empty OR < 35 CFU/ m3
• <1 CFU/ m3 clostridia or < 30 CFU/ m3 Staph. au.
• During Surgery <180 CFU/ m3
• <20 CFU/ m3 at periphery or < 10 CFU/ m3 at center

Ventilation
• 100% fresh air circulation
• Air conditioning without exhaust fan can spread infection
• Air flow
• Air change

Air Flow
• From clean to less clean area
• 0.28-0.47 m/s in ultra clean not < 0.2 m/s
• Surgical area - High pressure
• Disposal areas - Lowest pressure
• Horizontal Air Flow
• Directional mechanical weighted valves
• Charnley’s tent
• Vertical flow

8
9
 Air Change

• 20-40/ hr
• Inlet
• 5 μ filters(HEPA) in AC duct at inlet
• Outlet
• At floor level for heavy gases to escape
• Scavenging system/ WAGD
• Anesthetic gases

10
 Temperature & Humidity

Septic/ Isolation Rooms

Air lock facility

Class S
• Standard-of-care
• Contact or droplet isolation
Class N
• Air borne droplet nuclei isolation
• Pressure - Room: -30 Pa; Ante-room: -15 Pa
Class P
• Profoundly immunocompromized
• Pressure - Room: +30 Pa; Ante-room: +15 Pa
Electrical Equipment
• Anti-static floor material
• Electrical sparks and fire hazards safety
• Sockets number and earthing
• Hazards made aware of warning signs
• Good Artificial Lights
• Alternate Power Supply 25%
• Generator/ invertor/ UPS
• Non-inflammable gas mixtures

11
 Service Lines

Teaching and Documentation

• Photography
• Videography
• Two-way communication to class room
• Conferencing

Day Care Theater

Concept
• Minor operations do not need hospitalization
• Save
• Time
• Space
• Staff
• Cost-effective
• Pain relief may be inadequate
Organization Responsibilities
Optimal utilization
Provision for emergency operations
OR supervisor
• Plans day-to-day running
• Maintains good rapport between staff and utilizers

12
Surgical Emergencies
Forms duly filled
Discussion by
• Surgical team, anesthetists and nurse in-charge
Cancellation
• Waste of time of OR and supportive services
• Dislocation of patient and relatives
• Building up of cases in the ward/ A & ED
• Strain on interpersonal relationships

Transport of Patients
Timely
Comfortable
Proper screening in the ward and at reception
Surgical Safety

13
Usual areas of deficiency in OTs
1. No reception area.
2. No separate rooms and change rooms for
 Surgeons
 Anaesthesiologist
 Jr. doctor
 OT attendants
3. Inappropriate size & type of doors etc.
4. Lack of laminar flow & mandatory air exchange systems
5. Lack of standard OT protocol.
6. No separate Central Sterile Supply Department (CSSD)
7. Waiting Area – Recovery - Not well equipped
8. Lack of basic amenities

Improving Care
Interaction within the OR to avoid tensions
• Doctors
• Nurses
• Attenders
• Janitors
Good communication with the ward
Definition of Emergency
Prevention of cancellation of cases

Interaction with other services

Wards
ICUs
Maintenance Department
• Electrical & engineering
Purchase & Stores
Radiology/ Labs/ Blood bank
Pathology
Pharmacy

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OR Committee

Representatives of all OR Users

• Surgeons, anesthetists, nurses, hospital administrators
Committee Meetings
• Frequent
• Policies
• Priorities
• Protocols
• Responsibilities
• Cost-benefit
• Expansion

Challenges during the pandemic

Initial strategy

• Segregate patients according to COVID-19 status

• Best bring the patient from suspect category to positive / negative
• Segregate procedures according to Aerosol generation risk
• PPE protocol accordingly to conserve use of PPE
• Negative and Positive OR (Negative pressure OR – Ducted to exterior through HEPA
filter)

15
Subsequent strategy

•Universal N95 use – 3 use for Non-COVID areas and single use for suspect/COVID
areas
•Subsequently – Green, Orange and Red zones
•Green – Negative zone
•Orange – Suspect zone
•Red – Positive zone

16
Red zone

Broad principles

Break transmission
Social distancing
Be mindful of crowded places - OPD, ward and ICU waiting area,
Casualty
Conserve resources
Hospital and ICU beds
PPE for patients and health care professionals (HCPs)
Respirators, equipment, ventilators etc.
Protect yourself
PPEs before patient contact
Alcohol based hand rub/Hand washing
Provide appropriate and timely surgical care
Non-operative management, if possible
Wait for COVID-19 tests in suspected patients if available
Avoid operating at night, due to limited staffing
Avoid Aerosol generating procedures (AGPs)
always use N95 masks and full PPE
No concrete evidence for Lap vs Open
But Avoid Laparoscopy if possible (pneumo, valve leak, etc. causes aerosolization)

17
Aerosol Generating Procedures (AGPs)

Intubation
Extubation
Tracheostomy insertion and care
NG tube insertion
UGI Scopy
NPL Scopy
Electrocautery
Pneumoperitoneum

Donning & Doffing

Further Reading
• http:/ /healthfacilityguidelines.com /ViewPDF/View IndexPDF
/iHFG_part_b_operating_unit
• https://www.who.int/patientsafety/safesurgery/ss_checklist/en/
• https://www.nabh.co/Announcement/RevisedGuidelines_AirConditioning.pdf

18
 Hospital Operations Management HHSM ZG614

OVERVIEW OF PHARMACY SERVICES

Topics to Discuss

History
Legal Requirements
Organization
Prescription
Purchase
Storage
Dispensing
Safe Disposal of Expired & Damaged Medicines

Management of Medication
The organization has a safe and organized medication process.

The process includes policies and procedures that guide the availability, safe storage,
prescription, dispensing and administration of medications.

Pharmacy Definition
Pharmacy is the science and technique of preparing as well as dispensing drugs and
medicines. It is a health profession that links health sciences with chemical sciences and
aims to ensure the safe and effective use of pharmaceutical drugs.

HISTORY
In olden days, drugs of vegetable, animal and mineral origin were more commonly
prepared. No medical and legislative control over their manufacture, storage or usage.

To control this activities Government of India, appointed a committee (The Drugs
Enquiry Committee) on 11thAug 1930 –Col. R.N. Chopra.

1
The main recommendations of the DEC are:
1. To form Central and State Pharmacy Councils to look after the education and
training of professionals.
2. To create Drug control machinery in central and in all the states.
3. To establish a well equipped Central Drug Laboratory (CDL)

In 1940, Government of India Tabled Drug Bill to regulate the import, manufacture, sale
and distribution of drugs in India. (Drugs and Cosmetic Act 1940 ). The Drugs and
Cosmetic Rules 1945.
To control and regulate the profession of pharmacy, Government brought the
pharmacy bill, 1945 finally adopted as the Pharmacy Act, 1948.

Drugs and Magic Remedies (Objectionable Advertisement) Act 1954 was passed and
enforced to control the advertisements.

Medicinal and Toilet Preparation (Excise Duties) Act 1955

Narcotics and Psychotropic Substances Act, 1985

Pharmacy –Part of Health Care System

After the appearance of Allopathic system, pharmacy and medicine professions got
separated. Pharmacists are no longer called compounders.
In addition to dispensing, pharmacist has to play an important role in Management,
Consultation , Planning and Establishment of proper pharmacy services.
Pharmacist is the liaison between the patient and physician

Functions of Pharmacist

Regulatory control and drug management

Community Pharmacy
Hospital Pharmacy
Clinical Pharmacy
Industrial Pharmacy
Academic activities
Training of other health care professionals

2
Code of Pharmaceutical Ethics

Are formulated by the Pharmacy Council of India for the guidance of Pharmacists
To guide the pharmacist as to how he should conduct himself in relations to himself,
his patrons, the general public, co professionals and members of the medical and other
health care professionals.

Pharmacist in relation to his Job

Scope of Pharmaceutical Services: Supply of commonly required medicines without

delay from licensed premises. Emergency supply of medicines at all times.

Conduct of Pharmacy: To preclude avoidable risk of error of accidental contamination

in the preparation dispensing and supply of medicine. The supply should made in the
presence of pharmacist.

Drugs and Cosmetics Act 1940 and Rules 1945

Objectives

To regulate the import, manufacture, distribution and sale of drugs & cosmetics
through license.
Manufacture, distribution, sale by qualified persons.
To prevent substandard in drugs.
To regulate the manufacture and sale of Ayurvedic, Sidda and Unani drugs.
To establish Drugs Technical Advisory and Board (DTAB) and Drugs Consultative
Committee (DCC) for allopathic and allied drugs and cosmetics.

Schedules

There are two schedules to the Drugs and Cosmetics Act, 1940.
1. First Schedule : Gives list of Ayurvedic, Siddhaand UnaniBooks.
2. Second Schedule : Standard to be complied with imported drugs and by drugs
manufactured for sale, sold, stocked or exhibited for sale or distributed.

3
Schedules to the rules

Schedule C –List of biological and special products.

Schedule C (1) –List of other special products

Schedule G –List of substances to be taken only under supervision of RMP.

Schedule H & H1 –Prescription drugs –to be sold by retail only on the prescription of a
RMP.

Schedule J –List of diseases and ailments which may not claim to prevent or cure.

Schedule M –Good Manufacturing Practice

Schedule N –List of minimum requirements of the Pharmacy.

Schedule P –Life period of Drugs

Schedule X –List of habit forming , Psychotropic and other such drugs.

Definitions
1.Drug Store–is a licensed premises for the sale of drugs, which do not require services
of a qualified person.
2.Chemist and Druggists-It is a licensed premises for the sale of drugs which requires
services of Qualified person but where the drugs are not compounded against the
prescription.
3. Pharmacy–It is a licensed premises for the sale of drugs which require services of
Qualified person and where the drugs are compounded against the prescription.

Sale of Drugs

Drugs and Cosmetic Act, 1940 restricts the sale of drugs only by license.

The license can be obtained from licensing authority appointed by the State
Government for the same.

Different licenses are required for wholesale, retail, motor vehicle sale, vendor sale etc.

4
Forms of Licenses

Conditions for Grant / Retention of Licenses

Form Adequate area
20/21 (Retail) 10 Square Meters
20 B/21 B (Wholesale) 10 Square Meters
20/21 & 20B/21B (Both) 15 Square Meters
ii) Equipped with proper storage for preserving the properties of the drugs –below 25⁰C
(as per Schedule P) can be achieved by providing air-conditioner.

iii) Qualification of a competent person

For retail
a) Registered Pharmacist

For whole sale

a) Registered Pharmacist or

b) Passed matriculation or its equivalent examination with four years experience

in dealing with sale of drugs or

c) Holds a degree with one year experience in dealing with sale of drugs

5
Particulars to be submitted for the Grant of Licenses

Form 19 dully filled with court fee stamp for Rs. 2/-for each License.
Declaration form
License fees of Rs.1500/-for each license paid through online mode (Online
application)
Partnership deed in Rs.300/-stamp paper
Rental agreement in Rs.20/-stamp paper for minimum period of 5 years with relevant
property tax receipt
Legal tenancy affidavit in Rs.20/-stamp paper
Blue print of the plan of the premises duly signed by Licensed Engineer, and the
applicant
Copy of Registration certificate of Pharmacist
Affidavit of registered pharmacist in Rs.20/-stamp paper
Copy of qualification and experience certificate of competent person
Passport size photo
Proof of Residence like copy of Ration card/ Driving License/ Voter ID card
Purchase bill for Refrigerator/working condition certificate
Premises shall be Air-conditioned
All documents shall be duly attested by Gazetted officer or Notary Public.

Conditions to be complied by the Licensee

A license in form 20 or 21 is granted provided licensing authority is satisfied that the
requirements for a pharmacy in Schedule N and following general condition such that
1. Adequate space
2. Equipped with proper storage condition
3. Qualified persons

Pharmacist has to maintain all the records and prescriptions of the drugs. The following
particulars should be entered in the register.
i) Serial number and date of supply
ii) Name and address of prescriber
iii) Name and address of the patient

6
iv) Name of the drug/ingredients and quantity
v) Name of the manufacturer, batch number, expiry date
vi) Signature of qualified persons

Schedule X drugs

The drugs specified shall be supplied only on a prescription of RMP. The supply drugs
shall be recorded at the time of supply in a register with following particulars

Date and purchase/transaction

Quantity received, name of drugs
Quantity supplied, Manufacturer name
Batch number, Expiry, Name and address of patient
Prescription reference number
Bill number and date
Signature of a qualified person

7
8
9
10
11
12
NARCOTIC DRUGS POLICY

A separate License for Narcotic and Psychotropic drugs are obtained from the District
Collector Office which is valid for one year from the date of Issue

List of Drugs stored in pharmacy under ND/RC License.

Morphine sulphate.10mg/ml,1ml, Inj.

Pethidine hydrochloride.50mg/ml,1ml Inj.
Fentanyl citrate, 100mcg/2ml, 2ml,Inj.
Fentanyl citrate, 500mcg/10ml,10ml,Inj
Fentanyl Patches,4.2mg
Fentanyl patches,8.4mg
Morphine sulphate tab.10mg, cr10mg, cr30 mg

•The Charge Nurse sends the Narcotic Drug request along with the empty ampoules and
narcotic prescriptions to Narcotic section before 10 am on all working days.
•The pharmacist checks request, prescriptions and the empty and receives.
•And makes entries in the registers and charges to the wards, packs the drugs and sends
to the ward through attendant.
•The charge nurse checks and signs the request

13
14
15
16
Pharmacy Department Organization

Functions of a Hospital pharmacy

1. Develop and maintain Standard Operating Procedures.

2. Purchase, storage, distribution and dispensing of drugs and pharmaceuticals to

patients.

3. Manufacture or compound tailor-made preparations that are not available in the

market or economical to the patient

4. Provide drug information to medical and other hospital staff.

5. Maintain strict control of Narcotic and Psychotropic drugs.

6. Inspect and maintain quality service in the hospital

7. Co-ordinate its functions with other departments and services in the hospital.

8. Participate in various Committees and Research activities of the hospital

9. Develop and maintain a Hospital Formulary.

10. Implement a continuing education program for medical, nursing and pharmacy staff.

11. Build up economic status of the hospital.

12. Establish and maintain adequate accounting procedures for all transactions.

17
History

Prescriptions have been in use since ancient times

Latin adopted as standard language

“Rx” = prescription

Definition - A prescription is a written, verbal, or electronic

order from a Registered practitioner to a pharmacist for a
particular medication for a specific patient.

Laws Governing Prescription

The heart of medication therap, lies the prescription; a legal document governed by the
following laws:-.

The Indian Medical Council Act, 1956

The Indian Medical Council (Professional Conduct, Etiquette & Ethics) Regulations,
2002
The Drugs and Cosmetics Act, 1940 and Rules 1945
The Pharmacy Act, 1948
The Narcotic Drugs and Psychotropic Substances Act, 1985 and Rules 1987
Drugs (Price Control) Order, 1995
The Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954 and Rules
1955

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Prescription Formatting

Heading

Body

Closing

Current Prescription Formatting

Heading

Name, address, and telephone number of the prescriber

Name, sex and age of the patient

Date of the prescription

Body
The Rx symbol
Name
dose size or concentration (liquids) of the drug
Amount to be dispensed
Directions to the patient

Closing
Prescriber’s signature

Refill instructions

Generic substitution instructions

19
Recommendations for writing quantity of drug:
a)Quantities of 1 gram or more should be written in grams. For example, write 2 grams.
b) Quantities less than 1 gram but more than 1 milligram should be written in Milligrams
For eg, write 100 mg, not 0.1 g
c) Quantities less than 1 milligram should be written in micro / nanogram as
appropriate. DO NOT abbreviate micro/ nanograms; since that can lead to Prescribing
errors. For eg. write 100 micrograms, not 0.1 mg, nor 100 mcg, nor 100 μg
d) If a decimal point cannot be avoided for values under 1, write a zero before it, for
example write 0.5ml not .5ml

List of dangerous abbreviations, and symbols

MINIMUM REQUIRED LIST

Abbreviation Potential Problem Preferred Term

U (unit) Mistaken as zero, four, or
cc
IU (international unit) Mistaken as IV or 10
Q.D., Q.O.D. Mistaken for each other.
Period after Q and O after
Q can be mistaken for “I”
Trailing zero and lack of Decimal point missed
leading zero
MS, MSO4, MgSO4 Confused for one another
Write “unit”
Write “international unit”
Write “daily” and “every
other day”
Never write a zero by itself
after a decimal point, and
always use a zero before a
decimal point
Write “morphine sulfate”
or “magnesium sulfate”

AMBIGUITY
Poor handwriting contributed to a medication
dispensing error that resulted in a patient with
depression receiving the antianxiety agent Buspar 10
mg instead of Prozac 10 mg

20
MAXIMIZE PATIENT SAFETY

ALWAYS write legibly.

ALWAYS space out words and numbers to avoid confusion.

ALWAYS complete medication orders.

AVOID abbreviations.

When in doubt, ask to verify.

PURCHASE
An effective procurement process should:
Procure the right drugs in the right quantities (Right Item)

Obtain the lowest possible purchase price (Right Cost)

Ensure that all drugs Procured meet standard quality (Right Quality)

Arrange timely delivery to avoid shortages and stock outs (Right Time)

Ensure supplier reliability with respect to service and quality (Right Source)

Set the purchasing schedule, formulas for order quantities and safety stock levels to
achieve the lowest total cost at each level of the system (Right Quantity)

Purchase methods

Direct purchase from manufacturer

Direct purchase from authorized wholesaler
Through tender from manufacturer or distributor
Purchase through competitive negotiation
Contract purchase through Mfg. / another agency
Fixed Quantity Contract
Running Contract
Rate Contract
Local purchase / Emergency purchase

21
TENDERS
1. Open Tender ( By Advertisement)
2. Limited Tender ( By Direct invitation to limited number of Firms)
3. Single Tender
4. Oral Tender

Accreditations (Regulatory Bodies)

USFDA (United States Food & Drug Administration)

WHO -GMP
UK-MHRA (United Kingdom’s Medicines & Healthcare Products Regulatory
Agency)
MCC South Africa (Medicines Control Council)
TGA Australia (Therapeutic Goods Administration)
ANVISA Brazil (National Health Surveillance Agency)
Health Canada
GCC DR (Gulf Central Committee for Drug Registration)

Balancing the cost of carrying high inventories and the cost of shortage is done through a
system of scientific inventory control.

22
Maximum Stock Level
It is the level above which stock should not be permitted to rise.
Minimum stock level
It is the level at which any further use of the item will necessitate withdrawal
from the buffer stock.
Danger level / warning Level
It is the level at which deliveries of the outstanding orders have to be speeded up.

Types of selective inventory control

1)ABC –
–Based on cost criteria i.e. annual consumption cost of the items
–Does not depend on unit price of the item
–Hence it is also know as Always Better Control

2) VED:-Vital, Essential, Desirable

–Based on importance, criticality and shortage cost of the item in terms of
availability, function, specifications, source of supply, production process, storage
etc.

3) HML :--
–Commonly used for management of consumable items.
–High, Medium, Low
–Based on unit price
–Does not depend on consumption

4) SDE -Scarce, Difficult, Easy to obtain

Based on purchasing terms with respect to availability

5) GOLF -Government Ordinary, Local and Foreign

Based on source of supply from which material is procured

6) FSN -Fast moving, Slow moving and Non moving

Based on issues from stores

7) XYZ –
Based on the value of Inventory stored

8) SOS -Seasonal, Of seasonal

Based on seasonal requirements

23
ABC ANALYSIS

A -Supplies accounting for a high percentage of the cost. This includes 10-20% of items
which account for 75-80% of expenditure
B –Supplies accounting for a medium percentage of the cost. This includes 10-20% of
items and 10-15% of expenditure
C –Supplies accounting for a low percentage of the cost. This includes 60-80% of items
but only 5-10% of expenditure.

VED ANALYSIS

V -Vital Drugs
They are potentially life saving or crucial for providing basic health services.
E -Essential Drugs
Effective against less severe but nevertheless significant forms of illness, but not
absolutely vital for providing basic healthcare.
D -Desirable
Used for minor illness

How to Reduce Inventory

1) Fixing up maximum limit of inventory in terms of value.
2) Fixing up responsibility of controlling the inventories with one person preferably at
Senior level reporting to top Management.
3) Meticulous materials planning and forecast.
4) A well designed and defined Inventory Control system.
5) Fixing up realistic Inventory levels i.e. maximum, minimum, reorder levels and safety
stock Inventory levels should be fixed item wise /location wise.
6) By reducing lead-time.
7) Adjustment in Inventory levels. Wherever called for Inventory levels should be
adjusted as per changes in requirement / consumption, changes in market conditions
etc.
8) Strict control on obsolete, slow moving and non-moving items.
9) Reducing the number of stock points.
10) Standardization and variety reduction.

24
11) Maintaining close co-ordination with other user Depts., Store, Quality Assurance,
etc.
12) By improving the buyer seller relationship, selecting the right source of supply in
terms of location, quantity/quality etc.

PHARMACY COMMITTEES
i) Pharmacy Purchase Committee
ii) Rate Contract Committee
iii) Formulary Committee

Pharmacy Purchase Committee (PPC)

The PPC role is to review reports, requests, issues related to drugs / supplies used within
the institution, and put forward decisions, responses, and resolutions based on the
review.

Membership

The PPC is formed by the following official members:

Medical Superintendent -Chairman

Head of Department, Pharmacy –Secretary

Associate Nursing Superintendent

Senior Manager (Finance & Accounts)

Senior Pharmacist, Purchase –Coordinator

Rate Contract Committee

The committee’s role is to address the choice of new brands and finalizing the
formulary list of brands maintained in the institution, in a consistent manner.
Membership
The rate contract committee is formed by the following core members:
Medical Superintendent –Chairman
Head of Department, Pharmacy –Secretary
Associate Nursing Superintendent

25
Senior Manager (Finance & Accounts)
Senior Pharmacist, Purchase

Formulary Committee

The Formulary committee role is to serve in an advisory capacity and review the
requests for inclusion on the hospital formulary of new drug entities, and to put forward
approvals or rejections based on the review.

The committee’s primary objective is to achieve optimal patient care and safety
through rational drug therapy.

Membership

The Formulary committee is formed by the following members:

Medical Superintendent –Chairman
Head of Department, Pharmacy -Secretary
Representative –Clinical Pharmacology
Associate Nursing Superintendent
Senior Pharmacist, Purchase
Pharmacist In-Charge, Drug Information -Coordinator
Other Senior Pharmacists attend meetings as consultants

Drug Storage
•All drugs are arranged as per alphabetical order of the Generic name or Brand name of
the drugs.

•Look alike and sound alike drugs are stored separately in the boxes stuck with eye and
ear pictures.

•2⁰to 8⁰C drugs are stored in refrigerators with list of items in it.

•High risk medications are stored in boxes with green color fluorescent labels.

•The bulk drugs are stored in separate area.

•Surgical items, external preparations etc. are stored in a separate area.

26
1. Medicines should be stored as per the manufacturer’s recommendations.

2. Pharmacy should be air conditioned to maintain below 25 degrees Celsius.

3. Daily room temperature is monitored and recorded.

4. The drugs to be stored between 2 to 8 degrees should be kept in the refrigerator.

Temperature should be monitored once in 12 hours and recorded.

5. Cold chain should be maintained for vaccines.

Sound alike and look alike medications are stored separately

1. Many ampoules ,vials ,tablets , capsules may look alike and also sound alike. The list
of such medicines should be identified and available in all the areas where drugs are
stored.
2. This list must be updated periodically
3. Pharmacists must be aware of this list.
4. One look alike is stored apart from the other look alike and same is applicable for
sound alike.
5. The look alike and sound alike medications can be colour coded or pictorially coded
to alert the pharmacist.
6. Awareness and training to be imparted to all staff about the LASA storage and
patient safety.

Policy on Look alike & Sound alike Medicines

Aim : To avoid potential harmful medication error.

Sound alike Medicines :

Drug that closely resembles another in pronunciation. These are stored in the
boxes/bins stuck with EAR pictures.
e.g. T. Trental 400mg –T.Tegrital400mg
T. Doxofylline–T.Deriphylline
Tab. Esperal–Tab. Inspiral

Look alike Medicines :

Drug that closely resembles another drug. These are stored in the boxes/bins stuck with
EYE pictures .
e.gT.Deplatt75mg -T.DeplattA75
T. Tryptomer25mg -T. Tryptomer10mg
T. Naprosyn250 mg –T. Aldactone100 mg
T. Banocideforte -T. Zyloric100 mg

27
High Risk Medication
High risk medicines are those medicines that have a high risk of causing significant
patient harm or death when used in error. Examples include medications with a low
therapeutic window, controlled substances, psychotherapeutic medications, etc
1. The organization shall ensure that it defines a list of high risk medications used in the
organization.

28
2. The process to prescribe the same shall adhere to national/ international guidelines
and regulatory bodies.

3. Strategies must be developed to access information about these drugs by

o Displaying the list of high risk medications in pharmacy and wards
o Education to doctors, nurses and pharmacists about the list and the potential
danger
o Can use coloured labels and automated alerts
o Can segregate the medications and store them separately
o Independent double checks or double check by the same person as applicable.

ISMP’s(Institute For Safe Medication Practice)

List of High Risk Medications

Adrenergic agents Methotrexate, oral, non oncologic use
Anesthetics Insulin/hypoglycemics
Liposomal products
Antiarrhythmics
Narcotics
Anticoagulants Neuromuscular blocking agents
Cardioplegic solutions Nitroprusside
Chemotherapy Oxytocin
Dextrose ≥20% Parenteral nutrition
Dialysis solutions Promethazine
Radiocontrast agents
Electrolytes (concentrated)
Sedatives
Epidural/intrathecal agents Sterile water for injection
Epoprostenol Vasopressin
Inotropic agents

Dispensing process
The important activities involved in the dispensing process can be grouped as

a) Receiving and evaluation of prescription

b) Interpretation of the prescription

c) Selection of items for the patient

d) Proper registration and issue of medicines

29
Dispensing procedure

The pharmacist in the counter receives the prescription and cash receipts in duplicate,
retains the prescription and duplicate receipt and gives back the original receipt marking
the token number ask the patient/relative to wait.
The pharmacist enters the token number once the drugs are packed and the patient
collects the drugs from pharmacist by submitting the original receipt, pharmacist checks
and signs it

Activities in dispensing areas

1. Drug distribution/dispensing
2. Compounding extemporaneous preparations
3. Stock maintenance
4. Accept drug returns
5. Send drugs by Registered post or courier service
6. Handling “No stock” or “Temporarily out of stock” drugs
7. Handling Narcotic and Psychotropic drugs
8. Handling “Special antibiotic” prescriptions
9. Provide instant drug information
10. Maintenance of records

Short Expiry Drugs

The short expiry drugs list is prepared by dispensing areas by viewing the check drug
expiry in the Pharmacy module and also physically checked.
Every month 3rdWednesday at 2.30 pm a meeting is organized to discuss this issue,
the representatives from the dispensing area with dispensing in charge scrutinizes the list.
The section in which the item move will agree to receive and liquidate . If not the drug is
returned to stores before 3 months of expiry.
From stores the short expiry drugs are returned to supplier.

Expired & Damaged drugs

•The expired drugs after auditing should be kept in yellow cover with a label stating
“Expired Drug Do Not Use”. The stocks are removed from the computer.
•The damaged drugs ( broken, cut strips, loose tablets etc.) after auditing the stocks are
removed from the computer.
•The expired and damaged statement is sent by the Audit department once a month, the
same is sent to Administrative committee for write off. After AC approval the same is
sent for safe disposal by M/S. Ken Biolink.

30
FORMULATION, PREPARATION, PACKING (FPPD)

This division is situated in a clean hospital atmosphere attached to the department of

pharmacy services.

The manufacturing unit is divided into two:

Parenteral manufacturing division

Non parenteral manufacturing division

QUALITY CONTROL LAB

General policy is as per Good Manufacturing Practices (GMPs) prescribed under

Schedule M of Drugs and Cosmetics Act
The lab has three sections: instrumental, chemical and microbiological/biological area.
Sampling, inspecting and testing of raw materials, intermediate, bulk, finished products
and packing materials and wherever necessary for monitoring environmental conditions.

DRUG INFORMATION AND CLINICAL PHARMACY

To provide carefully evaluated, literature-supported evidence to justify specific

medication-use practices to enhance the quality of patient care and improve patient
outcomes
Functions of drug information services:
Provides drug information to healthcare workers, committees, patients and other CMC
staff
Maintains hospital formulary based on scientific evidence of efficacy, safety, cost and
patient factors
Coordinates formulary committee meetings and prepares relevant materials for drug
evaluations
Publishes monthly bulletins to educate and inform healthcare workers in CMC on
rational medication use
Educating staff pharmacists, hospital/clinical pharmacy trainees, and interns/students

31
Clinical Pharmacy

To optimize medication use; promote rational, individualized and cost-effective

prescribing.
Functions:
1.To assess the patient’s health status and determine if the prescribed medicine is
appropriate to treat the underlying medical condition.
2.To monitor the patient for actual or potential drug therapy problems.
3.To follow the patient’s progress to determine the safety and efficacy of the medication.
4.To liaise with the healthcare team and provide recommendations about treatment
regimens.
5.To encourage adherence to hospital and international guidelines.
6.To provide apt, evidence based verbal or written drug information in case of any
queries.

EDUCATION & TRAINING

To make every pharmacist in the department updated with current knowledge about
the pharmacy practice and new drugs.

Continuing education Program

Pharmacist Trainee classes

Interdepartmental orientation program

Training of Visitor-Observers:

Pharmacy Symposium, Refresher Course for working pharmacists

32
 Hospital Operations Management HHSM ZG614

Human Resource Management

Broad Functions

1. Workforce planning & Recruitment

2. Training & Development
3. Employee Engagement / Labour Relations
4. Performance Management
5. Compensation Benefits
6. Rewards and Recognition
7. Policies, Regulatory & Statutory Compliances
8. Employee Separation

1.1 Workforce Planning & Recruitment

1
1.2 Training & Development

Best practices in Training and Development

•Training Needs Identification as a periodic process

•Training Needs linked to yearly Performance Management System

•Indices to measure T&D Delivery and Compliance

•T&D feedback reports towards actionable & initiatives

•Compliance of Functional Training Initiatives on record

1.3.1 Employee Engagement / Labour Relations

2
1.3.1 Employee Engagement Practices

•Define the Engagement Drivers

•Engagement calendar and events

•Team interconnect / Programs to foster

interpersonal relationships between stakeholders

•Integrating family into the Organization

•Work Life Balance / Quality of Life

•Job satisfaction

•Opportunities & Rewards

•Organizational Branding

•Feedback and Actions

•Connect with employees at all levels -at all touch points

1.3 Performance Management

3
1.5.1 Compensation Benefits

1.5.2 Compensation and Benefits

4
1.5.3 Compensation and Benefits – Total Rewards

1.6 Rewards & Recognition

1.7.1 Policies, Regulatory & Statutory Compliances

HR Rules / Policies
•Recruitment and Appointment policy, Separation / Termination Policy,
Attendance and Leave Policy, Transfer policy, Travel policy, Performance
Management & Promotion Policy, Code of Conduct, Benefits Policies
•Dress Code, IT / Devices policy, Work from Home Policy, Confidentiality
policy, Whistleblower Policy, Communications / Social Media Policy

5
Applicable Acts –Labour
•EPF Act, 1952
•ESI Act, 1948
•Payment of Bonus Act, 1948
•Payment of Gratuity Act, 1972
•Minimum Wages Act, 1948
•Workmen’s Compensation Act
•Standing Orders
•Shops and Establishments Act
•POSH Act 2013 –ICC / Grievances Procedures
•State specific laws on employment and benefits

1.7.2 Statutory Compliances

The recently passed Labour law Codes (Code on Wages, Code on Social Security,
Industrial Relations Code, and Occupational Safety, Health and working Conditions
code) which replace the labour acts
Minimum Wages

6
1.7.3 Statutory Benefits – Leaves

1.7.4 Statutory Benefits – Maternity Leave

7
1.7.5 Statutory Benefits – Holidays

1.8 Employee Separation (Exit Management)

Productivity and Cost -The Critical Factor of Today

Productivity & Cost

Metrics for Productivity, Cost and Utilization at all levels
Concerted efforts and initiatives in dialogue with Business

8
Individual KPIs linked with Performance Management System and productivity
improvement measures
Continuous review and restructuring of processes for efficiency improvement
Implementation of analytics, tools, systems for achieving the same

HR MIS & HR Analytics

Agenda

•Defining, Capturing, Extracting & Analyzing HR Data

•Creating / Choosing an MIS for HR

•Utility Value of Data -Critical Dimensions

•Fallacies to avoid in Data Analysis

1 Defining, Capturing, Extracting & Analysing HR Data

1.1 Scope of Data

9
1.2 Data Definition (Structuring the Data)

1.3 Data Collation and Management

10
1.3 Data Collation and Management – HR MIS

1.4 Data Analysis

11
2 Utility Value of Data

3.1 Fallacies in Data Analysis –Case

12
13
3.2 Fallacies to avoid in Data Analysis –Don’t Dos

Correlating to the base (Ex. Gender wise Attrition)

Sampling non-representative data to suit hypotheses
Incentivizing to get desired results
Cherry picking results
Reduction in Attrition is always good

14
A few final pointers –HR Data & HR MIS

•Start perfecting right from day 1

•Never be dependent on an individual for any data driven process / system/ module.
Create a process for knowledge sharing / rotation right from day 1
•Be patient with data. It may take even 5 years for building a strong “Data driven”
Organization, or for data to gain acceptance from all stakeholders

•HR MIS -comprehensive, but simple

Finance and legal alignment is imperative

Accuracy, Real time, instant availability of data, and access controls -ensure
these in whichever MIS or application choose
Keep all stakeholders in loop and take feedback from all involved when
choosing a new HR MIS
Firm deadline for transition to HR MIS. Emphasize and ensure periodic
reconciliation with actuals till the system stabilizes

15
 Laboratory Services in Health Care

Hospital Operations Management HHSM ZG614

Laboratory Services in Health Care Theophilus S Vijayakumar

nephrovijay@gmail.com
Christian Medical College-Vellore
Laboratory

■A laboratory is defined as

–“a facility

–for the examination of materials derived from humans

–for the purpose of providing information for the diagnosis, prevention

Laboratory in HealthCare - Overview

Role of Laboratory in Health Care

Laboratory Services

Establishing a Laboratory

Infrastructure

Instrumentation

Human Resources

Quality & Safety

Role of Laboratory in HealthCare

Diagnosis
Treatment Efficacy
Progress Monitoring
Predictive/Prognostic
Companion Diagnostics /Individualized Medicine or Personalized Medicine
 Laboratory Services
Scope of Services - What labs are required?

Depends upon the scope of clinical services offered

Pathology /Clinical Pathology

Biochemistry
Microbiology

Clinical Pharmacology etc

Scope of Services - What tests to offer?

Depends upon the scope of clinical services offered

In-house vs Commercial kits/reagents

Outsourcing -Accredited/standard labs; MOU

Outreach (Costing/tariff/increase in N)

Establishing a Laboratory - Planning Infrastructure

Based on present (current) and future (anticipated) needs

Services Offered

Work process & flow, instruments and personnel

Budget

Facility Design
Location
Area Required
Access –restricted
Anti-rodent measures

Establishing a Laboratory - Instrumentation

Basic Equipment
Specific Equipment
Safety Equipment

Budget
Equipment
Maintenance
Consumables/recurring expenditure
Cost is not the only factor e.g. CO2 incubator

Establishing a Laboratory - Human Resources

Qualified Personnel
Education & Skill
Training
Experience
Expertise
Laboratory Testing - Manuals & Training

•“What you hear you forget”;

•“What you see you remember”

•“What you do you learn”

Written Instructions (unambiguous)

Procedure Manual
Standard Operating Procedure Manual

Laboratory Management - Training

Generic Training –for all

Work Place
Quality & Safety Practices
Specific training
Work-process
Continued Training

Laboratory Management - Materials Management

Policies governing

Procurement (applicable licenses)

Supply
Storage
Usage
Disposal

Laboratory Management - Equipment Maintenance

Preventive Maintenance Contract

Calibrations
Internal maintenance team / protocol / schedule
Equipment Performance Monitoring

Laboratory Testing - Testing & Reporting

Specimen Collection Manual

Services Offered, specimens required, collection and transport procedure
Specimen Transport & Acceptance/Rejection criteria
Chute system (cost-benefit)

Turn Around Time

Reporting: (policies; documentation)
Urgent Report
Critical Report

Reports/Records
Documentation

Access Control

Confidentiality

Communication (hard copy/soft copy)

Laboratory Testing - Laboratory Information system

■Hard Copy/Soft Copy

■“A system to receive, process, and store information” associated with the testing services,
the laboratory processes and the outcome (report)

■To interface with the Hospital Information system

–CMC Hospital Information Processing
–Online –records, requests, results etc including imaging –“real-time”

Laboratory –Clinician Interface

Present and Future

Existing services
Feedback
Need for additional services
Introducing newer services
Validation

Verification

Clinical validation –cut-offs etc

Laboratory Services - Quality & Safety

Two vital components of structure and process

Laboratory

■A laboratory is defined as
–“a facility

–for the examination of materials derived from humans

–for the purpose of providing information for the diagnosis, prevention

Laboratory Services - Quality & Safety

Accreditation standards
NABH (Institution & laboratories)
NABL (laboratories)
 Factors influencing analytical variables

Laboratory Services - Quality Assurance Program

Quality Assurance Program

Quality Manual (Systems & processes)

Internal Quality Control (IQC) -to detect (immediate errors) and minimize them

External Quality Assessment (EQA) -to monitor long term precision and accuracy of
results

Laboratory Services - Quality Indicators

Key Performance Indicators

Define
Monitor
Rectify defects
Sustain standards
Raise the bar
e.g. turn around time, redos, reporting errors
Benchmarks
Laboratory Services - Audits & C.A.P.A.

Audits –Periodic-scheduled/unscheduled
Compliance and Non-conformance to expected standards
Problems/Risks
Root Cause Analysis
C.A.P.A.
Corrective action –to prevent recurrence
Preventive action –to prevent occurrence
Remedial action -

Laboratory Services - Quality –Errors

Before Testing (Pre-Analytical)

Specimen Collection

Specimen Transport

Specimen receipt (acceptance/rejection)

During Testing (Analytical)

Equipment-reagent-process (IQC & Calibration)

After Testing (Post-Analytical)

Transcriptional

Communication

Laboratory Services - Safety

Occupational Health & Safety

Safety Signage (Colors & Meaning)

Laboratory Safety - Hazard Management

■HIRA (Hazard Identification and Risk Assessment)

■Hazard Control
Laboratory Safety - Hazards

■Physical

–Slips, Trips & Falls

–Temperature
–Sound
–Humidity
–Electrical
–Mechanical

What is Hazmat?

•Any substance (solid, liquid or gas) capable of harming people, property or the
environment.
•Pose risk to Health, Property& Environment

■Chemical
Hazards –Chemical

■Physical, Health & Environmental Hazards

■Chemical Inventory –Hazmat List

■Hazard Identification & Risk Assessment

■Safety Data Sheet (SDS) -the backbone of chemical safety

■Appropriate Safety Measures for storage, usage and disposal

■Safety equipment

–Specific P.P.E.

–Emergency eye wash station/kit,

–Emergency shower

■Spill Management Protocols

Safety Data Sheet
Hazard Communication

Spill Cleanup Protocol

Mercury

Generic
■Biological

Standard Precautions (Universal Precautions)

Biosafety equipment (Biosafety Cabinet, Biosafecentrifuges etc)
Appropriate P.P.E.
Hand Hygiene
Biomedical Waste Management

Standard Precautions (Universal Precautions)

Where
When
How

Biosafety Equipment
Training
Information Resources
SOP
Personal Protective Equipment
Commission and Omission

Hand Hygiene
Provisos of various types

BIOMEDICAL WASTE MANAGEMENT

SEGREGATION at SOURCE

DISINFECTION

Prevention
Vaccination
■Hazards -Radiation

■Radiation Hazards
■Laboratories and other areas such as imaging services and radiation therapy units
■A.E.R.B. guidelines
■Appropriate P.P.E. & safety equipment
■Monitoring Exposure

■Hazard - Fire

■Sources of Fire
■Areas of High Risk
■Firefighting Devices & Training
■Fire-fighting Team
■Emergency evacuation protocols
■Mock Drills

■Hazards - Ergonomics-Physical & Cognitive

Ergonomics is the science and practice of designing tasks and workplaces considering our
capabilities and limitations OR Fitting the work to the person –User, Equipment/Work
Space & Tasks

Prevention of Work-Related Musculoskeletal Disorders (WMSD)

Reduced fatigue and discomfort; Increased productivity; Improved quality of work

■Work Area

■Work Practices

■Work Processes

■Pipetting (Repetitive motions); Microscope usage (neck & shoulder pain)

■Biosafety Cabinet (constrained knee & leg postures)

Laboratory design, Task variability

Hazards –Ergonomic –Cognitive

■Multitasking
■Increase in demand on multiple fronts
■Errors in prioritization
■Errors/failure in tasks
–Leads to
■work stress,
■depression and
■poor productivity
■Interface with patient, instrument and clinician
–Errors in information, input-output-communication

Hazards –Incident Management & Emergency Preparedness

Futuristic

■Satellite centers for specimen Collection

■Mobile collecting/testing facilities etc

Laboratory Sciences - Summary

Role of Laboratory in Health Care

Laboratory Services

Establishing a Laboratory

Infrastructure

Instrumentation

Human Resources

Quality & Safety

 Hospital Operations Management HHSM ZG614

Medical Records Management

Esther KeziaJames
MA., BMRSc.,
Sen. Sel. Gr. Tutor

What is Health Records?

It’s a clear, precise and accurate history of a patient’s life and health history and illness
written from the medical point of view.
The health record must contain sufficient data written in sequence of events to identify the
patient, support the diagnosis and justify the treatment and warrant the end results.
Health record is the Who, What, Why, Where and How of the patient care.

Health Records Department is a place where the records of the patients are usually stored,
maintained and retrieved and sent to various users of the Record.
The role of the Health Records department is to provide Health Information services

Functions of Health record and Health Information department

To facilitate ongoing care and treatment of patients

To support clinical decision making and communication among clinicians
To provide information for the evaluation of the quality and efficacy of the care provided
To provide information in support of medical research and education
To help facilitate the operational management of the facility
To provide information as required by local and National laws and regulations
To document the services provided in support of reimbursement (in countries like US)
Develop statistical and informative reports
Develop, analyze and technically evaluate health records
Maintain birth, death and MLC(medico legal cases)
registers and give necessary information to the governmental agencies
Inform the governmental agencies about the communicable diseases according to
government regulations
Uses of Health records

Patient care management

Quality review –adequacy and appropriateness of care
Education & Research
Public health
Planning & Marketing
Financial reimbursement(in other countries)

Role of Health Information Manager

Oversee health record information
Manage health-related information
Ensure that it meets relevant Medical, administrative and legal requirements

Functions of Health Information department

 Classification and coding

 Abstracting pertinent information based on predetermined data sets
 Registry development
 Storage :Implementation and oversight of computer based and paper based filing
systems
 Retrieval: Process of making information stored in various media and sites accessible
 Release: Responding to requests for information
 Analysis: Process of conducting qualitative and quantitative analysis of
documentation against standards

Coding

Coding is a system used by Physicians and other healthcare providers to classify and code
all diagnoses, symptoms and procedures recorded in conjunction with hospital care.
It provides a common language for reporting and monitoring disease. This allows the
world to compare and share data in a consistent and standard way between hospitals,
regions and countries over a period of times
Why is coding important in healthcare?

It is extensively used for Study and research purposes

ICD is the global health information standard for mortality and morbidity statistics
It is closely tied in with the process of medical billing in countries like US

Computer based Patient records

In computer based patient records you directly enter the information in the computer
It also provides users with access to complete and accurate clinical data, practitioner alerts
and reminders, clinical decision support systems and links to Medical Knowledge

Numbering and filing system of Health records

There are several types of Numbering and filing systems

Unit numbering: Patient is assigned a number on his first visit to the facility and this
number is retained throughout the subsequent visits

Serial numbering: Patient is assigned a new number each time he is treated or admitted
Serial Unit numbering: This is a combination of serial and unit numbering system

Filing

The most common types of filing are:

1. Straight numeric filing
2. Terminal digit filing

1. Straight numeric filing: Strict numerical sequence is followed. Records are filed in
numerical order. This is very easy and needs no special training
eg., 226585, 226586, 226587, 226588, ….

Terminal Digital Filing

The number is divided into 3 groups . So there can be only 100 primary, 100 secondary and
100 tertiary numbers
Example

In this filing system the entire filing area is divided into 100 sections –00 –99

36-62-01 98-99-20 98-03-26

37-62-01 99-99-20 99-03-26
38-62-01 00-00-21 00-04-26
39-62-01 01-00-21 01-04-26

Scanning is one way of electronically storing physical records

Scanning -Indexing -Uploading

Scanning
It is the process by which a document is read into an optical imaging system. Here the
records are scanned and maintained in data bases
Indexing
It is the labeling of the scanned documents so that they can be easily stored
Uploading
It is the storing of the scanned files in a centralized computer system

Medico legal case records(MLC)

A MLC is one where, besides the Medical treatment investigations by law enforcing
agencies are essential to fix the responsibility regarding the present condition of the Patient
Legal case requiring medical expertise when brought by the police for examination
Medico legal is something that involves both medical and legal aspects.
Attending Casualty Medical Officer (CMO) has the authority to decide whether the case is
to be registered as medico-legal or not
1. Admission Office

2. IP Assembling & Deficiency Checking

3. Coding

4. Birth & Death Entry

5. Discharge Analysis

6. Statistics

7. Scanning

8. Scanning MLC

9. Chart Preparation

10. Two-Line Stickers

11. Records Storage Area

12. Bar Coded Paper

 Hospital Operations Management HHSM ZG614

Public Relations
Objectives, Functions and Methods

Durai Jasper, PRO CMC Vellore.

Definitions

•A public relations professional builds awareness and interest.

•Serves as a spokesperson and manages the flow of information to the public for a person,
product or company.

•Must be an effective communicator in print, person and on the phone

•‘About reputation –the result of what you do, what you say and what others say about
you.

•Public relations is the discipline which looks after reputation, with the aim of earning
understanding and support and influencing opinion and behaviour.

•It is the planned and sustained effort to establish and maintain goodwill and mutual
understanding between an organisation and its publics.’

Job description

•Communicating the mission & vision

•Production and use of brochures, handouts, books promotional videos and multimedia
programs etc.,

•Press release, Press meets

•http://www.pressreleasewizard.net/

•Organizing hospital tours

•Maintenance of the official website

Who is a PRO ?

•Managing the organization's reputation -the public in general and clients in particular.
•At the helm of managing a hospital's public image, is the public relations manager
( Officer)
•The Manager enhances the efforts of other wings (PRO, Development, PTP) in
maintaining a favorable image of the institution

•May have to draft speeches of the hospitals top administrators for public meetings.
•Responsibility of improving the relationship between the management and its employees
•Preparing the in-house newsletter
•Working in close co-ordination with the labor relations manager (Personnel Manager)

Publics are audiences that are important to the organisation. They include customers –
existing and potential, employees and management, investors, government, suppliers, the
local community and opinion-formers etc.,
In the public relations literature you may find the terms publics and target audiences used
interchangeably.
A public is a group of individuals or organizations who have a common problem, cause or
goal. There are six major groupings

Employees

Consumers

Media

Financial markets

Government agencies

Community

What PR is not....

•Public relations is not handshaking.

•Public Relations is not drinking parties.
•Public relations is not journalism.
•Public relations is not advertising.
•Public relations is not marketing.
For PR to work there are several prerequisites

•It must first put its own house in order

•PR must have the respect of employees and community

•Management must justify its profits and prove that it is not profiteering

•Work for the community as an able corporate citizen

Advertising

•“Advertising is bringing a product (or service) to the attention of potential and current
customers. Advertising is focused on one particular product or service. Thus, an advertising
plan for one product might be very different than that for another product. Advertising is
typically done with signs, brochures, commercials, direct mailings or e-mail messages,
personal contact, etc.”

Skills
•Has to show a good understanding of the hospital's objectives and pro-activeness in
generating new ideas

•Strong leadership qualities and the ability to successfully complete projects

•To have good managerial and communications skills

•Understanding how the media works

•Maintaining a positive image of the organization

•To be able to bail one's company out of a situation of crisis

•Be able to think out of the box and react quickly

 Hospital Operations Management HHSM ZG614

Hospital Food Service

.Manimegalai.,M.Sc.,M.Phil.,RD.,
Senior Lecturer & In-Charge
Department of Dietetics

Learning Points
Uniqueness of hospital diet
Organogram of hospital dietary kitchen
Functions
Role and Responsibilities
Food Safety & hygiene
Importance of audits
Conclusion

Introduction
Hospital food service has an indispensable influence in the treatment process of in-
patients by giving nutritious food.
Hospital food service is unique just because it serves food to the patients group.
Patients get hospitalized to get treatment for their ailments and nutrition plays an
extremely critical role in many disease conditions.
The types of diets that are available in the hospital will not be available anywhere
except in the hospital food service.
Apart from the types of diets there are many other things that are very unique in it’s
own way like the role played by a clinical dietitian, guest relation executives, food
service stewards etc.
Hospital food service is just not only a food service; it is a part of the patient’s
treatment.
Hospital food service doesn’t work independently; it is a collaborative team effort of
several disciplines to provide the ultimate patient experience.

1
Uniqueness of Hospital Food Service
The uniqueness of hospital food service
Types
varieties of diets prepared in hospital kitchen.
Hospital food might not get the best reputation when compared with the Restaurant /
Hotel Foods just because of the level of expectations of the taste.
Hospital foods have the right amount and right quality of ingredients with the right
amount of salt without any taste enhancers, artificial colours and preservatives.
Hospital food service sets high quality standards when it comes to good nutritional
offerings.
Patient on hospital diet does not usually have the alternative of purchasing meals
elsewhere.
Since the patient does not have any other option, it is the obligation of the hospital
food service to provide patient acceptable nutritious diet throughout their course of
treatment in the hospital.

Functions
Therapeutic Diet Planning and Execution
Food Preparation and service matching the needs of the patient.
Providing nutritional care for in-patients.
Providing diet consultation for both in-patients and outpatients.
Offers a course in P.G. Diploma in dietetics and M.Sc in Clinical Nutrition
Holding lectures on nutrition and dietetics for doctors, nurses, medical and nursing
students.
Undertaking research projects in collaboration with other medical and nursing and
allied health units
Offers dietetic internship for student of various colleges/universities for 4/6 weeks and
6 months internship for post graduate students.
Conducting Nutrition Education and Nutrition Awareness programs for the public as a
team with other health care personnel.

2
Responsibilities of Chief Dietitian
To oversee the function of the department and to carry out the operation.
Directs activities of the department providing quality food service and nutritional care.
Inspect food preparation and food service for conformance with the prescribed diets
and standard.
Establishes policies and procedures, and provides administrative direction for menu
formulation, food preparation and service, purchasing, sanitation standards, safety
practices, and personnel utilization.
Coordinates interdepartmental professional activities, and serves as consultant to
management on matters pertaining to dietetics.
Directs departmental educational programs.

Role of a dietitian
Dietitian shall be the head of dietary department
Dieticians in the hospital are the nutritional experts who outline a customized diet plan
for each patient based on the medical condition and the diet prescription recommended
by the treating doctor.

Meal planning
The prime objective of meal planning is to achieve nutritional adequacy.
The diets are planned in such a way it meets the nutritional needs of the individuals
getting hospitalized.
Since no single food can meet all the nutritional requirements and hence it becomes
extremely important to achieve a balance of nutrients through a combination of different
foods included in the hospital diet.
The diets in the hospitals are usually planned by including foods from the five food
groups.

Principles and objectives of therapeutic Diet

To maintain good nutritional status.
To correct nutrient deficiencies which may have occurred due to the disease
To afford rest to the whole body or to the specific organ affected by the disease.

3
To adjust the food intake to the body’s ability to metabolize the nutrients during the
disease.
To bring about changes in body weight whenever necessary.
To reduce the complication and severity of the disease.

NUTRITIONAL CARE FOR PATIENTS

1. Provision of Nutritional care
a. Assessment of the nutritional requirement
b. Plan diet appropriate according to the disease condition and nutritional
requirements and provide counseling if required.
2. Dietitians visit the allotted wards and they are responsible for inpatient nutritional
care.
3. Visit the patient within 24-48 hrs. Of diet order except on Saturday & Sunday &
institutional holidays.
4. Check and document the following details in patient’s medical chart
i. Name, Hospital number, Bed number,
ii. Diagnosis
iii. Reason for admission,
iv. Biochemical tests results,
v. Gender, Age, Height, Weight,
vi. Appropriateness of Diet ordered
5. If not appropriate, inform the nursing staff/Clinician and the patient.
6. Necessary corrections are made and documented in the memo card.
7. Nutrition re-assessment for patients on therapeutic diets will be done after 4th day of
Initial Assessment. Re-assessment will vary depending upon patients’ health conditions.

IMPORTANCE OF DIET COUNSELLING AND PATIENT EDUCATION

The major objective of dietary counseling is to educate the patient regarding the nature
of the disease, its hazards, how a disease can be recognized and prevented.
It is essential to advice the patient on personal hygiene, individual instructions on diet
and any specific therapy needed.
Diet counseling makes the patient aware of the fact that diet plays an important role in
the treatment of the disease.

4
With today’s emphasis on prevention of disease, diet counseling helps to reduce the
risk of some illness by appropriate counseling.
Diet counseling is effective when the counselor assists the patient in setting realistic
goals and provides the necessary guidance in menu planning, food purchasing and
preparation.

Food service
Delivering right diet to the right patient every time is a carefully orchestrated team
effort when it comes to patient food service.
Food is prepared according to standardized recipes and according to conventional or
automated preparation methods.
Food is freshly prepared for each meal and is directly portioned, dished up, garnished
and served after the cooking process/preparation process which can also take place in
batches.

Role and Importance of Health, Safety, Environment& Quality (HSEQ) Executive

HSEQ is a safety programme which promotes a proactive safety culture in the working
place.
This is to ensure that every employee is accountable for safety practices in their
respective working areas to achieve excellent health and safety and food safety
performance.
The executive carries out internal audits on a regular basis to measure the performance
of the food service kitchen.
The executive very critically monitors the movements of the kitchen to ensure that
there no deviations.
In case of any deviations, the same is escalated and documented and ensures that the
deviations are rectified.

The routine of a HSEQ Executive in the hospital kitchen

1. Employee grooming & Personal Hygiene
2. Availability of Personal Protective Equipment’s (PPE)
3. Ensures that the walkthrough is hazard free.
4. Identifying any unhygienic practice

5
 5. Ensures that the emergency exits are clear
6. Availability of all the Standard Operating Procedures (SOP)
7. Availability of JSA –Job Safety Analysis posters
8. Availability of Food Safety Policy
9. Availability of Health and Safety Policy
10. Availability of Environment Safety Policy
11. Training –HSE Induction for new employees
12. Daily Staff Training according to Tool Box Topic
13. Ensures availability of calibrated thermometers wherever required
14. Checks on the receiving records
15. Checks on the storage records
16. Checks on the Sanitization records
17. Checks on cooking, reheating and cooling and food transfer records
18. Checks on Wastage and Scrap oil record

Risk Assessment by HSEQ Executive

The HSEQ executive frequently performs risk assessment at the unit level.
A risk assessment is a vital element for health and safety management and its main
objective is to determine the measures required to comply with the HSE requirements to
reduce the level of incidents / accidents.
The HSEQ executive follows the 5 step risk assessment guide.
1. Identifies the Hazards
2. Decides who might be harmed and how
3. Evaluates the risk and decides on control measures
4. Records the findings and implements them
5. Reviews the assessment and updates if Necessary

Guest Relation Executives in Hospital Food Service

Guest Relation Executive (GRE) plays a very important role of customer service in
any industry.
GRE’s are the recent trends in hospital industry.
GRE use their skills and experience to ensure that patients are delivered with highest
standards of services during their course of hospitalization.
The Strategy of the GRE is to get closer to the patient to try and understand the
requirements better and try to help patients during their course of hospitalization to a
possible extent.
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This strategy was adopted to build in confidence to the patients that there is a
committed team of members to look after their needs.

TYPES OF CATERING SERVICES

Conventional food system

 Food is freshly prepared each meal, cooked and served
 Food is prepared according to standardized recipes
 Directly portioned dished up, garnished and served
 Dishing up and garnishing of complete meals in suitable crockery and transported
on trays in suitable trolleys
 Decentralized

Cyclic Menu
To set a very good menu option; cyclic menu is the best way to prevent dissatisfaction
resulting from monotony.
The ‘MENU’ is the blueprint of operation in any catering establishment.
A hospital food service usually has a minimum of 2-5 weeks cyclic menu.
Nutritional concerns with respect to sugar, salt and complex carbohydrate content of
the diet is addressed in the menu planning by the nutritional experts making it as a
pleasant dining experience to the patients without compromising on the nutritional
quotient.

FOOD EVALUATION
Half an hour before the meal setting all main items are evaluated by
the dietitian on duty and recorded in the Food Evaluation Register.
The dietitian will taste the food.
Dietitians look for taste, flavour, and texture.
If any modifications are required the dietitian will intimate After
making necessary corrections the food is evaluated again, If not
satisfactory the food item is rejected and fresh item is prepared by
consulting HOD.
The dietitian records the quality of food item after evaluation in
Taste Evaluation Record.

7
Food safety
The term “food safety” refers to the manner of handling, preparation and storage of
foodstuffs with the aim of preventing contamination of the product and subsequent food
borne illness (or injury) of the consumer.
Food safety is relevant to everyone, but vulnerable people are more likely to be affected
even by low-level pathogens and, therefore, more likely to be infected.
This puts even greater responsibility on medical institutions to do everything possible to
ensure that safe food is always prepared and served.
Safety must be the top priority when it comes to hospital food which is used for
nutritional therapy and not just for taste.
The food must be free of hazardous chemical compounds and pathogenic
microorganisms.

Do Bacteria enter the Food Supply?

The hospital itself is the source of infection.
Without rigorous procedures and protocols,
dangerous microorganisms like pathogens,
viruses, etc., can disseminate among patients
and staff

Food poisoning bacteria can come from four

main sources:
Food handlers
Raw foods like Raw meat, poultry, shellfish and
vegetables
Pests and animals
Air, dust, dirt and food waste.

Contributing Factors for Outbreaks

CDC estimates that approximately 18-20% of foodborne outbreaks are associated with
an infected food worker
Thetop contributing factors for outbreaks from the Centers for Disease Control and
Prevention (CDC):

8
Food handlers contaminating ready-to-eat food through bare-hand contact
Food handlers contaminating food through a method other than hand contact (such as
with a utensil they contaminated)
Food handlers contaminating ready-to-eat food through gloved-hand contact
Food handling practices leading to growth of pathogens (such as food not kept cold
enough)

Food Safety Management System

Receiving Area
It is imperative to have a designated clean area for receiving and storing the food
materials.
In the receiving area, temperature control and quality inspections must be maintained.
These inspections should encompass specifications, brand names, condition of the
packaging and labeling.
Vegetables need to be disinfected right at the point of receiving them.

Sorting for physical hazards

Preliminary washing in cold running water and

soaking in 100 ppm chlorine solution for 5
minutes

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Storage Area

Storage area: it is divided into:

Dry storage: for food items like sugar, dal, rice, fruits, vegetable salt and other
dry items.
Wet storage: for items like milk curd ghee juices etc.
FIFO/FEFO: date marking and FIFO are some of the most impactful methods to cut
down on food waste and helps to use before it goes bad.
Digital Thermometer: to be installed

Wet Storage

Dry Storage

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Are we storing foods at the right temperature?

Food Preparation Area

11
Time/temperature Control for Safety or TCS Food

Involved in most food borne illnesses

Generally high protein foods
Meat and meat products

Cut leafy vegetables

Sliced fruits

Cooked vegetables

Eggs and milk

Calibrated probe thermometer

Use proper methods to thaw frozen foods
Keeping under running water

Leave at refrigerator

Bacteria that grow on these foods thrive when the temperature is warm, usually between
about 41°F (5°C) and 135°F (63°C).
This temperature range is usually referred as temperature danger zone.
Keeping hot foods hot (above 135°F) and cold foods cold (below 41°F) can keep these
bacteria from growing.

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Safe Plastics for Packing Foods

Food Service
Food hygiene, which refers to the many practices needed to safeguard the quality of food
from production to consumption.
Food hygiene is vital for creating and maintaining hygienic and healthy conditions for
the production and consumption of the food that we eat.
Meticulous cleaning of kitchen
Preheating the bain-marie
Holding food at 65°C or above
Packing and serving food in clean hot cases along with appropriate cutlery.

Wash Hands

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Wash hands regularly and properly to
prevent cross contamination.

SANITIZATION TUB

Disinfection Carried Out For Perishable Items

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Food Sampling
Why is it important ?
Is a process used to ensure the quality and safety of any food products

Hospital cafeteria serves food that is nutritionally and medically appropriate; a sample
must be taken and preserved.
If there is any suspension of food poisoning or if a patient complains, the food will be
tested to determine the source of contamination, whether it occurred during preparation,
transportation, or due to a lack of a Food Safety Management System (FSMS)
Regardless of the cause, this issue is punishable and compensation must be provided to
the affected patient or consumer.
Minimum 250 g of sample must be stored
The bags/Containers should be sealed properly with appropriate labeling-date
and time/ service of preparation (Breakfast, Lunch, Snacks, Dinner & Feed etc.).
The food samples to be retained/ kept in a freezer for 72 hrs.

Pest control Methods

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Pest control measures are taken every week
After this procedure, entire area is cleaned thoroughly and ready for the next day
operations
Effectiveness of the pest-control program should be verified on a regular frequency

PPE : Why is it mandate ?

What happens when head gear is not used?

According FDA food code : “A hair restraint keeps away hair from ending up in the
food and may deter employees from touching their hair." This is crucial to prevent cross
contamination.
Staphylococcus aureus is an example of a common pathogen that is found on skin and hair.
If enough of the bacteria is ingested, it could cause illness. Common symptoms of this
illness include vomiting, nausea, and stomach cramps.

What happens when gloves is not used?

It is important to understand why avoiding bare-hand contact is crucial to food safety.
Even after washing your hands, they can still have pathogens on them.
Norovirus, for example, can easily be spread through person-to-food contact. In addition
to bacteria and viruses, dirt and grime can get stuck on your hands and pass to the food.
Bare hand contact with ready to eat food causes 30% of food borne illness outbreak

Taking Responsibility for Personal Hygiene and Hand Washing

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25% of all food borne illness is due to improper employee practices
Anyone working with food must wash their hands
Employees who are ill with colds or employees with cuts or burns are at high risk for
transmitting illness
No smoking/eating/drinking
Avoid touching face, sneezing or coughing over the food
Single-use gloves should be used for only one task
Cuts to be covered with water proof dressing

Practicing good sanitization methods to prevent cross contamination

Cleaning Utensils
Cross contamination is the transfer of harmful bacteria from one food to another
Utensils, equipment, human hands
Use proper sanitizing solution to minimize and prevent cross contamination.
Disinfect boards and knives and food contact surfaces between different food types
Hand contact surfaces need to be disinfected.
Remember to change washing water once it is dirty.

There are five steps to utilize correctly in a three compartment sink

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Medical Check up

Medical check up is done once in a year

Blood and urine and stool
Skin
Eye
Deworming is done once in six month

Vaccine is given once in three years for enteric group of diseases

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Food Safety Training and Re-Education
It's important to educate those handling food on the
importance of maintaining cleanliness, and to conduct
regular inspections to ensure they are following proper
hygiene protocols.
The nutrient content and density of the food is the
responsibility of dietitians, however we must closely
monitor and manage food safety and hygiene aspects as
well to deliver safe clean nutritious food.
Making food safety a priority will not only help prevent
food borne illness, it will also help provide excellent
and trustworthy service to our patients!

Importance of Plate Waste Assessment in a Hospital Kitchen

Plate waste is a methodology used in the hospital inpatient’s kitchen to find out the
amount of food that remains uneaten on the patients’ plate after a meal.

WHY CONDUCT PLATE WASTE AUDITS IN HOSPITALS?

No matters how well a diet has been planned, it matters the most only when the patient
consumes the food completely.
Only then the nutrition goals of the patients are achieved.
Plate waste assessment is one of the effective determinants of the level of acceptance of
food by the patients.

HOW TO CONDUCT PLATE WASTE AUDITS IN HOSPITALS?

To decide on the meals to be surveyed
Determination of the method of plate waste assessment

Two methods of plate waste assessments are

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Weighing Estimation -Accurate and exact assessment of the plate waste generated.
Visual Estimation -Greater convenience and time-saving assessment.
Taking Pictures
Taking pictures of the trays which have not been touched by the patients at all.
This will give an immediate idea as to what has gone to the patient so that when
interacting with the patient, the dietitian will have a clear idea what has been served to
the patient and will facilitate to make appropriate changes to the patient meal keeping in
mind the items which the patient did not like.

Regular Monitoring and Recording

Record Keeping is very much essential to keep a track on the FMS
Cleaning Schedules
Temperature log of equipment
Food sampling
Garbage disposal
Pest control
Grooming

LICENSES
Labourand FSSAI licenses are obtained every year
Calibration-Protocols and calibration methods must be established for all equipment that
could impact on food safety. These include:
Thermometers

Refrigeration controls

Golden rules for safe food preparation

Cook raw foods thoroughly.

Thorough cooking will kill the pathogens, which means the temperature of all parts of
the food must reach at least 70°C.
Avoid contact between rawfoods and cooked foods.
Safely cooked food can become contaminated through even the slightest contact with
raw food.

20
Wash hands repeatedly.
Hands should be washed thoroughly before preparing, serving or eating food and after
every interruption, especially after use of rest rooms
Keep all food preparation premises meticulously clean.
Since foods are so easily contaminated; any surface used for food preparation must be
kept absolutely clean
Use safe water
Safe water is just as important for food preparation as for drinking

How clean is our kitchen?

Effective cleaning and disinfection is essential to

get rid of harmful bacteria and stop them
spreading to food..
The proper cleaning and disinfection of food
premises can contribute significantly to
controlling food safety hazards and risks
associated with cross-contamination and
inadequate cleaning.
Cross-contamination is one of the most common risk
factors reported in outbreaks of food poisoning

21
 Hospital Operations Management HHSM ZG614

Water & Waste Water Treatment in Health Care Facility

Mr. JOEL SABASTIN

BTech (chem.) MBA
NEERING
What is Water Supply Engineering?
Deals with supply of water from:
SOURCE OF WATER
Collection
Treatment
Storage
Distribution
Consumer
Water demand…per capita consumption
Involves design of a water supply scheme with the amount of water available and amount of
water demanded by the public
1. Domestic
a. Flushing: 45 litres / day / person
b. Other purposes: 90 litres/day/person
c. Total Consumption: 135 litres/day/person
2. Industrial
3. Public Use
4. Fire Demand
5. Losses such as waste, theft
Water requirement for buildings…

Recommended Standards Of Drinking Water

Specific Parameter of Drinking water

1. Total Hardness:
•Mineral content in a water sample
•Total hardness = total calcium + magnesium hardness.
2. Total Dissolved Solids (TDS)
•TDS -total of organic and Inorganic substances present in a liquid(Water).
•minerals, salts and organic matter -general indicator of water quality.
The Previous slide has important parameter, which are monitored for portable water

LICENSES FOR WATER SUPPLY

No objection certificate –obtained from the local competent authority
Ground water clearance certificate from the Executive Engineer, Ground Water
Division

Treatment of Drinking Water

1. Chlorination/Disinfection:
The Drinking water is primarily treated with 5% Sodium Hypo chlorite, a disinfectant used
to resist the Microbial Growth.
2. Chlorine di oxide:
Chlorine dioxide –is a bleach in liquid form. Effective at low concentrations.
Chlorine dioxide is a very strong oxidizer. Effectively kills pathogenic microorganisms such
as fungi, bacteria and viruses.
Chlorine dioxide is a powerful disinfectant for bacteria and viruses. Chlorine dioxide
prevents the growth of bacteria in the drinking water distribution network. chlorine dioxide
is active for at least 48 hours, its activity probably outranges that of chlorine.

In case of Hard water –water to be undergone with chemical treatment

1.Temporary Hardness
-Dissolved salts such as Calcium or Magnesium bicarbonate
-Ways to remove are Boiling.
2.Permanent Hardness
-Calcium and Magnesium chlorides /Sulphides
-Removed by Addition of Ion exchange process (Softening plant)

3. Chemical treatment
Softening plant:
Ion exchange softening, also known as zeolite softening, passes water through a filter
containing resin granules.
In the filter, known as a softener, Calcium and magnesium in the water are exchanged for
sodium from the resin granules.
The resulting water has a hardness of 0 mg / Land must be mixed with hard water to
prevent softness problems in the distributed water.
Application:
•Ion exchange softening is effective at removing both carbonate and noncarbonated
hardness. •It is used for waters high in noncarbonated hardness and with a total hardness
more than 350mg/L.

Storage & distribution of Drinking Water

Storage of Drinking water:
Storage of clear water in underground Sump and over head tanks in respective Blocks.
Distribution of water through pipelines.
The Water is distributed to the respective over head tanks from the Drinking water sumps
through channelized pipeline with a scheduled operational time.

SEWAGE & WASTE WATER TREATMENT

DEFINITION
•Maintenance of the environment such that it will not affect the public health in general.

•Preventive measure for the preservation of health of the community and individual
‘Health’: Physical and mental soundness of the human body so that it is in a position to
discharge daily routine functions
WHY TREAT WATER ???

Water Contains A Number Of Dissolved & Suspended

Impurities Which Need To Be Removed Before consuming The Water.
Water Contains
• Cations, • Anions, • Turbidity, • Collidal Particles, • Organic Matter, • Alkalinity,
•Silica, • Heavy Metals Etc.
Different Methods Of Treatment Have To Be Applied To Remove Different Impurities
Steps involved in Sanitation

Treatment Stages
TYPICAL SEWAGE TREATMENT SYSTEM
SEWAGE TREATMENT PLANT
Biological processes
A. Aerobic Process
1. Suspended growth process
eg., Activated Sludge process(ASP)
2.Attached growth process
eg., Fluidised Aerobic Bioreactor (FAB)

B. Anaerobic Process
1.Suspended growth process
2.Attached growth process

TECHNOLOGY INCORPORATED IN CMC, VELLORE

1. Stabilization Ponds –Aerobic & Anaerobic Systems (UASB/AF etc.)

2. Conventional Method-(ASP)
3. Submerged Aerated Fixed Film (SAFF)
4. Fluidized Aerobic Bio Reactor (FABR)
5. Sequential Batch reactor (SBR)
6. Membrane based treatment system
7. DEWAT SYSTEM
Integrated water supply system in CMC
FAB REACTOR – The New Generation Sewage Treatment Plants
Fluidized
Aerobic
Bio
Reactor
FAB –REACTORS
Works on the principles of Attached Growth Process.
Media will be in suspension -Specific gravity less than water.
Media fluidization -by virtue of hydraulic currents set by Aeration.
High SRT

DETAILS OF THE PLANT

Inlet Characteristics
•BOD : 500

•COD : 1000

•TSS : 400

•pH : ~ 7
PRIMARY TREATMENT – SCREENING
BAR SCREEN
* The arrested material like plastics, papers, floatable particles etc. to be removed on a
regular basis .
* Regular cleaning of screens will avoid the problems of pump choking, overflowing of
chambers etc.

OIL & GREASE TRAP

•Removes free floating oil & grease

•Oil removal will ensure the smooth operation of biological system [ FAB Reactors]

RECEIVING SUMP
EQUILIZATION TANK
•Dampens / absorbs fluctuations.
•Homogenizes effluent.
•Uniform feed to biological system
•Continuous air supply in the sump will not allow the solids to settle in the tank

Essential Components of FAB Reactor

CARRIER MEDIA
FAB BASED TREATMENT SYSTEM

FEATURES
TUBE SETTLER

TUBE SETTLER OBJECTIVE & OPERATION

• Removes biological dead mass /sludge generated in FAB reactors.
• The settled sludge from tube settler can be dewatered and / dried.
• Sludge from tube settler to be drained every 4hrs for approx.1-2 minutes based on visual
observation till total sludge is drained.

CHLORINE CONTACT TANK [CCT]

•Sodium hypochlorite [NaOCl] is to be added in CCT for dis-infection /killing of the

bacteria.
•The dose of free chlorine to be maintained @ 3.0ppm for disinfection.
•Sodium hypochlorite contains free approx. 8 to 10 % free chlorine
•The mixing of chlorine in CCT is achieved by zig-zag / upflow-down flow passing of
treated sewage with chlorine in CCT.

DMF/ACF FILTER
DMF : Removal of SS escaping from TS
ACF : Removal of trace organics , Color and odor in the treated effluent
Both filters need periodic backwashing (Typically once every 8hrs.)
Sludge Handling System
Following are the options available :
A. Sludge drying beds
B. Filter press
C. Centrifuge
D. Sludge digester etc.
Advanced Tertiary Treatment:
It involves filtration and disinfection mechanisms
• The Treated water is filtered using a Ultra filtration membrane to produce an ultra clear
water for Flushing.
• chlorination –adding chlorine( 5% Sodium Hypo chloride solution) as an disinfectant to
make it safe from microbial growth.

Disposal of treated water

•Toilet flushing
•Gardening
•Laundry pre wash water
•Chiller/cooling towers

View of GARDENS using Treated Water

 Hospital Operations Management HHSM ZG614

CSSD and its function

HISTORY

1928 –American College of Surgeons –CSSD

•1942 –World War II. Cairo, British SDS Unit.
•1955 –Cambridge Military Hospital –Regular
CSSD in UK
•1965 –First CSSD in India –Safdarjung Hospital
in New Delhi
•1972 –CMC CSSD in Vellore

DEFINITION

A Central Sterile Supply Department (CSSD) is a hospital support service, which is

entrusted with processing and issue of supplies including sterile instruments and
equipment used in various departments of a hospital. In certain hospitals, especially in
the developed countries, this department is called the central service department and
encompasses many other functions in addition to sterilization such as the purchasing,
stocking and distribution of supplies.
“As that service, with in the hospital, catering for the sterile supplies to all departments,
both to specialized unit as well as general wards and OPDs.”

OBJECTIVES

The objectives of establishing a CSSD are to:

To provide reprocess the and provide Sterile materials required within the health care
facility.
To take some of the work of the Nursing Staff so that they can devote more time to
their patients.
To avoid duplication of costly equipment’s which may be infrequently used. To
maintain record of effectiveness of cleaning, disinfections and sterilization process.
1
To monitor and enforce controls necessary to prevent cross infection according to
infection control policy.
To maintain an inventory of supplies and equipment.

PLANNING A CSSD DEPARTMENT

1. Physical Planning

2. Functional Planning

3. Personnel Planning

4. Equipment Planning

5. Financial Planning

6. Quality Control

7. Preventive Maintenance

LOCATION

It should be centrally located with proximity to the major departments to which it
supplies its material, preferably in the same building.

It should have easy access to the stores, from where it gets its raw material and also to
the laundry for a clean supply of linen,

LAYOUT DESIGNING PRINCIPLE

• There is no back tracking of sterile goods.

• One way movement from receiving counter to issue counter.
• Sterile area should be prior to sterile storage and issue.
• The receiving counter must be away from the issue counter.
• Separate receiving and issuing counter
• There should minimum six basic division in CSSD

2
ZONING
Department is typically divided into four zones:
•Zone I : Reception, inspection and decontamination (removal of bio-burden).

•Zone II : Assembly and packing.

•Zone III : Sterilizing.

•Zone IV : Storage and distribution

In the first zone, used items are received, disassembled, cleaned and decontaminated
by means of manual or mechanical processes.
In the second zone, cleaned items are received and then inspected, replaced if
necessary, assembled, packed and labeled for further processing like sterilization.
In the third zone sterilized items are received and stored until it is time for them to be
issued.

CSSD Design Concept 3 Zones and 2 Barriers

•Physical separation between soiled, clean and sterile zone

•The first barrier avoids cross-contamination of goods spread by staff

•The second barrier avoids mixing up clean and sterile goods

•Good building design will contribute to correct staff working routines and avoid wrong
human behavior

CSSD Design Concept Goods Work Flow

•Separated entries and exits for soiled, clean and sterile goods

•Strict separation of the staff working in the 3 different areas

•Controlled room ventilation -for good production conditions:

3
 -Soiled zone –negative pressure vs. adjoining areas
-Clean zone –positive pressure vs. to all adjoining areas
-Sterile zone –positive pressure
•Straight workflows -for simple, reliable working routines

Functional Areas required for a CSSD.

Accepted Practice Guidelines

•CSA-Canadian Standards Association International

•AAMI-Association for the Advancement of Medical
Instrumentation
•ASHCSP-American Society for Healthcare Central Service Professionals
•AORN -Association of Operating Room Nurses
•ORNAC -Operating Room Nurses Association of Canada
•CDC -Centers for Disease Control and Prevention
•HISI -Hospital infection society of India

4
FUNCTIONS OF CSSD

5
RECEIVING

The Personnel involved in receiving

must be properly attired in protection
gown or plastic Apron, cap, mask and
should wear gloves.
At CSSD, the instruments must be
checked for proper count and
disassembled for manual or machine
cleaning.

CLEANING AND DRYING

Cleaning is the first and most important step in the sterilization process.
Sterilization alone will not be sufficient to get free from potential health hazards.

ANNING A CSS DEPT

METHODS OF CLEANING

6
SELECTING PACKAGING MATERIAL
•Various packaging materials are used for sterilization
methods
•Depends on contents of pack

7
•Designed for need of storage
•Two types of sterile packaging
•Reusable
•Disposable

8
 Reuse of flexible pouches / Reels not permitted
 Fill only ¾ of pouches / Reel (Leave 25%)
 Pack must be dry after sterilization
 Never peel against peel direction to avoid tear off of paper fibre.
 Put labels or marking on film side only or out of seal area
 Use blunt pen to avoid pin holes
 May use Single wrap/ double wrap.

9
LABELING

It should identify the contents of the product.

Other information such as expiry date and

identification regarding where, when and how the
product was sterilized may also be incorporated.

This could be identified by a discrete number

which tells us about the sterilizer cycle, date and operator.

An indicator could also be attached to the label to differentiate between processed and
unprocessed goods.

• On film side only

• date of manufacturing to calculate the shelf life.
• no printing at filling area as medical item is not allowed to get in touch to printing
color.
• printing report on reel
• lot no manufacturer name or brand-indicator
• size code
• peel direction for pouches.

STERILIZATION

It is a process of freeing an article from all microbes including spores.

A material is pronounced sterile if it achieves 100% (99.99%) free from spores
Methods of sterilization is chosen based on the type of material

10
STEAM STERILIZATION

11
1. START –door seals, jacket warms chamber

2. PURGE–steam enters chamber, while air is purged through the chamber drain

3. CONDITIONING –positive pressure and negative vacuum pulses continue to heat

load and purge air

4. HEAT UP–steam pressure builds to selected exposure temperature and pressure

5. EXPOSURE –timing begins for selected exposure time and temperature

6. EXHAUST–chamber drain opens and ejector water creates vacuum in chamber to

exhaust steam

7. DRYING –ejector water controls vacuum in chamber for selected dry time

8. AIR-IN –chamber returns to atmospheric pressure

9. CYCLE COMPLETE –door can be opened

ITEMS STERILIZED BY STREAM

Methods of sterilization is chosen based on the type of material.

Advantages of Steam Sterilization

Ideal method for sterilizing Fabrics & Surgical Instruments.

• Short Process Time compared to EO Sterilization and Dry Heat Sterilization.
• Requires less temperature 1210c & 1340c than dry heat sterilization 160 0c.
• It is a reliable method of sterilization.
• Economical
• Most preferred method of Sterilization.

12
Disadvantages of Steam Sterilization

•Take 10 to 15 minute to dry a load.

•Steam is not effective in the sterilization of unhydrous substances such a soil, powder
and grease.
•Steam is not suitable for heat sensitive items such as plastic materials lighted
instruments (endoscopes) etc.,

ROUTINE MONITORING

DAILY
Bowie-Dick (EU Standard)

WEEKLY
All Daily Tests
Safety Checks (door seal, door safety checks, and safety valves/devices)
Leak Rate Testing

QUARTERLY
All Weekly Tests

YEARLY
All Quarterly Tests
Steam Quality
Requalification

BOWIE AND DICK TEST

The test devices its name from J.H.Bowie and J.Dick Department of Microbiology.
Edinburgh Scotland. It was developed to expose the pattern of residual air within the
load consisting of a single pack in a high vacuum sterilizer and it helps in detecting the
proper stream penetration

Uneven color changes indicates incomplete sterilization.

Even color changes indicate that it is sterile.

13
 Equipment Control

PLACEMENT OF BD TEST

14
BACTERIOLOGICAL OR BIOLOGICAL INDICATORS

A biologic indicator is a preparation of living spores resistant to the sterilizing agent.

These may be supplied in a self-contained system, in dry spore strips or discs in
envelopes, or in sealed vials or ampuls of spores in suspension.
Moist heat–BACILLUS STEAROTHERMOPHILUS.
Dry heat –BACILLUS ATROPHEUS
Ethylene Oxide Gas–BACILLUS ATROPHEUS

ETHYLENE OXIDE GAS STERILIZATION

Heat sensitive Hospital use article can be effectively sterilized by this method because
of high penetration.
Low grade temperature 500c .

15
Type of Articles sterilized by ETO

Rubber Goods
Catheters
Delicate surgical instruments
Electrical Equipment
Plastic Materials
Lenses instruments

MONITORING SYSTEMS – ETO

•Monitors available
•Chemical
•Biological
•Integrators
•Chemical –Tapes. These indicate that items have undergone a process & is not a check
for sterilization
•Biological indicators–kill factor test

•Integrators –advanced forms to indicate whether all critical parameters have been met,
indicates status of sterilization

•Integrator (Dosimeter)-Indicates completeness of process

DRY HEAT STERILIZATION - HOT AIR OVEN

Temperature should be closely regulated.

Sterilizer should not be overloaded.
Some space should be allowed between
articles in the sterilizer to promote
penetration permit free circulation of air
All articles exposed to dry heat sterilization
must be clean of all organic materials and
must be free from traces of oil or grease.
Temperature:1600ctime1hour

16
ADVANTAGES

Dry heat does not corrode ground glass surface. Hence good for sterilizing glass ware.

Dry heat sterilization is satisfactory for anhydrous oils, grease powder etc.

DISADVANTAGES

Deterioration of materials due to excess heat.

Heat penetration is slow and difficult
Longer exposure period.
Decomposition and discoloration of grease, powder or oil sterilized.
Temperature is likely to vary with in the load.

STERILE STORAGE

STORAGE CONDITIONS

• Should meet EN standards.

• Room should be dry, air conditioned and clean no direct
light.
• Maintain room temp 15-25°c
• Relative humidity 30 - 60%
• Pest free area.
• RESTRICTED ENTRY OF PEOPLE.
• KEEP AWAY FROM DISINFECTANTS AND
SOLVENTS

17
STORAGE

Sterile goods should be stored in the order of their date of expire.

Personnel working here must follow proper hygienic practices.
Sterile material should be stored on wire mesh (non soled) open shelves.
Shelves should be at least 8 to 10 inches from the floor, at least 18 inches from the
ceiling and at least 2 inches from the wall.
At sterile store room no dry sweeping must be done.

IDENTIFICATION AND TRACEABILITY RECALL

Instrument Recall
Procedure followed
•RCA
•CAPA
•Mock drill (annual)

Incident Reports
•RCA
•CAPA

•Identification number or code, and the cycle number, the date of sterilization
•Specific contents of the lot or load including quantity, department, and a specific
description of the items
•Name or initials of the operator;
•Results of biological testing, if applicable
•Results of bowie-dick testing, if applicable
•Tracking
(Details of the used set in log register & Patient file)

POLICIES AND PROCEDURES – DOCUMENTED MANUAL

Organogram

Departmental Structure

Job Description & Responsibilities

Area Layout and Zoning

Operational Procedures

18
Validation for various Sterilizers

Recall Procedure

Reuse of SUMD

DOCUMENTATION

Policies and Procedures-Documented Manual

Validation Documents
Log Book/Registers
Training Documents
Staff Health Check-Vaccination Status
Instrument Recall
Incident Reports
Chemical Register
Checklists

VALIDATION DOCUMENTS

Installation Qualification

Operational Qualification

Performance Qualification

Bowie Dick Test

Leak Rate Test

Biological Indicator Test

Chemical Indicators

Revalidation after PPM

PERFORMANCE QUALIFICATION / BATCH PROCESS RECORD

•Sterilizer identification;

•Cycle number

•Batch number

•Date of sterilization

•Reference number of the master process record

•Temperature (chamber temperature)

19
•The pressure (chamber pressure)

•A signature confirming whether cycle was satisfactory

20
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26
 Hospital Operations Management HHSM ZG614

Hospital Information System

Godwin Jebakumar C V
Senior Programmer
Department of Medical IT (CHIPS)
Christian Medical College Vellore

Agenda

•What is Hospital Management System (HMS)

•Application of HIS

•Benefits of a Hospital Management System

•Security Levels

What is Hospital Information System

Several components work together to add value to an organization:

1.Hardware –physical components

2.Software
1.-instructions that tell the physical components what to do
Operating systems –interacts with the hardware

Application software –interacts with the user

3.Data -collection of facts
1
4.People –Doctors, Nurses, Technicians (Medical and Non Medical)

5.Process -Series of steps to achieve a desired outcome

A system enabling Hospitals to manage information and data, related to all aspects of
healthcare –
-Processes, -Providers, -Patients, and more, which in turn ensures that processes
are completed swiftly and effectively.

Applications of HIS

1.Patient Information System (PIS)

2.Nursing Workstation System (NWS)
3.Laboratory Information System (LIS)
4.Picture Archiving Communication
System (PACS)
5.Stores Information System (SIS)
6.Financial Information System (FIS)
7.Administration / Management
Information System

2
Core Modules

Architecure Modules

Add on Modules

Third Party Solutions

3
Patient Management

Patient Info OPD IPD Admission Emergency

Registration Registration
Patient Search Rooms Availability Appointment Basic Patient
Accounts
Basic Patient Patients’ All Details Registration Report Occupancy Report
Accounts

Nursing

Staff Scheduling Dispensing of Blood Bank Requisition Req –

Medicine Pharmacy
Requisition Req – Medical Internal Posting Nursing Assessment
Store Req. to pharmacy Rec.
Inpatient Room Status Emergency Call Alert System to Doc
Monitoring & Monitoring Logging
Logging
Nursing Assessment Medical Nurse Note Progress Note
Rec. Observation

Lab Management

Test Wise Group wise Patient Wise Sample Acceptance

Worksheet Worksheet Worksheet
Report Entry & Culture Reporting Histopathology Interfacing with Lab
Printing Reporting Equipments
Remote Reg. of Test Reports Export PDF, XML, Word,
Tests to RTF

Radiology & Imaging

Report Master X-Ray 2D – Echo Ultrasound

Cathlab CT Scan MRI ECG

Stores Management

Master Voucher Reports Utility Management

Management Management
Search
Equipment Management

Equipment Master Equipment Equipment Status Current Stock

Maintenance Entry Report Report
Item Location AMC Master Service Report Warranty Expiry
Report Entry Report
AMC & Date Work Order Work Request Renewal of
Report Agreements
Preventive Safety Inst. Master Work Type Master Work Trade Master
Maintenance

4
Transaction / Billing Management

Order to Supplier Purchase Voucher Claim Memo Claim Received

Cash Payment Cheq. Payment Stock In & Out Sale Voucher
made to Supplier made to Supplier
Cash Collection of Cheque Collection Daybook Patient Wise Cash
patient of Patient collection
Supplier Wise Cash Daily Order Requisition
Payment Generation

General Setup

Organization / Collection Centre Doctor Donor

Company
Employee Vendor Medicine Surgery
Account Head Disease Department Bank
Privilege Card General Setup Other Setup OPD Reg. Setup

Reports

MIS Reports MRD Reports Accounts Reports Forms &

Certificates
Report Gallery

Advantages of HIS

1.Improved quality of patient care

2.Improved communications within the hospital
3.Increased productivity
4.Reduced chances of errors
5.Reduced costs.

Security Levels


Authentication
Access control
Audit trails
Physical security of communications, computer, and display systems
Control of external communications links and access
Exercise of software discipline across the organization
System backup and disaster recovery procedures
System self-assessment and maintenance of technological awareness.

5
 Hospital Operations Management HHSM ZG614
Supply Chain Management

Topics to be covered
•SCM –Theory
•What do we do in CMC Vellore?
•Sections under Materials Department
•Materials cycle in CMC
•Purchase Procedure
•Purchase Section
•Coding
•Ordering
•Follow up
•Imports
•Tenders and Enquiries

Supply Chain Management –Theory

•Supply chain management is the management of the flow of goods and services and
includes all processes that transform raw materials into final products.
•The five most critical elements of SCM are developing a strategy, sourcing raw
materials, production, distribution, and returns.
•A supply chain manager is tasked with controlling and reducing costs and avoiding
supply shortages.

Some stalwarts in the field

•Apple
•Relationship
•Flexibility
•Cost
•Walmart
•Responsive to customer demand–through company inventory system
•Amazon
•Strong supplier chain network – multiple ware housing–aggressive
negotiation tactics
1
What do we do in CMC Vellore?

Materials Department

Materials Department –Purchase Cycle in CMC

2
Purchase Procedure at CMC Vellore

Procedure for equipment

•For value below Rs. 50,000/-and consumables –chemicals, kits and reagents –Purchase
Committee
•For value above Rs. 50,000 –Biomedical equipment –GAAT A
•For value above Rs. 50,000 –Non-Biomedical equipment –GAAT B
•Administrative Committee (Apex Body)

Purchase Committee
•The Chairman

•The General Superintendent

•Deputy General Superintendent (Materials) Convener

•Biomedical Engineer

•Mechanical Engineer

•Stores In Charge

•CRS In Charge

•CSSD In Charge

•Add. Dy. Nursing Superintendent

•Treasurer
3
Committee

GAAT A (Medical)
Assoc. Director (Admin)
Medical Superintendent
Treasurer
Dy. Nursing Superintendent
Dy. General Superintendent
Senior Biomedical Engineer
Legal Officer
Clinicians

4
GAAT B (Non Medical)
Assoc. Director (Finance)
General Superintendent
Treasurer
Dy. General Superintendent (Materials)
Dy. Nursing Superintendent (Materials)
Senior Biomedical Engineer
Other members

Administrative Committee (AC)

Director
Principal
General Superintendent
Medical Superintendent
Nursing Superintendent
Dean, CON
Treasurer
Assoc. Directors
AC members

5
Purchase Section
Objectives
•Ensuring continuous supply of quality materials at competitive pricing to the Hospital &
College
•Executing control over the procurement process
•Controlling the inventory and maintaining optimum stock
•Acting as an interface between the end users and suppliers

Process flow for raising Purchase Order

6
Sections of Purchase Department
MMM Section
Ordering Section
Follow Up Section
Imports & Advances Section
Tenders
Committees

7
MMM Section
●Method of Material Management in which symbols, numbers and alphabets are used
(either individually or in combination) to represent materials.
●Materials may include raw materials, consumables, spares or even equipment
●Eg.RM00001A

Why Material Coding?

●Material Coding is done to
○Digitalize materials
○Classify/group materials
○Aid in the procurement, storage, usage and disposal of materials.
●Material Codes should be
○Simple and Easy to Understand
○Unique
○Consistent
○Flexible

Material Coding in CMC

● Material Code: Code for a Material

Format Used: Material Name and Relevant Specs
Eg. BULB -LED -15W

● Item Code: Code for a Specific Material

Format Used: Brand Name Material Name -Relevant Specs –CAT NO (Make)
Eg. Stellar BULB -LED –15W –1001 (Philips)
The Brand, Make, CAT No, relevant specs of the items are pertinent for item code
creation.

8
Ordering section
•Approved ePRsare allotted based on round-robin method to staff

•Staff check the ePRson pricing, negotiate if the rates have changed etc.,

•Orders are placed to the supplier

•Following are the types of orders placed

•Regular
•Confirmatory
•Import
•Standing

9
 Follow up section
•After placing order, a notification email within 7 days is sent to the supplier.
•After due date is over, 2 reminder emails are sent in 7 days interval and final reminder is
sent.

Imports

Tenders and Committees

In a day in Materials Department

No. of Purchase Orders raised in Purchase 240

No. of GRs processed in CRS 257

No. of issues handled in Stores 350

Value of PO and Invoice processed 2 crores

10
Materials Department –Statistics:
Purchase Statistics – 2022 - 23
NO. OF NO. NO. OF NO. OF TOTAL PO NO. OF NO. OF
PURCHASE PURCHASE IMPORT CASH VALUE ENQUIRIES MATERIAL
REQUESTS ORDERS ORDERS ORDERS SENT CODES
RECEIVED PLACED PLACED PLACED GENERATED

TOTAL 47,302 65,903 132 418 500 436 10,762

CRORES
APPROX.

Recent developments
•Machine Learning and Artificial Intelligence

•Medical Devices Rules / CDSCO

Class Type Licence required under
MDR
A Low risk Form 5
B Low moderate risk Form 5
C Moderate low risk Form 9
D High risk Form 9

Materials Department –Developments

Expansion to Ranipet and Chittoor Campus: Stores and CRS were established in the
Ranipet and Chittoor Campuses of the Institution.

11
Stores & CRS –Ranipet Campus

Stores & CRS –Chittoor Campus

12
Materials Department –Developments

•New Section – Material Master Management (MMM) Section: Started in the

Purchase Department in July 2021, with 3 project staff and as supervisor, the team
updated around 30,000 material codes (containing irrelevant, inadequate information)
within a year. Today the team ensures that new material codes are created as per the new
developed format.

•New Purchase Order Format: Replaced the old Purchase Order Format with a new
one containing multiple line items, revised PO terms and conditions.

13
•New Purchase Committee Module: Developed and implemented a new module, with
the provision for 1) Attaching invoices / documents 2) Viewing PR with history of the
item code 3) Option for tracking user information 4) Tool tip of material description
and 5) Option for viewing documents pertaining to PR/PO.

14
•Implementation of eGRN : An initiative that 1) Reduced the man hours spent in
sending and receiving manual GR, 2) Eliminated the time delay in getting signed GR
from the department 3) Reduced cost on Stationery.

Manual GR
eGRN

•Inventory Module in PCS: The inventory module which was a standalone software
by BME was migrated into the CRS module that 1) Enabled Automatic capturing of
PO Details for Equipment Purchases 2) Made inventory data available to users.

15
Inventory module

Inventory data made available for Depts

16
•New Vendor Portal : A new portal in which, the supplier will be able to view the PO,
enter consignment details, track invoice status and update their profile was developed
and implemented.

17
Vendor Portal

18
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•Concealed the exposed pipelines in CRS–Main Campus: The exposed pipe lines in CRS in
the main campus, which were not only as oretotheeye but also a safety hazard was
concealed.

•New Automated Shutters in CRS–Main Campus : Manual shutters were replaced with
automated shutters, which made opening and closing of the large shutters effortless.

Transition to the new campus: The Transition of 13 departments to the New Ranipet
campus was facilitated by CRS and Coordinated by the MSOffice. An external agency
(M/s Fidelis Global) was appointed for moving bio medical assets. Almost 160 trips
were taken to transfer 3000 assets to the new campus.

21
 Hospital Operations Management HHSM ZG614
Central Receiving Section (CRS)

Materials Department

Functions of CRS

Statistics in 2022-2023
NO. OF NO. OF GRN NO. OF NO. OF NO. OF NO. OF
ITEMS PROCESSED INVENTORY CYLINDERS INVOICES INVOICES
RECEIVED GENERATED DISTRIBUTED PROCESSED REGISTERED
TO
ACCOUNTS

TOTAL 17,300 80,436 35,800 15,689 75,000 7,800

Receiving

An administrative function that involves checking of the quality, quantity, and condition
of the incoming goods followed by their proper storage.

•One of the first things that should be considered when receiving and processing
incoming goods is that the receiving bay or loading dock is well organized and clean.
Also should have facilities for receiving and unloading of material.
1
Receipt of Material
Goods Receipt Note (GRN) is a written record that indicates the receiving details of
materials from a supplier to the inventory location.

Mode of Material Delivery

•Hand delivery
•Courier Delivery
•Transport Delivery
•Waybill clearance

Waybill & DC

Delivery checking

•Confirm delivery address

•Check number of package/s
•Condition of the package/s
•Any payment indication
•Any other special instruction
•Check tilt dog indication

2
Physical Verification

•Document -Invoice / Delivery Challan

•Check for
•Supplier name & Address
•Description of the material
•Quantity
•Rate
•Any other charges / Discounts
•GST number
•Appropriate GST rate
•Warranty period

•Material:
•Catalogue number
•Manufacturing date
•Expiry date
•Quantity
•Quality
•MRP
•Pack size

Certificates:
•Test Certificate
•Warranty Certificate
•Absorbent Certificate
•Calibration Certificate
•Weight & Measures Certificate
•User manual
•Certificate of Analysis
•Any other

Technical Checking
•Bio-medical •Mechanical •Electrical •Air Condition •Laboratory
•Other

3
Intimation to supplier

•Damage
•Receipt of material without proper cold chain
•Short receipt / missing of package
•Installation
•Any other discrepancy

Inventory

•Biomedical equipment
•Non-Biomedical equipment
•Computers
•Copiers
•Mobile phones / Tablets

4
•Data pertaining to equipment like
•Serial no.
•Supplier, User Department
•Date of purchase, Warranty details
•Service Department
•Image is captured
•Inventory label is affixed

Inventory module

Inventory label

5
Documentation

GRN Prepared by CRS

6
Queued for CRS In charge Approval

eGRN

7
acknowledged eGRN received in CRS

Acknowledged eGRN received in CRS

8
Invoice forwarded to accounts
Covering letter

CRS checklist

Discrepancy

•Discrepancy while receiving

•Invoice
•Rate
•Quantity
•GST
•HSN Code
•Supplier Address
•Description
•Catalogue no.,
•Goods
•Excess quantity
•Decreased quantity
•Quality issues
•Technical issues
•Damage
•Temperature
•Date of expiry

9
•Supplier, Purchase Department and User Department are informed of the discrepancy
by email.
•Discrepancy item is returned to Supplier through packing slip and replacement is
requested
•For invoice discrepancy, we request for revised invoice or credit note.
•Once discrepancy is sorted out, GRN is prepared and payment is settled

Payment process

•Once eGRN is approved by the concerned User Department.

•It is sent to Accounts Department for making payment.
•The Accounts Department check for three way match i.e. the invoice, GRN and the
Purchase Order should match.

•The invoice is checked for the following

•Supplier name & address
•Supplier GST and CMC GST no.
•Description
•Rate and Quantity
•Catalogue no. / model no.
•HSN (Harmonized System of Nomenclature) code and GST
•Packing and forwarding charges
•Discount
•Once everything is cleared, payment is made online.
•If there is any discrepancy, the discrepancy is amended through proper procedure and
payment is processed.

10
 Hospital Operations Management HHSM ZG614

STORES MANAGEMENT & INVENTORY CONTROL

Topics covered
Stores
Inventory
Inventory Control
Objectives
Types of Inventory System
Concepts
What do we do?

STORES
“Stores” is an area set aside into which all the items and materials required for
production and/or for sale/distribution are received, where they are housed for
safekeeping, and from which they will be issued as required.

INVENTORY
Are stock of materials of any kind stored for future use.

1
Need for Inventory / Stock Control

Balanced flow of material

Minimize stock out
Reduces the possibility of excess stock
Eliminates duplication in ordering
Inventory Control is a major Materials Management function, which requires
the reduction in materials cost without impairing operational efficiency also
known as stock control

Objectives
to minimize the total cost

to keep optimum inventory

uninterrupted supply of items

Types of Inventory System

Two-Bin System
Max and Min System
Periodic Review System
Barcode Inventory System
RFID Inventory System

TWO BIN SYSTEM

Materials are issued from the first bin.

When the first bin is empty materials are ordered.

Replenishment arrives just when the second bin is empty.

When delivery is received both the bins are again filled.

This method is appropriate when the consumption rate is constant

MAX MIN SYSTEM

Maximum level & Minimum level are fixed

Re-order is done after a period of review when the quantity touches a certain level i.e. re-
order level

2
Max Min Method

Re-order quantity (EOQ) 1,500 units

Lead Time 4 to 6 weeks

Maximum consumption 400 units per week

Average consumption 325 units per week

Minimum consumption 250 units per week

PERIODIC REVIEW SYSTEM

Time-bound system
Periodic reviews of stock levels of all items
Period of review is fixed either 3,6 or 12 months
When requirements of all items are worked out afresh, the levels are updated

Barcode Inventory
A barcode is an optical machine-readable representation of data, which shows data
about the object.
Linear Code
Q R Code
Mostly used in Retail Stores

RFID
Termed as RADIO FREQUENCY IDENTIFICATION

Consists of a tiny Silicon computer CHIP and an antenna

The remote reader scans this and sends it to the database.

The CHIP is known as the Spy CHIP

3
CONCEPTS

SAFETY STOCK

•A safety stock is a cushion to prevent against stock outs. A system that can absorb the
shocks of large fluctuations at the least possible cost
•

•Safety Stock = 100 box of mask per day * 15 days –50 box of mask per day * 10 days =
1500-500 = 1000 boxes

Lead Time

Time Period between PR raised and receipt made in Stores.

Factors influencing:
Administrative Lead Time
Delivery Lead time

Ordering Cost
Clerical Cost
Administrative cost.
No of orders * Cost per order

Inventory Carrying Cost

The costs of holding these goods in stock are
known as carrying costs, or inventory holding costs.

Obsolescence 10%

Interest in Invtry. investment pymt 6%

Physical deterioration/prevention cost 5%

Distribution, handling & transportation 3%

Tax, insurance, rent etc. for storage 1%

4
Economic Order Quantity

Most Economic purchase order quantity which keeps balance between Inventory
carrying cost and ordering cost.
For example, consider a retail clothing shop that carries a line of men’s shirts. The shop
sells 1,000 shirts each year. It costs the company Rs.100 per year to hold a single shirt in
inventory, and the fixed cost to place an order is Rs. 20.
The EOQ formula is the square root of (2 x 1,000 shirts x 20 order cost) / (100 holding
cost), or 28.3 with rounding. The ideal order size to minimize costs and meet customer
demand is slightly more than 20 shirts.

What do we do?

5
GOODS INWARD BOOKS
Register maintained in stores to record the
material directly received in stores without
necessary Document.
Information like Po number, Invoice no/DC
number & Description and date forwarded to
CRS for Proper Documentation.

Goods Received Note (GRN)

Mandatory Document for Payment process

Multiple levels of Approval .
To avoid double payment with original invoice and Accounts copy of GRN is required
for payment.
All the documents including Warranty and inventory numbers are captured in GRN.

Discrepancy note Register/Intimation slip

If there is any deviation in the product from the purchase order then discrepancy note is
made.

Information will be conveyed to CRS & Purchase for administrative decision .

Packing Slip
Slip generated for returning the
goods to the supplier .

Unique number is generated

along with suppliers documents .

Two copies generated one is for

supplier and other one is retained
in CRS.

6
Stores Receipt
Confirmation receipt generated by stores before
updating the stock .

Unique ID number is generated for a batch of

materials

Cannot be revoked .

Issue Slips
ID numbers generated
for issuing the materials
to the wards for better
accounting.

Captures Material Code

Bin details Account
number and other
valuable informations.

EMR Slips
Excessive Material Return slip .

Returning the material back to store if wrongly

indented or idle stocks .

Two copies generated one is for store record

keeping and other is for Accounts

Weekly / Annual Stock Register

Weekly Audit report is stored but stock is not updated .

Annual Stock take is done in the business year end Mar 31 .

Record of the update is maintained for future reference.

7
FUNCTIONS OF STORES

Receive the materials, Check them for quantity, co-ordinate for inspection and quality
checks.
Accept the passed materials, and prepare documents for the supply received. Reject the
materials failed in Quality checks.
Take into Stock the accepted materials, store them in respective locations.

Receive Indents from users, Issue the required materials to users, Issue Slips prepared,
Record and update the Stock registers/ledgers.

Periodic review of Stock levels, raising Purchase Requests when Reorder level reaches.

Keep the storage place clean for facilitating handling and movement and observe all
safety measures and security regulations.

Periodical physical verification of Stock and ensuring proper accounting.

TYPE OF STORES

Decision by Management.

Centralized Stores –ensure economy by reducing man power, economy in inventory &
effect better control. But difficult to cater the needs of various work centers scattered
in different locations.

Decentralized Stores –various stores kept near the production floors/work areas
ensure immediate supply. Waste of money by blocking up large capital in the same
material inventory by various stores of the institution.

CLASSIFICATION AND CODIFICATION

Classify materials to their permanent basic characteristics, and then proceeding from
the general to the particular, bring together all closely similar materials and parts
irrespective of their functions and assemblies for which they were originally designed.
Identification through proper codification resulted in elimination of the multiplication.
A rationalized system of codification would reduce the number substantially at the same
time make their identification an easier job, avoiding lengthy descriptions and
confusions.

Codification
1. Alphabetical system -first alphabet of the name of the material is the starting point of
codification
2. Numerical system –Based on simple numbers (One number is allotted against each
material) or block numbers ( Eg: raw materials 1-1000, packing materials 1001 –2000
etc.)
3. Decimal system -0-9 digits are used in this classification and each digit signifies some
characteristics of that material
Alpha Numerical system

8
MATERIALS ACCOUNTING

Bin Card–a record of movement of materials the daily transactions (daily receipts,
issues) and material codes, description, balance quantity on hand & Re-order levels. It
serves as a check on Stock Ledger and helps physical verification of stores.
Stores Ledger–PR details with quantity ordered, Stock levels, Material code number and
bin number, GR No., Supplier name & Quantity received, Issue details –user
department, indent number, quantity issued
Materials Returned Note(EMR)

PRICING/CHARGING
•FIFO
•LIFO
•AVERAGE COST METHOD

PHYSICAL VERIFICATION

Necessary to ensure against embezzlement, spoilage, damage, obsolescence and errors.

Discrepancy found the causes are investigated and records reconciled.
PERIODIC VERIFICATION
CONTINUOUS VERIFICATION
ANNUAL STOCK VERIFICATION

AUDIT CONTROL
Periodic or surprise audit may reveal some potential security problems. Audit may take
the role of a watch-dog, pointing out weak spots and then advising for remedial action.
It controls inaccurate record keeping and fraudulent practices.

Auditing – Internal

-External

Statistics 2022-2023

9
 Hospital Operations Management HHSM ZG614

EMERGENCY DEPARTMENT
Dr. Sandeep Nathanael David
MD, MEM (SEMI), MRCEM(UK)
Assistant Professor, Dept of Emergency Medicine
CMCH, Vellore

Introduction
•Emergency -a dangerous or serious situation that happens unexpectedly and needs fast
action in order to avoid harmful results.
•Emergency care starts in pre-hospital setting, usually provided by paramedic and
ambulance services.
•Continued at the hospital at the Emergency Department

What do we do?
•Casualty Emergency Department
•Stabilise critically ill patients from all ages groups, across all specialities
•Ensure that patients receive appropriate further care from concerned departments
•Training and Research

Scope of patient footfall

Expected patients
• Trauma and Accident victims
• Acute medical or surgical illness –MI, CVA, Acute Abdomen etc
• Poisoning and Deliberate Self Harm

Non emergent visits

• Patients with admission slips but lack of beds
• Patients who require admission from OPD but delay in arranging beds
• Patients with CLD, CKD, etc on routine follow up
• Patients referred to other departments for further management

1
CMC Emergency Department
• Started in the ground floor of OPD building and was managed by interns (Casualty)
• Moved to the current location in 1990’s and became an independent Emergency
department (A & E)
• 1 year fellowship course was started in 1997 which was extended to 2 year course in
2008.
• Currently it has evolved into Department of Emergency medicine with a recognized
MD program, and is further staffed by fellowship registrars and senior house officers

ED Personnel
• Consultants –MD/MS/FAEM/MRCEM
• Registrars –PG, Fellowship and Non PG trainees
• Staff nurses
• Emergency medicine technicians/Paramedics
• Attenders
• Housekeeping staff
• Radiology technicians
• Security

Emergency Department Layout

•Triage
•Resuscitation Room – Immediate threat to life and/or limb
-ABC Compromise
•Bays 1, 2, 3, Trauma bay -Incumbent threat to ABC
-Pain relief, Pregnant women
-Trauma patients without immediate ABC compromise
•Consultation room -Stable patients, no danger to life, limb or ABC

2
Flow of Patient-Care

Triage
•“Trier” –‘To sort’
•“The right patient gets the right treatment at the right time
•Different systems exist –1-3, 1-5, Colour systems, etc
•In CMCH, follow a 1-4 system
•Done by a trained Triage-Nurse, can also be done by a Doctor

3
Triage
Condition Time to be seen
Priority
-ABC compromise
I Immediately
-Immediate threat to life or limb

-Haemodynamically stable, needing

intervention/further care ½ hour to 1 hour, earlier if
II
-Potential ABC compromise feasible
-Severe pain
-Pregnancy
-Vitals stable, ambulant
>1-2hours depending on patient
III -Chronic complaints
flow
-No emergency care needed
IV -OPD referral required Usually sorted out at presentation

Priority I –Resuscitation Room

•Triage level 1, should be seen immediately
•Manned by 1-2 doctors, trained in advanced airway management, ACLS, Trauma
management
•Separate nursing and EMT team
•Blood gas analysis, NIV, mechanical ventilation if required
•Bedside Ultrasound –E-FAST, RUSH protocol
•Rapid handover and disposition

Priority II –Bays I, II, III, Trauma

•No immediate danger to life/limb ; No ABC compromise
•Bulk of ED patients, should be seen within ½ hour to 1 hour
•PI patients can be shifted here after stabilization
•2-4 doctors
•Focused history, examination, differential diagnoses. Relevant investigations and
interventions (analgesia, splintage, IV fluids, etc)
•Handover to concerned unit

Priority III and IV –Consultation room

•Stable, ambulant patients. Waiting time often longer than an hour
•1-4 doctors, depending on need/availability
•Usually referred to other specialty departments
•May be evaluated if needed, if no obvious acute intervention needed, sent to OPD
•Vigilance needed here as well

4
Core competencies required
•Good clinical skills, better decision-making skills
•Must have a basic knowledge of emergencies from all fields
•ACLS, Trauma care, advanced airway management, IV access, Intra-osseus access
•Basic Bedside Ultrasonography
•Anaesthesiology, Orthopedics, Pediatrics
•Diplomacy, good people-skills
Equipment required
• Trolley –mobile, tiltable
• Monitors with SpO2, ECG, NIBP and
ETCO2
• Wall Oxygen supply as well as
O2cylinders
• Defibrillators with pacing paddles
• Airway –Direct and Video Laryngoscope
• CPAP, BiPAP and Ventilators
• AMBU bag and Bain’s circuit
• Portable Ultrasound machine
• Blood gas analyzer
•Tiltable, mobile trolleys
•Uninterrupted Central Oxygen supply
•Oxygen cylinders, periodically checked
and maintained
•Biphasic Defibrillator(s)
•Monitors with continuous NIBP, pulse
oximetry, ECG monitoring
•Blood glucose/serum ketone strips
•Urine-dipstick tests
• Blood glucose and serum ketone analyzer
• Portable X-ray machine
• In-house Radiology suite
• Handheld Doppler
• Opthalmoscope and Otoscope
• Computers and Telephones
• Refrigerators for drugs
• Splints
•Refrigerators at strategic areas
•Drugs, including cardio-active and
anaesthetic agents
•Computer terminals and telephones at all
areas
•Blood Gas Analyzers
•Splints
•In-house radiology suite
•Portable X-Ray
•Bedside USG
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Special Liaisons
1. Trauma services –Special Trauma pager, through the telephone exchange
-Trauma surgery, Orthopaedics, Neurosurgery, Radiology
2. Stroke Team -Within 4.5 hours of a clinically diagnosed stroke
-Stroke team manages the patient and decides on further
care
3. Obstetrics - Rapid transfer to Labour room/Scan room after initial stabilization
4. Cardiology – Shift for PCA/Thrombolysis once ECG diagnosis of STE-ACS is
made and initial management done

Services offered
•Procedural Sedation and Analgesia
•Code-blue rapid response team for certain areas of the hospital
•Stabilization of OPD patients
•Command centre in the event of a Mass-Casualty-Incident

Medico-legal duties
•Road Traffic Accidents –Incident Report,
detailed documentation of injuries, blood
alcohol levels
•Brought dead –Incident report if unnatural
death suspected/confirmed
•Deliberate Self Harm –Incident report
•Child Abuse/Sexual assault –Incident
report, inform senior paediatrician
/obstetrician

Training
•Structured training courses
•MD Emergency Medicine (3 years), Fellowship in Accident and Emergency Medicine
(2 years)
•Non-PG residency also offered
•EMTC, MSEED

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Quality
•External: • NABH
• Internal:
• Audits
• Chart audit
• CPR audit
• Mortality audit
• DAMA/DAR audit
• 72 hr revisit audit
• Trauma audit (With Trauma Sx)

“No Trolleys!!!”
•Code grey declared, no more patients to be admitted in the ED
•Duty ED consultant directly speaks to the admitting unit consultant, involves in
admitting patients
•De-prioritize patients to priority III, or directly discharge patients to OPD
•Code-red can be lifted when trolleys are free

Conclusion
•Face of the hospital for the sickest patients, 24 x 7 x 365
•Ensure competency and compassion in patient care
•Proper acute management of sick patients can make the difference between life and
death
•Needs support of other departments to prevent overcrowding and optimal functioning

7
 Hospital Operations Management HHSM ZG614

ROLE OF ENGINEERING SERVICES IN

HOSPITAL OPERATIONS MANAGEMENT

JEYALIN VINO J V
M.E. STRUCTURAL ENGINEERING
Asst. Engineer
Department: Engineering Planning.
INTRODUCTION
•Engineering services have large contribution towards shaping the environment of
Hospitals.
•Engineering services are an integral part of hospital infrastructure
Hospital Engineering Services are considered as ‘Backbone of the hospital’

FUNCTIONS OF ENGINEERING SERVICES

•To provide safe & hazard free environment.

•Ensuring that the facilities /services under their scope are in compliance with the
relevant legal provisions and are in order.
•Ensuring optimum operational efficiency of engineering system.
•Preventive maintenance to avoid break down.
•Preparedness for break down to reduce down time.

ENGINEERING SERVICES
Hospital Engineering services are the life line
for a smooth functioning of the hospital.
Engineering services are broadly classified as

1
CIVIL ENGINEERING

ELECTRICAL ENGINEERING

2
ELECTRICAL ENGINEERING –Electricity supply

ELECTRICAL ENGINEERING –Power and Voltage

•Switchgears & Control panels are inside in a shaded / dust free environment
•Proper earthing should be provided
•Dual supply should be provided in emergency, OT, ICU etc
•Standby Noise free DG sets with SEB, SPCB approvals
•One electrical circuits for 10 lights / fan points and One power circuit for two 15 amps
sockets / 1800 watts
•Use of Appropriate MCB
•Steel conduits will be more than PVC tubes ensure more protection against fire.
•No Socket/Switches in anaesthetic store room
•Illumination standards to be different for different areas such as High illumination in
Admin offices, Nursing station, Dietary store, Examination rooms.

ELECTRICAL ENGINEERING –Lift

3
ELECTRICAL ENGINEERING –AC & REFRIGERATION

MECHANICAL ENGINEERING

BIO MEDICAL ENGINEERING

4
ENVIRONMENTAL ENGINEERING

ENVIRONMENTAL ENGINEERING –water supply

ENVIRONMENTAL ENGINEERING –Waste water disposal

5
CHIPS (Computerized Hospital Information Processing System)

Computer and Information Technology Engineers have emerged as an important

Engineering group, who cater to the Data Management needs of the hospital.

6
Telecommunication

7
The use of digital information and communication technologies to access health care
services.

STANDARDS FOLLOWED FOR CIVIL ENGINEERING DESIGNS

The Hospital being a specialized establishment for providing Patient care, its
infrastructure not only needs to satisfy all the statutory norms, but also needs to meet
some additional specialized requirements, which are closely linked to Patients care &
safety. Thus, by referring to Indian Standard & National Building Codes and various
guidelines, Facility Engineers can enhance the safety of the infrastructure and thus,
help in Enhancing Patient safety.

CIVIL ENGINEERING –Land development Standards

8
CIVIL ENGINEERING –Water Requirement Standards

MECHANICAL ENGINEERING –Air Ventilation Standards

In order to achieve air changes given above, we can plan the type of air ventilation need
for the respective spaces.

ORGANOGRAM OF ENGINEERING DEPARTMENTS

9
MAINTENANCE

•All Engineering Service Departments have their own maintenance Team for carrying
out various Maintenance Works.
•In order to prevent and to oversee the defects of each service, an maintenance team is
required.
Maintenance can be classified based on its requirement as

DAILY MAINTENANCE

•Daily / Routine maintenance refers to any maintenance task performed at regular, time-
based intervals that keep facilities operating smoothly.

•Routine maintenance can be as simple as making sure all bathrooms is stocked with
toilet paper at the end of every day or as complex as inspecting and adjusting heavy
machinery.

Examples:
janitorial tasks
Cleaning debris and excess lubricant from equipment

Emergency Maintenance
An emergency where immediate maintenance is essentially any repair that you need to
do immediately to keep people and assets safe. If left unattended, the damage could be
substantial and even hurt your bottom line and have reputational costs.
These situations have the possibility to cause a significant amount of loss, and it
sometimes is hard to get the emergency under control.

10
Examples:
•Fires
•A sewer line backing up into a unit or complex
•Air conditioning going out in extreme temperatures
•Elevators breaking down with people trapped inside
•Burst pipes
•Leaking roofs
•Gas Leaks etc

Planned Maintenance
Planned Maintenance covers any maintenance that is planned, scheduled, and
documented. It is specifically defined as preventive maintenance that is carried out
according to a set plan.

Break Down Maintenance

Breakdown maintenance is maintenance performed on equipment that has broken down
and is unusable.

Preventive Maintenance
Any break in any of the services may spell serious trouble of some or the other kind into
the Efficiency of the entire patient care delivery system of the hospital and that’s why we
have this Preventive Maintenance Program.

Preventive Maintenance is is defined as taking precautionary steps or actions to prevent

equipment failures before they actually occur. Preventive maintenance typically involves
routine inspections, upgrades, proper lubrication (where applicable), adjustments, and
replacement of outdated equipment or parts.

Advantages
 Increase Longevity of the system
 Ensures safety and Prevent hazards
 Prevent break in continuity of the system
 Prevent costly emergency repair

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Preventive Measures against Safety Hazards –Common For all Branches

1. Prevention of Engineering Connected Safety Hazards:

This is achieved by following the steps below:

1. To manage the Engineering services, with full efficiency and effectiveness, the hospital
requires a full department of engineering services with adequate fully trained staff
including qualified Engineers.

2. The department should be headed by senior well qualified Engineers with vast
exposure in the relevant field of Engineering.

3. Adequate supervisory and other staff in all branches should be available to attend to
problems round the clock.

12
4. Availability of a documented Quality manual with clearly defined role and scope of
services of the engineering department and the policies and procedures covering every
aspect of their activities.
5. A procedure for detection/reporting of defects and their repair/maintenance with the
minimum possible downtime and fixed minimum time frame for restoring the facility to
operational state.
6. A check list of all the legal compliances and a mechanism for ensuring regular
updating of the Licenses/registrations/Certifications.
7. A comprehensive equipment management program and a system of equipment audit.
The records of proceedings including the audit points and corrective actions are to be
maintained.
8. An updated inventory of all the equipment and a comprehensive history sheet in
respect of each and every equipment unit.
9. A standardized system and format for registering complaints giving the details of:
i. Ward/ department
ii. Details of the equipment
iii. Details of the defects
iv. Urgency involved (routine/urgent/immediate)
v. Date and time of complaint
vi. Authentication by the complaint.
10. A record of breakdown complaints and the response time for attending to
complaints (restoration of operational status) is to be maintained and monitored.
11. Regular periodic Inspection and Re-Calibration of the Equipment by Authorized
Agencies.
12. Adequate potable water supply round the clock with 3 days reserve and a system of
regular periodic testing of water samples at the source as well as at the user end.
13. Planned periodic cleaning of AC ducting and cleaning/replacement of filters.
14. Availability of a Fire safety Manual with a check list of actions to be taken by the
staff during Fire/other emergencies.
15
a. It is to be ensured that Up to date floor plans along with the Escape routes
are available, the escape routes are kept free of any obstacles and there is a documented
plan for safe escape of Patients, Public and Staff during a Fire or other Emergencies.

13
 b. Operational readiness of the equipment is ensured by regular periodic
inspection and planned preventive (and breakdown) maintenance of all fire safety
equipment.
16. Hospital safety committee has to regularly inspect the facilities at least twice a year
and after a detailed exercise in Hazard Identification and Risk Analysis (HIRA)
Submit their findings and recommendations in writing. A record, including the actions
taken, is also to be maintained.
In CMC we have a Committee and inspection will be done once in every month
17. There should be a documented system of periodic inspection and Planned
Preventive (and breakdown) maintenance and risk reduction in respect of each of the
following facilities/services.
a. Buildings and environment for loose stones/ plaster/ slates, bricks.
b. Electric supply and distribution system including the diesel generator (DG)
sets UPS systems and stabilizers: No loose hanging wires or temporary
connections to be allowed.
c. Water supply and distribution system including the supply of hot, cold, potable,
ultra pure water and steam supply: - There should be no dripping taps, leaking
pipes or blocked sewage lines.
d. Air conditioning and refrigeration facilities.
e. Centralized gas and vacuum supply service.
f. Communication system.
g. Traction/transportation system.
h. Lightening Protection-Periodic testing of patency of Earthing.
i. Public health engineering system (waste storage/disposal, effluent treatment
plant).
j. Proper earthing of all electric equipments.
k. Periodic checking of all switches/ sockets to ensure their adequacy and hazard
free functioning.
2. Prevention of Hazards Related to Construction / Maintenance Activities:
 Construction and maintenance activities are activities that temporarily throw the
system out of gear and disrupt the normal functioning for a variable period.
 Any demolition/new construction may mean temporary change of entry/exit
routes, spread of debris or building materials here and there, disconnection of

14
 electric cabling, shutting down the power supply or water supply or
communication lines.
 It also has the hazards of accidental fall of construction materials on the patients,
public or staff nearby, leading to serious injuries.
 In order to prevent any disruption of normal functioning and its adverse effects on
the health and safety of people, the Management and the Engineering services
shall make the following arrangements.
1. Plan the activities in advance in a phased manner to ensure minimum
disturbance of the normal functioning of the services.
2. Put in place and test the alternate arrangements before actually starting the
activities.
3. Inform all concerned departments about the activities and their timings well in
advance and also the changes necessary in the system of functioning.
4. Ensure that the people are fully protected from any possible/accidental injurious
effects of demolition/construction activities by creating barriers to dust, noise, falling
materials.
5. Ensuring that the maintenance activities are started only after making all spares/
equipment/tools available, so that they can be completed as per the schedule.
6. Timings for such activities may be adjusted so that they have minimal disruptive effect
on the patient care activities.
7. If necessary, suspending some of the services or shifting locations/timings, as an
interim measure.
8. Placing warning signs and directional signs wherever indicated.
9. Any other measures necessary to ensure safety of patients and their
safe/uncompromised treatment.
Construction and maintenance activities do have an adverse impact on the Life Safety
Systems in the hospital.

CONCLUSION
Hence, it’s clear that the Role of Engineering Services plays an extremely vital service
on` the efficiency of the entire Patient care delivery system of the hospital’.
And it is also evident that the Facility Engineers are responsible for the Design,
Detailing, Inspection, repair and maintenance of all the facilities and services mentioned
above to ensure their optimum operational reliability and reduction / Elimination of any
risks associated with them

15
 Hospital Operations Management HHSM ZG614
NURSING SERVICES & WARD MANAGEMENT
Mrs.Lillian Percy Kujur
Deputy Nursing Superintendent

Nursing services
Nursing services refers to the department of the Christian Medical College managing the
Nursing task forceof the hospital.
The Office of the Nursing Superintendent, known as Nursing Service Office (NSO) is the
central hub for all nursing care activities.

Nursing Administration
Is the strategic management of nursing personnel, patient care, and facility resources
through the support of regulating policies.

Levels of nursing management

1
Elements of administration –POSDCORB

1. Planning
A plan is a future course of actions. Planning involves selecting objectives, policies,
strategies, programmes for the nursing services.

Role of nursing administrator in planning

•Laying down the vision and mission of Nursing Service and the Institution
•Representation on committees such as Administrative committee, executive committee,
quality steering committee, safety steering committee, budget management etc.
•Planning of human resources, equipment, infrastructure etc.

2
VISION
‘Christian Medical College seeks to be a witness to the healing ministry of Christ through
excellence in education, service and research.’
MISSION
‘The primary concern of the CMC, Vellore is to develop through education and training,
compassionate, professionally excellent, ethically sound individuals who will go out as
servant-leaders of health teams and healing communities’.

VISION:
The Nursing Service of the CMC, Vellore seeks to provide Christ Centred,
Compassionate, holistic state of the art quality patient care through nurses excelling
professionally in practice, education, management and research

MISSION:

 Committed to care for patients and their families in the physical, psychological,
social and spiritual dimensions maximizing the potential for health and
productivity or maintaining the patient's comfort and dignity until death.
 Strives to develop Nurses personally and professionally to be of sound faith,
integrity, ethical conduct and responsible to our society
 Advocates the mandate of Christ to excel by developing nurse leaders who will
impact nursing practice through diligent management, education and research

OBJECTIVES
•To practice the art and science of Nursing in the spirit of Christ
•To provide promotive, preventive and curative care to patients irrespective of their
caste, creed and socioeconomic status with compassion
•To equip the practising Nurses with the knowledge, guidance and resources required to
provide holistic, evidence based care

3
2. Organization

•Process of developing physical, informational, and human resources as per plan.

Organizing involves the grouping of activities necessary to accomplish goals and plans,
the assignment of these activities to appropriate departments and provision of authority,
delegation and coordination.

PRINCIPLES OF ORGANIZING

4
•Hierarchy or chain of command –it means the rule or control of higher
over the lower.
•Span of control –refers to the number of subordinates a manager can effectively
manage.
•Integration (unification) vs disintegration (diversification)

•Centralization and decentralisation

Centralisation refers to the concentration of

authority and decision making in one single
position in the organization
Decentralisation – is one in which the lower
levels are allowed the discretion to decide
most of the matter

•Unity of command –An employee must get orders from one superior only.

5
•Delegation–assignment of the work to subordinates

Delegation of activities

•Centralization: Activities such as recruitment, human resource planning, disciplinary

action are centralized and acted upon by the Nursing Superintendent

6
•Decentralization: Day to day activity planning, staff development and training are
handled by the Department Heads and the Nurse Managers

Nursing Superintendent in the Organization

NSO ORGANOGRAM

7
The Nursing Superintendent is also assisted by the following administrative members:

Associate Nursing Superintendent 1-Human Resource management

Associate Nursing Superintendent 2-Peripheral area management

Deputy Nursing Superintendent 1-Quality management

Deputy Nursing Superintendent 2 -Material management

Deputy Nursing Superintendent 3 -In-service education

CATEGORIES OF Nursing personnel

3. Staffing
It involves manning the organizational structure through proper and effective selection,
appraisal and development of nursing personnel.

8
The staffing process includes:

Recruitment and placement

• Competency based training program

• Placement based on appropriate

experience

• Induction training

Education and training

9
Performance appraisal

•Every 3 months-2 yrs

•Every 6 mo-1 yr

•Every year-confirmed staff

10
Staff welfare

•Organize welfare activities of staff –curricular and extracurricular activities

•Protecting the rights of staff
•Advocating for Nursing Staff
•Formulate policies related to staff welfare

1. Communication–It is the process of sharing and transferring the information

between nurse managers and their subordinates
2. Supervision–involves guiding the efforts of others to achieve stated work output
3. Motivation–is the desire to act and move toward a goal
4. Leadership –it is a continuous process of influencing and supporting subordinates
to work enthusiastically towards achieving goals

11
5. Co-ordination
It is the act of synchronizing and unifying individual staff efforts for better action to
achieve organizational objectives.

Types of coordination

12
6. Controlling
It is the measuring and correcting the performance or the activities of staff as per
expected performance.
Steps of control
Standards are determined
Actual performance is measured
Actual performance is compared with standards
Appropriate corrective actions are taken

Standards of care

Capturing of quality indicators

•Pressure sore
•Medication error
•Falls
•Extravasation
•Accidental de-lining
•Skin tear –Medical Adhesive Related Skin Injuries, Cautery burn
•Needle stick injury

13
7. Reporting and Recording
Reports are oral or written exchanges of information shared between caregivers or
workers in a number of ways.
A report summarizes the services of the person, personnel and of the agency
Reports are written usually daily, weekly, monthly or yearly.

8. Budgeting
Budgeting process is a systematic activity that develops a plan for the expenditure of a
usually fixed resource during a given period to achieve a desired result.

Budgeting is the allocation of resources (human, material and financial) to best assure
the accomplishment of nursing organizational goals.
Operating budget –daily activities and services including patient care revenues, labour
costs, outside purchase services, supplies etc.
Capital budget –money earmarked for the purchase of permanent equipment or major
renovation, construction projects

14
Florence Nightingale
To be in charge is certainly not only to carry out the proper measures yourself but to see
that everyone else does so too.

•Ward management is a process whereby the ward manager through people and with
people makes use of ward resources to achieve ward objective. Kozier, Erband Burk
(2011)
•Ward manager -a person responsible for the management of a hospital ward.

Objectives of Ward Management

 To foster team spirit in the ward that will provide highest quality healthcare
services.
 To provide a clean, well ventilated environment, free from infection, accidents
and hazards for patients.
 To provide facilities that meet the needs of patient and their attendants.
 To optimally utilize ward resources for maximum output.
 To encourage personnel training, job satisfaction and advancement for
patient care.

15
Factors influencing ward management
Ward management is one of the prerequisites for good nursing care. Nurse
Manager/Supervisor should understand the following thoroughly for good ward
management:
(1) Knowledge of the ward –duties and activities performed
(2) Planning the schedule of the ward –to save time
(3) Starting the work on time
(4) Preventing interruptions
(5) Establishment of ward routines for delegation of work
(6) Use of democratic method in establishing ward policy –to encourage staff
participation as it will enhance the cooperation
(7) Orientation of new personnel to hospital and unit –induction training is a must for
new staff
(8) Maintenance of suitable environment

MANAGEMENT OF ENVIRONMENT
1. Adequate Lighting
2. Prevention of Noise
3. Elimination of unpleasant odors (Bad Smell)
4. Dust control
5. Safe water supply
6. Safe disposal of waste

16
 7. Freedom from insects
8. Provision of adequate privacy
9. Prevention of cross infection
10. Control of visitors

(9) Providing supplies and equipments

For good management, all materials (supplies and equipment) should be:
 Free from repair
 Accessible
 Conveniently located
 Maintaining standard
 Maintaining good exchange system
 Maintaining good inventory and requisition

17
10. Clear cut and specific orders for medical therapy and
nursing
Clear cut doctors orders and nursing orders
help to :

11. Record keeping

 Maintain accurate records –has legal and scientific value

 Eg. Patient clinical records
 Administrative records
 Equipment records
 Personnel performance records

12. Reporting

18
 13. Morale
Refers to the confidence, enthusiasm, and discipline of a person or group at a
particular time. Maintenance of high morale among all members of the staff.

14. Establishment of good relationship

Establishing good working relationship within the ward and with other associates is an
essential factor in good work management.

15. Delegating responsibility

Delegation is the process in which a nurse directs another person to perform nursing
tasks and activities

19
 16. Assigning duties and responsibility
Methods of assignments

Patient method –a nurse is expected to give complete nursing care to one or more
patients.

Team method –several staff members under the leadership of a professional nurse are
assigned to a group of patients. Ideally the team cares for the patients throughout
their entire hospitalization

17. Time planning

The objectives are:
To provide adequate staff for good nursing care for 24 hours
To provide the best possible experience for nursing students
To comply with good personnel policies and keep nurses happy and contented

20
 18. Good teaching
For both the students and staff should be
ensured.
Incidental teaching
Clinical demonstration
Individual conference
Group conference

19. Good supervision

•Supervision is a cooperative relationship between a leader and one or more persons

to accomplish a particular purpose. -Lambertson
•It is a teaching learning process.
•Good supervision helps the individual nurse to set up objectives and attain it.

Espirit de Corps (union is strength)

States that an organization must make every effort to maintain group cohesion in the
organization.

21
 CMC
Vellore
Biomedical Equipment
Management in Hospitals
Please
Insert your
Photo Here
Arul Prakash
BE, MBA
Head of Biomedical Engineering

Christian Medical College Vellore

Serving the nation since 1900

 Learning objectives
CMC
Vellore

• In this session you will learn

• What is Biomedical Equipment Management?
• As a manager what you should know about Biomedical
Equipment Management program?
• What is the importance of such a program?
• What are the components of such a program?
• Importance of Inventory, Maintenance and Calibration
• Monitoring and improving such a program with quality
indicators
• Terms used in Medical Equipment Management like PPM,
Breakdown, Inventory, Calibration, AMC, , KPI, MDR, MDIR etc.,
 Biomedical Equipment
CMC
Vellore

• Biomedical Equipment or Medical Equipment or Medical Device plays a

vital role in hospitals as they directly impact patient care
• Biomedical Equipment are used for diagnosis, monitoring, life support,
treatment and therapeutic purposes
• Healthcare practitioner decides on the course of action based on the
results/outputs obtained from Medical Equipment
• Medical Equipment forms a combination from handheld devices such as
Glucometers, Pulse oximeters, Monitors etc, to major hi-end equipment
like Xray, CT, MRI, CATH Labs etc
 Life cycle of Biomedical Equipment
CMC
Vellore

Operation
 Biomedical Equipment Management Program
CMC
Vellore

• A Biomedical Equipment Management Program (BEMP) is a well

defined and structured plan of activities that covers the entire life
cycle of Medical Equipment from planning till disposal
• Medical Equipment are valuable assets to a hospital and hence needs
proper management and maintenance
• BEMP is an essential tool for efficient management of Medical
Equipment

World Health Organization:

Medical Equipment maintenance, when well planned, managed and
implemented, allows for all the equipment in a healthcare institution to be
reliable, safe and available for use when it is needed for diagnostic procedures,
therapy, treatments and monitoring of patients. It also has the ability to
prolong the useful life of equipment and minimize the cost of ownership
Ref: Medical equipment maintenance programme overview - WHO Medical device technical series
 Importance of Biomedical Equipment Management Program
CMC
Vellore

• Proper selection of Medical Technology

• Equipment reliability
• Equipment safety
• Equipment availability
• Minimize breakdowns
• Minimize maintenance cost
• Improves life of Equipment
• Improves efficiency
• Improves quality of care
 Hospital Biomedical Engineering
CMC
Vellore

• In order to implement such a program, you will require an in-house Biomedical Engineering
department (for large hospitals) comprising of Biomedical Engineers and Technicians with proper
testing equipment and tools
• For small hospitals and nursing homes with less number of Medical Equipment, the maintenance can
be outsourced or managed with 1 or 2 in-house Engineers/Technicians

Director / Head of Facilities

/ Chief Engineer

Head / Manager - Biomedical

Dy. Head / Dy. Manager

Section 1 Section 2 Section 3 Section 4

Engineer / Engineer / Engineer / Engineer /
Supervisor Supervisor Supervisor Supervisor

Junior Engineers Junior Engineers Junior Engineers Junior Engineers

and Technicians and Technicians and Technicians and Technicians
 BEMP - Committees
CMC
Vellore

Biomedical Engineer will serve the following committees to implement BEMP or

in other words the following committees are part of BEMP
• Purchase committee
• Capital Budget committee
• Technology acquisition committee
• Quality & Safety committees
• Condemnation committee
 Components of Biomedical Equipment Management Program
CMC
Vellore

Selection of Medical Equipment /

Technology

New Equipment Acceptance process

Inventory Management

Maintenance Management
Biomedical Equipment
Management Program Calibration and Testing

Annual Maintenance Contract

Management

Stock Management

Training & skill development

Condemnation - Disposal
 Components of BEMP
CMC 1. Selection of Medical Equipment / Technology
Vellore

• Selection process should be done collectively by a committee or team comprising of

• Admin / Representative
• Purchase Manager
• Finance Manager
• Biomedical Manager
• Clinicians / Surgeons / Nursing
• Policy and procedures for Equipment procurement / Replacement
• End user requirements / specifications
• Available technologies / choices / vendors
• Tendering / quotations / technical / commercial comparisons
• Short listing & negotiations - commercial, warranty, terms & conditions
• After sale service and Annual Maintenance contracts
• Maintenance and operational cost / spares cost
• Availability of other support services (Space, Electrical, UPS, AC etc.,)
• Statutory & Legal requirements (Licenses, Approvals, PNDT, AERB etc.,)
• Final approvals – procurement & logistics
 Components of BEMP
CMC 2. New equipment inspection, installation, acceptance & testing
Vellore

• Pre-installation testing : All new equipment should be inspected and tested for
acceptance
• Equipment should be installed / tested in the presence of Biomedical Engineer
• Electrical safety testing & Functional testing to be done and recorded
• Service and Technical manuals
• Factory calibration & testing certificates
• Trainings for End user / Operator / Biomedical Engineer
• Inspection report format
• Records and documentation (File / Software)
• Equipment hand over for patient use after inventory
 Components of BEMP
3. Inventory Management
CMC
Vellore

• As an Administrator / Manager you should know how many Medical Equipment are in use,
how many should be replaced, what is the maintenance cost for an equipment etc.,
• Hence all Medical Equipment should be inventoried
• An unique ID number can be provided to each Medical Equipment
• This inventory system will be of immense help to
• Identify and track each equipment
• Purchase details
• Maintenance history
• Cost of ownership
• Spares replaced details
• Analyze breakdowns
• Age of equipment
• Capital budgeting
• Asset control
 Components of BEMP
4. Maintenance Management
CMC
Vellore

• There are two types of maintenance

• Planned Preventive Maintenance (PPM)
• Breakdown or Corrective Maintenance (BM / CM)
• PPM should be scheduled for each piece of equipment based on its inventory and location
• PPM should be carried out as per manufacturer’s recommendations
• PPM helps to reduce breakdowns
• Helps to plan for spares or kits replacement in advance
• Regular PPM ensures safety and reliability
• Improves efficiency and life of equipment
• BM or CM is unexpected or sudden failure of equipment which requires corrective action in order to
get it functional
• Proper stock of spares should be maintained
• Should have service/technical manuals
• Staff should have been trained on servicing
• For AMC equipment, the service provider should respond within response time
• For both PPM and BM, proper records should be maintained. All activities should be recorded
• In CMC we have online reporting system for breakdowns that captures events with time
• CMMS software records all maintenance activities and details can be retrieved anytime
• PPM and BM month reports should be sent to Management every month
 Components of BEMP
5. Calibration and Testing
CMC
Vellore

• Calibration in its simplest terms, is a process in which an equipment’s (DUT) accuracy is compared with
a known and proven standard (Master device)
• Calibration and testing is part of maintenance and should be performed at regular intervals
• Calibration is mandatory and should be performed as per manufacturer’s recommendations /
standards
• Calibration can be performed in-house or can be performed by authorized agencies
• Calibration is essential for accreditation processes (NABH/NABL/JCI)
• Testing includes functional testing and electrical safety testing
• Equipment should be tested and calibrated after repair or spare replacement
• Calibrated equipment can be labelled with details of due date etc.
• Calibration and test reports should be stored in CMMS against inventory number
 Components of BEMP
CMC
6. Stock Management - Spare & Accessories
Vellore

• Stock of spares / accessories required for PPM/BM should be maintained

in central stores or biomedical stores
• Inventory of stock should be monitored
• Stock inventory should be updated during receipt and issue
• Spares should be issued against inventory number and work order
• Standardization of equipment models will help to reduce the investment
on spares
• Standardization will also help to optimize spares utilization and better
control over stock management
• Standardization will help to salvage spare from similar condemned
equipment
 Components of BEMP
CMC
7. Annual Maintenance Contract Management
Vellore

• There are 2 types of maintenance contracts

• Comprehensive Annual Maintenance contract
• Labour Annual Maintenance Contract
• AMC should be negotiated along with equipment purchase
• AMC will start after expiry of warranty
• AMC agreement should have PPM/BM visits
• Response time for BM calls should be defined
• End user / BME should ensure that the scheduled PPM are carried out
• End user / BME should ensure that BM calls are attended within
response time
• All AMC related activities should be recorded in CMMS to find the
compliance of services provided during the period
 Components of BEMP
CMC
8. Training and skills development
Vellore

• Periodical training is essential for end user as well as biomedical engineer

• There are 2 types of training
• Application training
• Technical or service training
• End user or operator should be given application training during new installation and
upgrades on how to operate the equipment
• Technical or service training should be given to biomedical engineering staff
• Only trained personnel should operate or service an equipment
• Training ensures error free operation, gives confidence to operate equipment and helps
to save time
 Components of BEMP
CMC 9. Condemnation and Disposal
Vellore

• Equipment can be condemned or removed from service if

• Unrepairable or non functional
• Beyond economical repair, Service and spare cost is more
• Clinically obsolete
• Technically obsolete
• Manufacturer has given end of life or support
• Condemnation check to be performed and certified by Biomedical Engineer /
Vendor
• Necessary support documents to be obtained
• Condemnation committee should assess all factors, equipment history and
then approve for condemnation/disposal
• Condemned equipment should be removed from inventory or in-use list
• Condemned equipment should be disposed properly as per guidelines
• If similar models are still in use, then condemned equipment can be retained
for spares salvaging
 Medical Device Recall
CMC
Vellore

What is Medical Device Recall (MDR)?

When a company learns that there is a problem with one of their medical devices, it proposes a correction or
a removal depending on where the action takes place
FDA uses the term “recall” when a manufacturer takes a correction or removal action to address a problem with
a medical device or group of device that violates FDA law. Recalls occur when a medical device is defective, when
it could be a risk to health, or when it is both defective and a risk to health.
A medical device recall does not always mean that you must stop using the product or return it to the company.
A recall sometimes means that the medical device needs to be checked, adjusted, or fixed
Who recalls medical devices?
Manufacturer, distributor, or other responsible party
What does the FDA Do about Medical Device Recalls?
FDA classifies and monitors the recall to ensure that the recall strategy has been effective. Only after the FDA is
assured that a product no longer violates the law and no longer presents a health hazard, does the FDA
terminate the recall
How does the FDA Notify the Public about Medical Device Recalls?
FDA posts information about the action in the Medical Device Recall Database.
FDA may post company press releases or other public notices about recalls, market withdrawals, and safety
alerts
FDA notifies the public in the weekly Enforcement Report
For more information visit: US Food and Drug Administration website
 Medical Device Incident Reporting
CMC
Vellore

What is Medical Device Incident Reporting (MDIR)?

Medical Device related adverse events, injuries or deaths are reported to regulatory authorities in
order to monitor and take corrective actions for the affected device or to alert the potential hazard
in using the device
• Each county will have its own MDIR system (online reporting)
• India - Drugs Controller General India launched Materiovigilance Program of India (MvPI) at
Indian Pharmacopeia Commission (IPC), Ghaziabad on July 6, 2015. The fundamental aim of this
program is to monitor medical device-associated adverse events (MDAE), create awareness
among health-care professionals about the importance of MDAE reporting and generate
independent credible evidence-based safety data of medical devices and to share it with the
stakeholders
• The MvPI aims to enable data collection and evaluation in a systematic manner so that
regulatory decisions and recommendations on the safe use of medical devices in India can be
evidence-based

For more information visit: Central Drugs Standard Control Organization

 Quality Indicators and Reports
CMC
Vellore

• Biomedical Equipment Management program should be reviewed periodically

• The performance of BEMP can be measured by having proper Quality Indicators or Key
Performance Indicators like
• Ratio of PPM
• Ratio of BM
• Response Time Monitoring
• Trend Analysis of Breakdowns
• Fault Index Analysis of Critical Equipment
• Quarterly reports of Quality Indicators, MDR, MDIR etc., should be submitted to
Management, Quality and Safety departments
• Monitoring, Reporting and Periodical review of BEMP will help to improve the program
 CMC
Vellore
 Hospital Operations Management HHSM ZG614

ICU Management

Dr. K. Subramani MD DA FRCA CST FANZCA EDIC FICCM

Senior Professor and Head
Surgical ICU
Christian Medical College
Vellore

FLORENCE NIGHTINGALE

Crimean War 1854

Reduced mortality from 20% to 2%

Challenging status Quo

Improving patient experience.

Improving patient outcomes

Evidence based practice

Teaching and Mentoring

PETER SAFAR

Advanced life support

1950

First Intensivist

First ICU in 1958 in the USA

1
MORE HISTORY

Bjorn Ibsen
Polio pandemic 1953
Monitoring for cardiac arrhythmias1960’s
Critical care nurses 1960’s
Intensivists1970’s
India moves forward 2010

CMC
Surgical ICU and Surgical HDU
Medical ICU and Medical HDU
NeuroICU
Cardiothoracic ICU
PaediatricICU
Neonatal ICU
Coronary Care Unit
Private block ICU (AICU)
ST ICU
Ranipet: Trauma / Medical / Neuro and CTVS ICU

CMC ICU’S

2
OVERVIEW

Structure
Equipment
Personnel
Function
Legal & ethical issues

STRUCTURE
Location
Size
Internal Structure
Non-patient areas
Utilities

Location
-Access
From the Casualty
From the operation theatre
To Radiology department
To lifts

Existing structure or new structure

Number of beds and size

10% of the hospital beds

Optimum number of beds: 6-12 per unit
General about 4%
Specialty up to 10%
Size
Patient care area 100 –125 sq feet / bed
Equal non-patient care area

3
Statistics

4
Internal structure
Patient Areas
Open vs cubicles
Isolation areas
Lighting

BED SPACE

5
SPACE

Space Behind The Beds

6
Isolation Areas

Too Crowded

Lighting

7
Location, Size, Internal structure
Non patient areas
Nursing Station
Visibility
Computers
Central monitoring
Desk space
Medication preparation

8
WORKING SPACE

Non patient areas

Storage area
•Linen

•Disposables

•Medications

•Equipment

9
10
Non –clinical areas

•Lounge / library / conference room / dining

•Changing room

•Toilet facilities

Location, Size, Internal structure

Non patient areas

Non –clinical areas

Utility area

Visitor area
Adequate area –Indian Culture
Toilet facilities
Telephone (?)
Counseling room

11
Therapeutic Equipment

Ventilators
Infusion and syringe pumps
Defibrillator
Dialysis equipment, balloon pump, etc

12
Bronchoscope
ECMO
Diagnostic –point of care equipments
ECG
Blood gas analyser
Echo cardiogram and Ultrasound

Utilities
Electricity
Mains
UPS backup
Medical gases
Water
Adequate quantity

POWER

EQUIPMENTS

13
OVERVIEW

Structure
Equipment
Personnel
Function
Legal & ethical issues

PERSONNEL

Medical
Non-Medical
Nurses
Allied Health
Respiratory therapists
Physiotherapists
Nutritionist
Pharmacist
Dialysis therapists
Counselors
Biomedical Engineer
Clerical
Attenders, Sweepers etc

PERSONNEL

Medical
Medical Director

Senior Medical Personnel

Junior consultant

Trainee Medical Officers

Medical Director
Coordination of medical care
Administrative responsibilities

14
PERSONNEL ISSUES
Discipline
Conflict
Retention
Motivation

OVERVIEW
Structure
Equipment
Personnel
Function
Legal & ethical issues

15
DIFFERENT ASPECTS OF FUNCTION
Type of Medical care
Gate keeping
Infection control
Protocols
Records & audit
Research & education

TYPE OF ICU
Open
Closed
Transitional

LEVELS OF CARE
Level 1
Level 2
Level 3

ADMISSION AND DISCHARGE CRITERIA

Necessary for an ICU running at or near capacity

Clear Written

GATEKEEPING IMPERATIVES
Give all salvageable patients a chance
Keep theatre schedules going
Keep Casualty open
Maintain quality of care
Pacify fellow physicians

INFECTION CONTROL
All personnel all the time
Training, monitoring
Good microbiology support
Good sterile supply

16
ACCESS CONTROL

ROUTINE CARE

All regularly carried out interventions should have written protocols
-Minimize error
-Junior / new personnel
-Breaking protocol justification
-Regularly reviewed and revised

CHECK LIST 1

17
ACADEMIC ACTIVITIES
Teaching

-Improve patient care

-Improve personnel
-Improve morale
Research

TRAINING

18
RESEARCH

DIFFICULTIES IN MANAGEMENT

Physicians preferences
-Treatment
-Admission / discharge

DIFFICULTIES IN FUNCTION

Maintaining standards
Treatment standards
Antibiotic stewardship
Infection control

Administrative pressure
-Financial
-Bed availability

ANTIBIOTIC STEWARDSHIP

19
ECONOMICS

20
 OXYGEN CHARG

(A) TYPICAL BILL

TRAUMA POST-OP

21
TRAUMA, NO SURGERY / VENTILATION

ROLE DURING EMERGENCIES

Mass casualty
Pandemics
Case load
Triaging
Treatment area
The increased case load
Existing load
Manpower
Existing
Secondment
Training
Support
Equipments
Disposables and drugs
Oxygen …..
Sedatives etc

22
COST REDUCTION & MAINTENANCE OF QUALITY

Sampling and Flushing

23
Sampling – The VAMP System

Commercial Custom Designed

Closing The System

24
Closed System

Closed System Sampling

Local Initiatives

25
Covered Probe

Custom Designed Drape

26
Full Drape – Double Procedure

Equipments

Ethical Issues

Primarily
Lack of Physical Resources
Financial Constraints
Lack of awareness

Quality

Mortality:
Standard Mortality Rate
Actual mortality / Expected mortality
>1, 1, <1
0.8 for SICU
0.3 for trauma ICU
27
Morbidity
Pneumothorax
Acute Kidney injury
Bed sore

Operational procedure:
Length of stay
Compliance
ICU readmission

Errors and patient safety:

Medication errors,
Adverse events,
Fall
Re-intubation rate
Needle stick injury Infection control:
Ventilator Associated Pneumonia, Blood Stream infection, Urinary Tract
Infection
Employee satisfaction
Patient / Family satisfaction

Medical Awareness

Duty to family
-Explanation, Prognosis
Capacity to understand

CONCLUSION

Intensive Care is a very complex environment
Deals with the sickest patients
Outcome may not always be favorable
High costs
Ethical considerations
Highly skilled personnel
Burnout

28
 Hospital Operations Management HHSM ZG614
Operation Theater MANAGEMENT
Pranay Gaikwad
DNB, MNAMS, DMAS, FMAS
Professor & Head
Department of Surgery Unit 1 – General and Head & Neck

Outline
Background
• Aim
• Components
• Structure
• Environment

Background
Theatre: a place for dramatic performances

1
Historical Surgical Operating Theatre

Aim
Provision of an environment that is:
• Safe
• Efficient
• User-friendly
• Free from bacterial contamination

Components
• Structure
• Environment
• Organizational responsibilities

Structure
Location and relationship to other facilities
• On the 1st floor
• Close to ICU on the same floor
• A&E on the ground floor
• Radiology on the ground floor
• Single suite
• Multiple separate units

2
Plan of the Suite
• Concrete with metal frames
• Jointless floors and walls
• Easy to clean mellow plastic paint, 3 m height
• PVC terrazo anti-static waterproof floor
• Space
• free floor space 50 m2
• Supporting facilities 150 m2

Supporting Facilities
• Office administration
• Reception
• Changing room with lockers
• Toilets
• Conference/ classrooms
• Lounge
• Scrub room
• Anesthesia room
• Recovery room
• Optional
• X-ray and Dark room
• Laboratory
• Pharmacy

3
4
5
 Outer Protective Zone

Intermediate Zone
Between reception and suites approached by inside and outside staff
 Counter
 Storage areas
 Facility to handle waste, linen
 Pharmacy, lounge, class room, sterile supplies
 Recovery room

6
 Inner/ Restricted Zone
Anesthesia room (induction)

• Advantages
• Patient comfort
• Free from disturbance
• Quick turnover
• Immediate recovery

• Disadvantages
• Duplication of equipment
• Transfer of unconscious patient
• Scrub room
• Operating room
• (X-ray & Dark room)

Scrub room
• A section of OR
• Antiseptic hand wash (wall mounted, no-touch)
• Water sinks, drainage

Changing area
• 10 m2
• Close to scrub area

Operating Room
• 50 m2
• Sliding doors
• Waterproof Electrical Supply
• Central supplies with piping
• Scavenging of gases
• Light
•400 lux (general)
•40,000 -50,000 lux (focus)
•8,000 - 10,000 lux (depth)
• AdjusTable
• Electrocautery - 400 MHz

Recovery Room

Environment

7
Cleanliness with periodic surveillance

• Volume of work
• Number of personnel
• Duration & magnitude of cases
• Ventilation

Microbiologically
• Empty OR < 35 CFU/ m3
• <1 CFU/ m3 clostridia or < 30 CFU/ m3 Staph. au.
• During Surgery <180 CFU/ m3
• <20 CFU/ m3 at periphery or < 10 CFU/ m3 at center

Ventilation
• 100% fresh air circulation
• Air conditioning without exhaust fan can spread infection
• Air flow
• Air change

Air Flow
• From clean to less clean area
• 0.28-0.47 m/s in ultra clean not < 0.2 m/s
• Surgical area - High pressure
• Disposal areas - Lowest pressure
• Horizontal Air Flow
• Directional mechanical weighted valves
• Charnley’s tent
• Vertical flow

8
9
 Air Change

• 20-40/ hr
• Inlet
• 5 μ filters(HEPA) in AC duct at inlet
• Outlet
• At floor level for heavy gases to escape
• Scavenging system/ WAGD
• Anesthetic gases

10
 Temperature & Humidity

Septic/ Isolation Rooms

Air lock facility

Class S
• Standard-of-care
• Contact or droplet isolation
Class N
• Air borne droplet nuclei isolation
• Pressure - Room: -30 Pa; Ante-room: -15 Pa
Class P
• Profoundly immunocompromized
• Pressure - Room: +30 Pa; Ante-room: +15 Pa
Electrical Equipment
• Anti-static floor material
• Electrical sparks and fire hazards safety
• Sockets number and earthing
• Hazards made aware of warning signs
• Good Artificial Lights
• Alternate Power Supply 25%
• Generator/ invertor/ UPS
• Non-inflammable gas mixtures

11
 Service Lines

Teaching and Documentation

• Photography
• Videography
• Two-way communication to class room
• Conferencing

Day Care Theater

Concept
• Minor operations do not need hospitalization
• Save
• Time
• Space
• Staff
• Cost-effective
• Pain relief may be inadequate
Organization Responsibilities
Optimal utilization
Provision for emergency operations
OR supervisor
• Plans day-to-day running
• Maintains good rapport between staff and utilizers

12
Surgical Emergencies
Forms duly filled
Discussion by
• Surgical team, anesthetists and nurse in-charge
Cancellation
• Waste of time of OR and supportive services
• Dislocation of patient and relatives
• Building up of cases in the ward/ A & ED
• Strain on interpersonal relationships

Transport of Patients
Timely
Comfortable
Proper screening in the ward and at reception
Surgical Safety

13
Usual areas of deficiency in OTs
1. No reception area.
2. No separate rooms and change rooms for
 Surgeons
 Anaesthesiologist
 Jr. doctor
 OT attendants
3. Inappropriate size & type of doors etc.
4. Lack of laminar flow & mandatory air exchange systems
5. Lack of standard OT protocol.
6. No separate Central Sterile Supply Department (CSSD)
7. Waiting Area – Recovery - Not well equipped
8. Lack of basic amenities

Improving Care
Interaction within the OR to avoid tensions
• Doctors
• Nurses
• Attenders
• Janitors
Good communication with the ward
Definition of Emergency
Prevention of cancellation of cases

Interaction with other services

Wards
ICUs
Maintenance Department
• Electrical & engineering
Purchase & Stores
Radiology/ Labs/ Blood bank
Pathology
Pharmacy

14
OR Committee

Representatives of all OR Users

• Surgeons, anesthetists, nurses, hospital administrators
Committee Meetings
• Frequent
• Policies
• Priorities
• Protocols
• Responsibilities
• Cost-benefit
• Expansion

Challenges during the pandemic

Initial strategy

• Segregate patients according to COVID-19 status

• Best bring the patient from suspect category to positive / negative
• Segregate procedures according to Aerosol generation risk
• PPE protocol accordingly to conserve use of PPE
• Negative and Positive OR (Negative pressure OR – Ducted to exterior through HEPA
filter)

15
Subsequent strategy

•Universal N95 use – 3 use for Non-COVID areas and single use for suspect/COVID
areas
•Subsequently – Green, Orange and Red zones
•Green – Negative zone
•Orange – Suspect zone
•Red – Positive zone

16
Red zone

Broad principles

Break transmission
Social distancing
Be mindful of crowded places - OPD, ward and ICU waiting area,
Casualty
Conserve resources
Hospital and ICU beds
PPE for patients and health care professionals (HCPs)
Respirators, equipment, ventilators etc.
Protect yourself
PPEs before patient contact
Alcohol based hand rub/Hand washing
Provide appropriate and timely surgical care
Non-operative management, if possible
Wait for COVID-19 tests in suspected patients if available
Avoid operating at night, due to limited staffing
Avoid Aerosol generating procedures (AGPs)
always use N95 masks and full PPE
No concrete evidence for Lap vs Open
But Avoid Laparoscopy if possible (pneumo, valve leak, etc. causes aerosolization)

17
Aerosol Generating Procedures (AGPs)

Intubation
Extubation
Tracheostomy insertion and care
NG tube insertion
UGI Scopy
NPL Scopy
Electrocautery
Pneumoperitoneum

Donning & Doffing

Further Reading
• http:/ /healthfacilityguidelines.com /ViewPDF/View IndexPDF
/iHFG_part_b_operating_unit
• https://www.who.int/patientsafety/safesurgery/ss_checklist/en/
• https://www.nabh.co/Announcement/RevisedGuidelines_AirConditioning.pdf

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 Hospital Operations Management HHSM ZG614

OVERVIEW OF PHARMACY SERVICES

Topics to Discuss

History
Legal Requirements
Organization
Prescription
Purchase
Storage
Dispensing
Safe Disposal of Expired & Damaged Medicines

Management of Medication
The organization has a safe and organized medication process.

The process includes policies and procedures that guide the availability, safe storage,
prescription, dispensing and administration of medications.

Pharmacy Definition
Pharmacy is the science and technique of preparing as well as dispensing drugs and
medicines. It is a health profession that links health sciences with chemical sciences and
aims to ensure the safe and effective use of pharmaceutical drugs.

HISTORY
In olden days, drugs of vegetable, animal and mineral origin were more commonly
prepared. No medical and legislative control over their manufacture, storage or usage.

To control this activities Government of India, appointed a committee (The Drugs
Enquiry Committee) on 11thAug 1930 –Col. R.N. Chopra.

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The main recommendations of the DEC are:
1. To form Central and State Pharmacy Councils to look after the education and
training of professionals.
2. To create Drug control machinery in central and in all the states.
3. To establish a well equipped Central Drug Laboratory (CDL)

In 1940, Government of India Tabled Drug Bill to regulate the import, manufacture, sale
and distribution of drugs in India. (Drugs and Cosmetic Act 1940 ). The Drugs and
Cosmetic Rules 1945.
To control and regulate the profession of pharmacy, Government brought the
pharmacy bill, 1945 finally adopted as the Pharmacy Act, 1948.

Drugs and Magic Remedies (Objectionable Advertisement) Act 1954 was passed and
enforced to control the advertisements.

Medicinal and Toilet Preparation (Excise Duties) Act 1955

Narcotics and Psychotropic Substances Act, 1985

Pharmacy –Part of Health Care System

After the appearance of Allopathic system, pharmacy and medicine professions got
separated. Pharmacists are no longer called compounders.
In addition to dispensing, pharmacist has to play an important role in Management,
Consultation , Planning and Establishment of proper pharmacy services.
Pharmacist is the liaison between the patient and physician

Functions of Pharmacist

Regulatory control and drug management

Community Pharmacy
Hospital Pharmacy
Clinical Pharmacy
Industrial Pharmacy
Academic activities
Training of other health care professionals

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Code of Pharmaceutical Ethics

Are formulated by the Pharmacy Council of India for the guidance of Pharmacists
To guide the pharmacist as to how he should conduct himself in relations to himself,
his patrons, the general public, co professionals and members of the medical and other
health care professionals.

Pharmacist in relation to his Job

Scope of Pharmaceutical Services: Supply of commonly required medicines without

delay from licensed premises. Emergency supply of medicines at all times.

Conduct of Pharmacy: To preclude avoidable risk of error of accidental contamination

in the preparation dispensing and supply of medicine. The supply should made in the
presence of pharmacist.

Drugs and Cosmetics Act 1940 and Rules 1945

Objectives

To regulate the import, manufacture, distribution and sale of drugs & cosmetics
through license.
Manufacture, distribution, sale by qualified persons.
To prevent substandard in drugs.
To regulate the manufacture and sale of Ayurvedic, Sidda and Unani drugs.
To establish Drugs Technical Advisory and Board (DTAB) and Drugs Consultative
Committee (DCC) for allopathic and allied drugs and cosmetics.

Schedules

There are two schedules to the Drugs and Cosmetics Act, 1940.
1. First Schedule : Gives list of Ayurvedic, Siddhaand UnaniBooks.
2. Second Schedule : Standard to be complied with imported drugs and by drugs
manufactured for sale, sold, stocked or exhibited for sale or distributed.

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Schedules to the rules

Schedule C –List of biological and special products.

Schedule C (1) –List of other special products

Schedule G –List of substances to be taken only under supervision of RMP.

Schedule H & H1 –Prescription drugs –to be sold by retail only on the prescription of a
RMP.

Schedule J –List of diseases and ailments which may not claim to prevent or cure.

Schedule M –Good Manufacturing Practice

Schedule N –List of minimum requirements of the Pharmacy.

Schedule P –Life period of Drugs

Schedule X –List of habit forming , Psychotropic and other such drugs.

Definitions
1.Drug Store–is a licensed premises for the sale of drugs, which do not require services
of a qualified person.
2.Chemist and Druggists-It is a licensed premises for the sale of drugs which requires
services of Qualified person but where the drugs are not compounded against the
prescription.
3. Pharmacy–It is a licensed premises for the sale of drugs which require services of
Qualified person and where the drugs are compounded against the prescription.

Sale of Drugs

Drugs and Cosmetic Act, 1940 restricts the sale of drugs only by license.

The license can be obtained from licensing authority appointed by the State
Government for the same.

Different licenses are required for wholesale, retail, motor vehicle sale, vendor sale etc.

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Forms of Licenses

Conditions for Grant / Retention of Licenses

Form Adequate area
20/21 (Retail) 10 Square Meters
20 B/21 B (Wholesale) 10 Square Meters
20/21 & 20B/21B (Both) 15 Square Meters
ii) Equipped with proper storage for preserving the properties of the drugs –below 25⁰C
(as per Schedule P) can be achieved by providing air-conditioner.

iii) Qualification of a competent person

For retail
a) Registered Pharmacist

For whole sale

a) Registered Pharmacist or

b) Passed matriculation or its equivalent examination with four years experience

in dealing with sale of drugs or

c) Holds a degree with one year experience in dealing with sale of drugs

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Particulars to be submitted for the Grant of Licenses

Form 19 dully filled with court fee stamp for Rs. 2/-for each License.
Declaration form
License fees of Rs.1500/-for each license paid through online mode (Online
application)
Partnership deed in Rs.300/-stamp paper
Rental agreement in Rs.20/-stamp paper for minimum period of 5 years with relevant
property tax receipt
Legal tenancy affidavit in Rs.20/-stamp paper
Blue print of the plan of the premises duly signed by Licensed Engineer, and the
applicant
Copy of Registration certificate of Pharmacist
Affidavit of registered pharmacist in Rs.20/-stamp paper
Copy of qualification and experience certificate of competent person
Passport size photo
Proof of Residence like copy of Ration card/ Driving License/ Voter ID card
Purchase bill for Refrigerator/working condition certificate
Premises shall be Air-conditioned
All documents shall be duly attested by Gazetted officer or Notary Public.

Conditions to be complied by the Licensee

A license in form 20 or 21 is granted provided licensing authority is satisfied that the
requirements for a pharmacy in Schedule N and following general condition such that
1. Adequate space
2. Equipped with proper storage condition
3. Qualified persons

Pharmacist has to maintain all the records and prescriptions of the drugs. The following
particulars should be entered in the register.
i) Serial number and date of supply
ii) Name and address of prescriber
iii) Name and address of the patient

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iv) Name of the drug/ingredients and quantity
v) Name of the manufacturer, batch number, expiry date
vi) Signature of qualified persons

Schedule X drugs

The drugs specified shall be supplied only on a prescription of RMP. The supply drugs
shall be recorded at the time of supply in a register with following particulars

Date and purchase/transaction

Quantity received, name of drugs
Quantity supplied, Manufacturer name
Batch number, Expiry, Name and address of patient
Prescription reference number
Bill number and date
Signature of a qualified person

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12
NARCOTIC DRUGS POLICY

A separate License for Narcotic and Psychotropic drugs are obtained from the District
Collector Office which is valid for one year from the date of Issue

List of Drugs stored in pharmacy under ND/RC License.

Morphine sulphate.10mg/ml,1ml, Inj.

Pethidine hydrochloride.50mg/ml,1ml Inj.
Fentanyl citrate, 100mcg/2ml, 2ml,Inj.
Fentanyl citrate, 500mcg/10ml,10ml,Inj
Fentanyl Patches,4.2mg
Fentanyl patches,8.4mg
Morphine sulphate tab.10mg, cr10mg, cr30 mg

•The Charge Nurse sends the Narcotic Drug request along with the empty ampoules and
narcotic prescriptions to Narcotic section before 10 am on all working days.
•The pharmacist checks request, prescriptions and the empty and receives.
•And makes entries in the registers and charges to the wards, packs the drugs and sends
to the ward through attendant.
•The charge nurse checks and signs the request

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Pharmacy Department Organization

Functions of a Hospital pharmacy

1. Develop and maintain Standard Operating Procedures.

2. Purchase, storage, distribution and dispensing of drugs and pharmaceuticals to

patients.

3. Manufacture or compound tailor-made preparations that are not available in the

market or economical to the patient

4. Provide drug information to medical and other hospital staff.

5. Maintain strict control of Narcotic and Psychotropic drugs.

6. Inspect and maintain quality service in the hospital

7. Co-ordinate its functions with other departments and services in the hospital.

8. Participate in various Committees and Research activities of the hospital

9. Develop and maintain a Hospital Formulary.

10. Implement a continuing education program for medical, nursing and pharmacy staff.

11. Build up economic status of the hospital.

12. Establish and maintain adequate accounting procedures for all transactions.

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History

Prescriptions have been in use since ancient times

Latin adopted as standard language

“Rx” = prescription

Definition - A prescription is a written, verbal, or electronic

order from a Registered practitioner to a pharmacist for a
particular medication for a specific patient.

Laws Governing Prescription

The heart of medication therap, lies the prescription; a legal document governed by the
following laws:-.

The Indian Medical Council Act, 1956

The Indian Medical Council (Professional Conduct, Etiquette & Ethics) Regulations,
2002
The Drugs and Cosmetics Act, 1940 and Rules 1945
The Pharmacy Act, 1948
The Narcotic Drugs and Psychotropic Substances Act, 1985 and Rules 1987
Drugs (Price Control) Order, 1995
The Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954 and Rules
1955

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Prescription Formatting

Heading

Body

Closing

Current Prescription Formatting

Heading

Name, address, and telephone number of the prescriber

Name, sex and age of the patient

Date of the prescription

Body
The Rx symbol
Name
dose size or concentration (liquids) of the drug
Amount to be dispensed
Directions to the patient

Closing
Prescriber’s signature

Refill instructions

Generic substitution instructions

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Recommendations for writing quantity of drug:
a)Quantities of 1 gram or more should be written in grams. For example, write 2 grams.
b) Quantities less than 1 gram but more than 1 milligram should be written in Milligrams
For eg, write 100 mg, not 0.1 g
c) Quantities less than 1 milligram should be written in micro / nanogram as
appropriate. DO NOT abbreviate micro/ nanograms; since that can lead to Prescribing
errors. For eg. write 100 micrograms, not 0.1 mg, nor 100 mcg, nor 100 μg
d) If a decimal point cannot be avoided for values under 1, write a zero before it, for
example write 0.5ml not .5ml

List of dangerous abbreviations, and symbols

MINIMUM REQUIRED LIST

Abbreviation Potential Problem Preferred Term

U (unit) Mistaken as zero, four, or
cc
IU (international unit) Mistaken as IV or 10
Q.D., Q.O.D. Mistaken for each other.
Period after Q and O after
Q can be mistaken for “I”
Trailing zero and lack of Decimal point missed
leading zero
MS, MSO4, MgSO4 Confused for one another
Write “unit”
Write “international unit”
Write “daily” and “every
other day”
Never write a zero by itself
after a decimal point, and
always use a zero before a
decimal point
Write “morphine sulfate”
or “magnesium sulfate”

AMBIGUITY
Poor handwriting contributed to a medication
dispensing error that resulted in a patient with
depression receiving the antianxiety agent Buspar 10
mg instead of Prozac 10 mg

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MAXIMIZE PATIENT SAFETY

ALWAYS write legibly.

ALWAYS space out words and numbers to avoid confusion.

ALWAYS complete medication orders.

AVOID abbreviations.

When in doubt, ask to verify.

PURCHASE
An effective procurement process should:
Procure the right drugs in the right quantities (Right Item)

Obtain the lowest possible purchase price (Right Cost)

Ensure that all drugs Procured meet standard quality (Right Quality)

Arrange timely delivery to avoid shortages and stock outs (Right Time)

Ensure supplier reliability with respect to service and quality (Right Source)

Set the purchasing schedule, formulas for order quantities and safety stock levels to
achieve the lowest total cost at each level of the system (Right Quantity)

Purchase methods

Direct purchase from manufacturer

Direct purchase from authorized wholesaler
Through tender from manufacturer or distributor
Purchase through competitive negotiation
Contract purchase through Mfg. / another agency
Fixed Quantity Contract
Running Contract
Rate Contract
Local purchase / Emergency purchase

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TENDERS
1. Open Tender ( By Advertisement)
2. Limited Tender ( By Direct invitation to limited number of Firms)
3. Single Tender
4. Oral Tender

Accreditations (Regulatory Bodies)

USFDA (United States Food & Drug Administration)

WHO -GMP
UK-MHRA (United Kingdom’s Medicines & Healthcare Products Regulatory
Agency)
MCC South Africa (Medicines Control Council)
TGA Australia (Therapeutic Goods Administration)
ANVISA Brazil (National Health Surveillance Agency)
Health Canada
GCC DR (Gulf Central Committee for Drug Registration)

Balancing the cost of carrying high inventories and the cost of shortage is done through a
system of scientific inventory control.

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Maximum Stock Level
It is the level above which stock should not be permitted to rise.
Minimum stock level
It is the level at which any further use of the item will necessitate withdrawal
from the buffer stock.
Danger level / warning Level
It is the level at which deliveries of the outstanding orders have to be speeded up.

Types of selective inventory control

1)ABC –
–Based on cost criteria i.e. annual consumption cost of the items
–Does not depend on unit price of the item
–Hence it is also know as Always Better Control

2) VED:-Vital, Essential, Desirable

–Based on importance, criticality and shortage cost of the item in terms of
availability, function, specifications, source of supply, production process, storage
etc.

3) HML :--
–Commonly used for management of consumable items.
–High, Medium, Low
–Based on unit price
–Does not depend on consumption

4) SDE -Scarce, Difficult, Easy to obtain

Based on purchasing terms with respect to availability

5) GOLF -Government Ordinary, Local and Foreign

Based on source of supply from which material is procured

6) FSN -Fast moving, Slow moving and Non moving

Based on issues from stores

7) XYZ –
Based on the value of Inventory stored

8) SOS -Seasonal, Of seasonal

Based on seasonal requirements

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ABC ANALYSIS

A -Supplies accounting for a high percentage of the cost. This includes 10-20% of items
which account for 75-80% of expenditure
B –Supplies accounting for a medium percentage of the cost. This includes 10-20% of
items and 10-15% of expenditure
C –Supplies accounting for a low percentage of the cost. This includes 60-80% of items
but only 5-10% of expenditure.

VED ANALYSIS

V -Vital Drugs
They are potentially life saving or crucial for providing basic health services.
E -Essential Drugs
Effective against less severe but nevertheless significant forms of illness, but not
absolutely vital for providing basic healthcare.
D -Desirable
Used for minor illness

How to Reduce Inventory

1) Fixing up maximum limit of inventory in terms of value.
2) Fixing up responsibility of controlling the inventories with one person preferably at
Senior level reporting to top Management.
3) Meticulous materials planning and forecast.
4) A well designed and defined Inventory Control system.
5) Fixing up realistic Inventory levels i.e. maximum, minimum, reorder levels and safety
stock Inventory levels should be fixed item wise /location wise.
6) By reducing lead-time.
7) Adjustment in Inventory levels. Wherever called for Inventory levels should be
adjusted as per changes in requirement / consumption, changes in market conditions
etc.
8) Strict control on obsolete, slow moving and non-moving items.
9) Reducing the number of stock points.
10) Standardization and variety reduction.

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11) Maintaining close co-ordination with other user Depts., Store, Quality Assurance,
etc.
12) By improving the buyer seller relationship, selecting the right source of supply in
terms of location, quantity/quality etc.

PHARMACY COMMITTEES
i) Pharmacy Purchase Committee
ii) Rate Contract Committee
iii) Formulary Committee

Pharmacy Purchase Committee (PPC)

The PPC role is to review reports, requests, issues related to drugs / supplies used within
the institution, and put forward decisions, responses, and resolutions based on the
review.

Membership

The PPC is formed by the following official members:

Medical Superintendent -Chairman

Head of Department, Pharmacy –Secretary

Associate Nursing Superintendent

Senior Manager (Finance & Accounts)

Senior Pharmacist, Purchase –Coordinator

Rate Contract Committee

The committee’s role is to address the choice of new brands and finalizing the
formulary list of brands maintained in the institution, in a consistent manner.
Membership
The rate contract committee is formed by the following core members:
Medical Superintendent –Chairman
Head of Department, Pharmacy –Secretary
Associate Nursing Superintendent

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Senior Manager (Finance & Accounts)
Senior Pharmacist, Purchase

Formulary Committee

The Formulary committee role is to serve in an advisory capacity and review the
requests for inclusion on the hospital formulary of new drug entities, and to put forward
approvals or rejections based on the review.

The committee’s primary objective is to achieve optimal patient care and safety
through rational drug therapy.

Membership

The Formulary committee is formed by the following members:

Medical Superintendent –Chairman
Head of Department, Pharmacy -Secretary
Representative –Clinical Pharmacology
Associate Nursing Superintendent
Senior Pharmacist, Purchase
Pharmacist In-Charge, Drug Information -Coordinator
Other Senior Pharmacists attend meetings as consultants

Drug Storage
•All drugs are arranged as per alphabetical order of the Generic name or Brand name of
the drugs.

•Look alike and sound alike drugs are stored separately in the boxes stuck with eye and
ear pictures.

•2⁰to 8⁰C drugs are stored in refrigerators with list of items in it.

•High risk medications are stored in boxes with green color fluorescent labels.

•The bulk drugs are stored in separate area.

•Surgical items, external preparations etc. are stored in a separate area.

26
1. Medicines should be stored as per the manufacturer’s recommendations.

2. Pharmacy should be air conditioned to maintain below 25 degrees Celsius.

3. Daily room temperature is monitored and recorded.

4. The drugs to be stored between 2 to 8 degrees should be kept in the refrigerator.

Temperature should be monitored once in 12 hours and recorded.

5. Cold chain should be maintained for vaccines.

Sound alike and look alike medications are stored separately

1. Many ampoules ,vials ,tablets , capsules may look alike and also sound alike. The list
of such medicines should be identified and available in all the areas where drugs are
stored.
2. This list must be updated periodically
3. Pharmacists must be aware of this list.
4. One look alike is stored apart from the other look alike and same is applicable for
sound alike.
5. The look alike and sound alike medications can be colour coded or pictorially coded
to alert the pharmacist.
6. Awareness and training to be imparted to all staff about the LASA storage and
patient safety.

Policy on Look alike & Sound alike Medicines

Aim : To avoid potential harmful medication error.

Sound alike Medicines :

Drug that closely resembles another in pronunciation. These are stored in the
boxes/bins stuck with EAR pictures.
e.g. T. Trental 400mg –T.Tegrital400mg
T. Doxofylline–T.Deriphylline
Tab. Esperal–Tab. Inspiral

Look alike Medicines :

Drug that closely resembles another drug. These are stored in the boxes/bins stuck with
EYE pictures .
e.gT.Deplatt75mg -T.DeplattA75
T. Tryptomer25mg -T. Tryptomer10mg
T. Naprosyn250 mg –T. Aldactone100 mg
T. Banocideforte -T. Zyloric100 mg

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High Risk Medication
High risk medicines are those medicines that have a high risk of causing significant
patient harm or death when used in error. Examples include medications with a low
therapeutic window, controlled substances, psychotherapeutic medications, etc
1. The organization shall ensure that it defines a list of high risk medications used in the
organization.

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2. The process to prescribe the same shall adhere to national/ international guidelines
and regulatory bodies.

3. Strategies must be developed to access information about these drugs by

o Displaying the list of high risk medications in pharmacy and wards
o Education to doctors, nurses and pharmacists about the list and the potential
danger
o Can use coloured labels and automated alerts
o Can segregate the medications and store them separately
o Independent double checks or double check by the same person as applicable.

ISMP’s(Institute For Safe Medication Practice)

List of High Risk Medications

Adrenergic agents Methotrexate, oral, non oncologic use
Anesthetics Insulin/hypoglycemics
Liposomal products
Antiarrhythmics
Narcotics
Anticoagulants Neuromuscular blocking agents
Cardioplegic solutions Nitroprusside
Chemotherapy Oxytocin
Dextrose ≥20% Parenteral nutrition
Dialysis solutions Promethazine
Radiocontrast agents
Electrolytes (concentrated)
Sedatives
Epidural/intrathecal agents Sterile water for injection
Epoprostenol Vasopressin
Inotropic agents

Dispensing process
The important activities involved in the dispensing process can be grouped as

a) Receiving and evaluation of prescription

b) Interpretation of the prescription

c) Selection of items for the patient

d) Proper registration and issue of medicines

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Dispensing procedure

The pharmacist in the counter receives the prescription and cash receipts in duplicate,
retains the prescription and duplicate receipt and gives back the original receipt marking
the token number ask the patient/relative to wait.
The pharmacist enters the token number once the drugs are packed and the patient
collects the drugs from pharmacist by submitting the original receipt, pharmacist checks
and signs it

Activities in dispensing areas

1. Drug distribution/dispensing
2. Compounding extemporaneous preparations
3. Stock maintenance
4. Accept drug returns
5. Send drugs by Registered post or courier service
6. Handling “No stock” or “Temporarily out of stock” drugs
7. Handling Narcotic and Psychotropic drugs
8. Handling “Special antibiotic” prescriptions
9. Provide instant drug information
10. Maintenance of records

Short Expiry Drugs

The short expiry drugs list is prepared by dispensing areas by viewing the check drug
expiry in the Pharmacy module and also physically checked.
Every month 3rdWednesday at 2.30 pm a meeting is organized to discuss this issue,
the representatives from the dispensing area with dispensing in charge scrutinizes the list.
The section in which the item move will agree to receive and liquidate . If not the drug is
returned to stores before 3 months of expiry.
From stores the short expiry drugs are returned to supplier.

Expired & Damaged drugs

•The expired drugs after auditing should be kept in yellow cover with a label stating
“Expired Drug Do Not Use”. The stocks are removed from the computer.
•The damaged drugs ( broken, cut strips, loose tablets etc.) after auditing the stocks are
removed from the computer.
•The expired and damaged statement is sent by the Audit department once a month, the
same is sent to Administrative committee for write off. After AC approval the same is
sent for safe disposal by M/S. Ken Biolink.

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FORMULATION, PREPARATION, PACKING (FPPD)

This division is situated in a clean hospital atmosphere attached to the department of

pharmacy services.

The manufacturing unit is divided into two:

Parenteral manufacturing division

Non parenteral manufacturing division

QUALITY CONTROL LAB

General policy is as per Good Manufacturing Practices (GMPs) prescribed under

Schedule M of Drugs and Cosmetics Act
The lab has three sections: instrumental, chemical and microbiological/biological area.
Sampling, inspecting and testing of raw materials, intermediate, bulk, finished products
and packing materials and wherever necessary for monitoring environmental conditions.

DRUG INFORMATION AND CLINICAL PHARMACY

To provide carefully evaluated, literature-supported evidence to justify specific

medication-use practices to enhance the quality of patient care and improve patient
outcomes
Functions of drug information services:
Provides drug information to healthcare workers, committees, patients and other CMC
staff
Maintains hospital formulary based on scientific evidence of efficacy, safety, cost and
patient factors
Coordinates formulary committee meetings and prepares relevant materials for drug
evaluations
Publishes monthly bulletins to educate and inform healthcare workers in CMC on
rational medication use
Educating staff pharmacists, hospital/clinical pharmacy trainees, and interns/students

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Clinical Pharmacy

To optimize medication use; promote rational, individualized and cost-effective

prescribing.
Functions:
1.To assess the patient’s health status and determine if the prescribed medicine is
appropriate to treat the underlying medical condition.
2.To monitor the patient for actual or potential drug therapy problems.
3.To follow the patient’s progress to determine the safety and efficacy of the medication.
4.To liaise with the healthcare team and provide recommendations about treatment
regimens.
5.To encourage adherence to hospital and international guidelines.
6.To provide apt, evidence based verbal or written drug information in case of any
queries.

EDUCATION & TRAINING

To make every pharmacist in the department updated with current knowledge about
the pharmacy practice and new drugs.

Continuing education Program

Pharmacist Trainee classes

Interdepartmental orientation program

Training of Visitor-Observers:

Pharmacy Symposium, Refresher Course for working pharmacists

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 Hospital Operations Management HHSM ZG614

Human Resource Management

Broad Functions

1. Workforce planning & Recruitment

2. Training & Development
3. Employee Engagement / Labour Relations
4. Performance Management
5. Compensation Benefits
6. Rewards and Recognition
7. Policies, Regulatory & Statutory Compliances
8. Employee Separation

1.1 Workforce Planning & Recruitment

1
1.2 Training & Development

Best practices in Training and Development

•Training Needs Identification as a periodic process

•Training Needs linked to yearly Performance Management System

•Indices to measure T&D Delivery and Compliance

•T&D feedback reports towards actionable & initiatives

•Compliance of Functional Training Initiatives on record

1.3.1 Employee Engagement / Labour Relations

2
1.3.1 Employee Engagement Practices

•Define the Engagement Drivers

•Engagement calendar and events

•Team interconnect / Programs to foster

interpersonal relationships between stakeholders

•Integrating family into the Organization

•Work Life Balance / Quality of Life

•Job satisfaction

•Opportunities & Rewards

•Organizational Branding

•Feedback and Actions

•Connect with employees at all levels -at all touch points

1.3 Performance Management

3
1.5.1 Compensation Benefits

1.5.2 Compensation and Benefits

4
1.5.3 Compensation and Benefits – Total Rewards

1.6 Rewards & Recognition

1.7.1 Policies, Regulatory & Statutory Compliances

HR Rules / Policies
•Recruitment and Appointment policy, Separation / Termination Policy,
Attendance and Leave Policy, Transfer policy, Travel policy, Performance
Management & Promotion Policy, Code of Conduct, Benefits Policies
•Dress Code, IT / Devices policy, Work from Home Policy, Confidentiality
policy, Whistleblower Policy, Communications / Social Media Policy

5
Applicable Acts –Labour
•EPF Act, 1952
•ESI Act, 1948
•Payment of Bonus Act, 1948
•Payment of Gratuity Act, 1972
•Minimum Wages Act, 1948
•Workmen’s Compensation Act
•Standing Orders
•Shops and Establishments Act
•POSH Act 2013 –ICC / Grievances Procedures
•State specific laws on employment and benefits

1.7.2 Statutory Compliances

The recently passed Labour law Codes (Code on Wages, Code on Social Security,
Industrial Relations Code, and Occupational Safety, Health and working Conditions
code) which replace the labour acts
Minimum Wages

6
1.7.3 Statutory Benefits – Leaves

1.7.4 Statutory Benefits – Maternity Leave

7
1.7.5 Statutory Benefits – Holidays

1.8 Employee Separation (Exit Management)

Productivity and Cost -The Critical Factor of Today

Productivity & Cost

Metrics for Productivity, Cost and Utilization at all levels
Concerted efforts and initiatives in dialogue with Business

8
Individual KPIs linked with Performance Management System and productivity
improvement measures
Continuous review and restructuring of processes for efficiency improvement
Implementation of analytics, tools, systems for achieving the same

HR MIS & HR Analytics

Agenda

•Defining, Capturing, Extracting & Analyzing HR Data

•Creating / Choosing an MIS for HR

•Utility Value of Data -Critical Dimensions

•Fallacies to avoid in Data Analysis

1 Defining, Capturing, Extracting & Analysing HR Data

1.1 Scope of Data

9
1.2 Data Definition (Structuring the Data)

1.3 Data Collation and Management

10
1.3 Data Collation and Management – HR MIS

1.4 Data Analysis

11
2 Utility Value of Data

3.1 Fallacies in Data Analysis –Case

12
13
3.2 Fallacies to avoid in Data Analysis –Don’t Dos

Correlating to the base (Ex. Gender wise Attrition)

Sampling non-representative data to suit hypotheses
Incentivizing to get desired results
Cherry picking results
Reduction in Attrition is always good

14
A few final pointers –HR Data & HR MIS

•Start perfecting right from day 1

•Never be dependent on an individual for any data driven process / system/ module.
Create a process for knowledge sharing / rotation right from day 1
•Be patient with data. It may take even 5 years for building a strong “Data driven”
Organization, or for data to gain acceptance from all stakeholders

•HR MIS -comprehensive, but simple

Finance and legal alignment is imperative

Accuracy, Real time, instant availability of data, and access controls -ensure
these in whichever MIS or application choose
Keep all stakeholders in loop and take feedback from all involved when
choosing a new HR MIS
Firm deadline for transition to HR MIS. Emphasize and ensure periodic
reconciliation with actuals till the system stabilizes

15
 Hospital Operations Management HHSM ZG614
Financial Management and Internal Control

Paul Chandra Kumar

Financial Management–a broad term

Includes financial accounting, cost accounting and management accounting
Will cover few theoretical and mainly practical aspects followed in any enterprise
The idea is to give you a feel of what are the various functionalities of Finance &
Accounts dept. in any organization

Various forms of organization

1. Sole proprietorship
2. Partnership
3. Company
4. Trust / AOP/Society
5. One-person Company (OPC)
6. LLP

 Financial Statements – subtle difference

Company
1. Listed
2. Public and Private limited companies
Governed by Accounting Standards & Accounting Practices (GAAP)
1. Old Accounting Standards
2. Ind AS
3. Criteria
4. Networth and listing status
Compliance / Response level depends on the form of organization you belong to
Finance department include:
1. Corporate Accounting
2. Corporate Banking
3. Corporate Taxation
4. Costing Department
5. Budgeting Department
6. Establishment Finance
7. Insurance Department
8. Sales / Marketing Insurance
9. Procurement Finance
10. Stores Accounting
11. Project Finance
12. Corporate Investments
13. Assets Management
14. Internal Auditing


CORPORATE ACCOUNTS FUNCTIONS

1. Preparation of financial statements

2. P&L, Balance Sheet, Cash flow Statement, Notes on Accounts, Various reports
 Receipts and Payment Account and Income and Expenditure Account
 Governed by statutes
 Listing agreement
 Accounting Standards
 Emphasis on current and non-current
 Annual reports
 Consolidation of accounts of divisions / units

Segment Accounting
1. Health care
2. Pharmacy distribution business
3. Digital 24/7
4. Clinics
5. Medical Tourism
Segment wise revenue/expense, assets / liabilities
CFS–JV/Subsidiary/Associates
Compliance level is different based on the forms of organizations
Role of corporate finance is to prepare all the financial statements for presentation to
Board of Directors and Stakeholders
CORPORATE BANKING

Multiple Bank accounts in the nature of current accounts, savings accounts, overdraft
accounts
Loan accounts –Term loans, ECL, Bridge loan etc., Amortization schedule, Current
and Non-current
Escrow accounts – SBI loan, FCRA
BRS
Accounting for interest
Cash Flow Statement
 CMC –FDs

Prohibition of cash transactions

 cash transactions over Rs.2 lakh are strictly prohibited u/s 269 ST of the Income
Tax Act
 For businesses, any expenditure in cash exceeding Rs.10,000 paid to a single
person in a single day is disallowed as an expenditure
 In the case of loan repayments, a person cannot accept an amount or make a
payment / repayment to an entity or individual exceeding Rs.20,000 in cash
under Sections 269SS and 269T of the Income Tax Act
 Even property transactions have an upper limit of Rs.20,000 for cash transactions,
including advances
 If a bank makes a cash payment of more than Rs 1 crore in a FY to its account
holder (i.e.any tax payer) from the account maintained by such tax payer, then
the bank will have to deduct TDS
L C payments
BG – Non-fund based
Creating security for assets –First charge, second charge, Paripassu (equal footing) etc.,
 A Second Charge Mortgage is an additional loan on top of your existing
mortgage.
Personal Guarantee
Loan Agreement-Reading between the lines

CORPORATE TAXATION
Specialized finance function
Broadly direct and indirect taxation
Main emphasis on Income Tax Act and GST
Income Tax Act
Various heads of income
For companies mainly income from business (or) profession
Allowances and Disallowances
Allowed on payment basis –Bonus, Gratuity, Leave encashment
MAT on book profit
Tax Audit
Transfer pricing
Income Tax for salaried class
Form16 – Part A and B
Form 12 BA for perquisites
Income tax deduction

Few tips
1. Rent to parents
2. Spouse not working
3. Gift to parents
4. Insurance and investment - Don’t mix
5. Only health and term insurance
6. Investment in MF direct plan
7.10 % in gold ETF
8. PPF
9. EPF - VPF
10. Power of compounding

GST
Awareness level
Two components
Output tax
Input tax
Definition of health care services, clinical establishment and authorized medical
practitioner
Services provided consists of
Outpatient department
Inpatient department
Various tests conducted
Sale of medicine
Exempt services
 Inpatient services including surgeries, room rent, consultancy charges, food and
beverages, bed charges, operation theatre rent, equipment charges, doctor’s fees
and pharmacy consumables
 Outpatient department –includes medical consultancy, regular checkups and
treatment without admitting a patient
 Disposal of biomedical wastes
 Services offered by blood banks by preserving the stem cells or any other
preservation
 Services provided by way of transportation of a patient through ambulance
 Services provided by a veterinary doctor

Not exempt
For purpose of care and not for any curing of disease
For beautification or improving physical appearance
Supply of drugs /medicines
Parking fees collected by hospital
Food and beverages sold by hospitals

Restriction on input tax credit

As per Section 17, Input Tax Credit is not allowed on input or input services used
for following purposes:
Used for non –business purpose (For example Property of Hospital is
used by doctor for his family purpose)
Used for exempted supplies

Composite supply
 Health care services are the most prominent element of the composite supply
 In contrast, medicines, implants and food supply are subsidiary to it and do not in
itself become principal supply.
 The taxability on a composite supply applies to the amount of primary supply
In case of health care services, the principal supply, i.e. health services is liable to tax at
Nil rate and hence Nil rate will be considered the rate of tax applicable on the composite
supply of health care services and supply of implants and medicines to IPDGST on
health care.
Exempt services under healthcare
ESTABLISHMENT FINANCE
Salary related work
Salary master based on appointment order
Flags for PF, Gratuity, HRA, Leave encashment etc.,
Automatic progression and annual increments
Deductions –Advance, Professional tax, Medical recovery, Income Tax
Generation of salary slips
Salary reconciliation
Programming for automated recoveries, Stoppage of salary on the date
of super-annuation etc.,
Provident fund
Gratuity
Pension–Defined contribution and defined benefit
INSURANCE RELATED

Coverage includes
1. Assets –Fixed assets–Standard fire and allied perils –Reinstatement value
2. Vehicles–IDV, Nil depreciation
3. Inventories (Stocks) –Valuation
4. Valuables including cash (Fidelity insurance)
5. Personnel related–PAI, Health insurance, Term Insurance–Group insurance
6. Claims /Settlement

SALES OR MARKETING FINANCE

In hospital parlance it is called billing

Revenue may broadly include
1. Revenue from healthcare services –inpatient and outpatient
2. Sale of pharmaceuticals and other products
3. Project consultancy income
4. Franchise fees
5. Income from clinical trials
6. Brand license fees
7. Other incomes
Interest income
Dividend income
Write backs of liabilities no longer required
Gain on sale of fixed assets
Billing to capture all collections
GST invoicing wherever applicable
Recognition of revenue-Timing
 Upon transfer of control of promised products or services to customers
  When there is uncertainty on ultimate collectability, revenue recognition is
postponed until such uncertainty is resolved

PROCUREMENT FINANCE (Purchase Accounting)

Indent for purchase (PR)
Approval–in principle
Check stores
If Nil float tender/obtain quotes
Techno-commercial negotiation
Management approval
Purchase orders
MRIR
Invoice Certification
Processing for payment
TDS on purchase
ITC eligibility to be checked
Align to credit terms
194 Q & 206 C (1H)
Robust system – Pull and Pay

STORES ACCOUNTING
MRIR–Costs include
Issue–Costing–FIFO
Inventory valuation
Reconciled stores ledger with financial ledger
PROJECT FINANCE
Capital WIP
Proper categorization of assets to be capitalized
Data for capitalization
Point of Capitalisation
Depreciation after SCOD
Pre-operative expenses–Apportionment
Interest capitalization
CORPORATE INVESTMENT MANAGEMENT
Investment schedules in Balance Sheet
Investments to be shown at cost or market value whichever is less
Dividend income in P & L
Gain on sale of investment in P & L
Investment in group companies – Separate disclosure

FIXED ASSETS MANAGEMENT

Fixed Assets Schedule
Useful life of assets-Depreciation rates and methods

Estimated useful lives of the assets are as follows:

Category of assets Useful Life (in years)

Buildings (Freehold) 60 years
Buildings (Leasehold) Over the lease term
Plant and Machinery 15 Years
Electrical Installation and Generators 10 Years
Medical Equipment 13 Years
Surgical Instruments 3 Years
Furniture and Fixtures 10 Years
Vehicles 8 Years
Office Equipment 5 Years
Computers 3 Years
Servers 6 Years

Useful lives of intangible assets

Estimated useful lives of the intangible assets are as follows:
Category of assets Useful Life (in years)
Software License 3 years
Non-Compete Fees 3 years
Trademarks 3 years
Internally Generated Intangible Assets 5 years
• Componentization - Asset componentization essentially involves the separation of an
asset into its various components in the accounting books. This allows companies to
account each component as an individual asset and take advantage of difference in
physical and economic life of individual components of asset.
• Physical Verification of assets
• Scrapping assets

COSTING AND STRATEGIC COST MANAGEMENT

Cost reduction strategies

 Out sourcing & Centralizing non-clinical, non-differentiating functions
 Consolidating management layers
 Foods and Beverage Service
 Floor Care Services
 Optimization of patient flow -Hospitals can decrease delays and wait times of
patients and ensure the maximum occupancy for each bed
 Optimized capacity utilizations of machines
 Bundling Bio Medical Engineering
Costing to arrive at various billing rates
ROI/Pay Back Period / NPV… (Technological obsolescence)
Break-even point
Variance analysis –Budget vs Actual
Variation in quantity
Variation in price
Standard costing formula

BUDGETING
•Capital Budget
•Revenue Budget
•Capital Budget

Basis
Operational necessity
Statutory requirement
Replacement
Cost efficiency
Technological Obsolescence
•Revenue Budget
•Sales/Billing budget
•Showing projected Sales / Income
 •Procurement Budget based on manufacturing plan / Services proposed
•Salary and administration overheads budget-Fixed and Variable
•Cost centers / Profit Centers
•Consolidate all and prepare a master budget
•Variance Analysis cost center wise
•Centralized and decentralized costs –Apportion

Internal Control Internal Auditing)

Main items of income
Types of expenses / payments
Preliminary audit of hospitals
 Inspection of books, documents, registers and other records by obtaining the list
as maintained by the hospital
 Examining the audit report of last year and check for qualifications if any
 Examine the system of receiving grants and donations
 Take note of important classes in the trust deed and policies and procedures
 Examine the minutes of meetings of the Board of Directors / Trustees
 Examine internal control system regarding the purchase of fixed assets,
medicines, stores and consumables
 Examine the system of recording the purchases, issue and storage of all items and
do physical verification
 Check the rate structure for fees, medicines and other services, powers to give
concession or waiver of fees

Audit of expenses of hospitals

 Check the distinction between capital and revenue expenses
 Salary of staff to be randomly checked by comparing with the appointment orders
 Documents relating to land and building should be inspected
 Any sale or purchase of fixed assets should be cross verified with the resolution of
the committee
 Outstanding liabilities to be verified including aging
 Physical verification of investments like shares, bonds etc.,
 Inventories to be physically checked
 Receivables and other arrears of bills to be checked along with aging schedule
 Unrecoverable arrears should be written off after proper approval
 Donations and Grants to be verified and ensure that FCRA compliances are
fulfilled
 Donations and Grants to be checked whether utilized for the purpose which it
was granted
Hospital Operations Management HHSM ZG614

HICC Roles and responsibilities –An overview

Dr.Hema Paul MD
Asso. Physician &
Hospital Infection Control Officer
Department of Clinical Microbiology
Christian Medical College, Vellore

1|Page
What are Hospital acquired infections?

•Commonly known as “Nosocomial” or Healthcare associated Infections [HCAI]

•Definition:
• Infections acquired during or as a result of hospitalization
• Occur 48hours after hospital of admission
• As a result of rendering health care services.
• Could manifest even after discharge from the hospital

2|Page
Healthcare associated infections

•At any given time 7 patients (developed) 10 patients(Developing countries) will acquire
at least 1 healthcare associated infection.
o10% of affected patients will die.
•Europe
 4 million are affected
 4.5 episodes of HAI annually
 16 million extra days of hospital days
 37,000 attributable deaths
•USA
 1.7 million patients are affected by HAI each year
 prevalence of 4.5%
 99,000 deaths

What are the Sources of Infections?

Endogenous
Patient’s own flora may invade patient’s tissues

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Endogenous Infections

Exogenous Infections

Why Do Infections Persist?

4|Page
How are these infections transmitted?

Common Health care Associated Infections

5|Page
What are the solutions to this problem?

•Ensuring that core components for infection control are in place at the national and
facility level
•Implementing standard precautions, particularly hand hygiene practices
•Improving staff education & accountability
•Conducting research to adapt and validate surveillance protocols based on reality of
developing countries

Infection Prevention and Control

Infection prevention and control (IPC) is a practical, evidence-based approach which
prevents patients and health workers from being harmed by avoidable hospital
acquired infections caused by antimicrobial resistant microorganisms

6|Page
Importance of IPC
•Preventing harm to patients, visitors, healthcare worker to achieve:
 Quality care
 Patient safety
 Health security
 Reduction in HAIs & antimicrobial resistance
 Prevent & reduce transmission of infectious diseases(IDs) which pose
global threat
 Clean, safe care is patients right

Principle behind infection prevention and control?

7|Page
The IPC Story …begins …
Smart (and brash) physician begins a new job at a hospital in a famous city
Watches people dying needlessly on a unit
Comes up with a simple solution to prevent deaths
Implements the solution on a small scale and observes a dramatic benefit

Father of Hand Hygiene

Realized that washing hand with a chlorinated lime solution decreased incidence of
newborn death from “puerperal fever’
reduced Maternal Mortality through Hand Hygiene

Attempts to spread his ideas and implement his simple solution elsewhere
(Mostly) ignored, ridiculed, rejected…out of a job
Goes to a different hospital; confirms his findings
(Mostly) ignored, ridiculed, rejected…dies at the
age of 47…in an insane asylum.

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Florence Nightingale
Minimized infections in wards during the Crimean war by rigorous environmental
cleanliness.

Complex Health Care System today

Challenges in today’s Hospitals

9|Page
The FIVE pillar of infection control
1. Isolation and barrier precautions
2. Decontamination of equipment
3. Prudent use of antibiotics
4. Hand Washing
5. Decontamination of environment

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Multimodal strategy
 Comprises of several components or elements (three or more)implemented in
integrated way, to improve an outcome or change in behavior

Five common elements

 System change (availability of good infrastructure & supplies ) to ensure IPC,
good practices
 Training and education of HCWs & Key players ( managers, heads of
departments etc)
 Monitor infrastructures, practices, processes , outcomes and provide feedback
 Reminders in workplace through IECs
 Strengthening of safety environment

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Minimum requirement by Core component at facility level
1. Infection control Program
2. Infection prevention & control
guidelines
3. IPC education and training
4. HAI Surveillance
5. Multimodal strategies
6. Monitoring ,Auditing of IPC
indicators & Feedback
Functional IPC Program
-Fulltime ICO; ICN 1:250 ; Dedicated
budget;
-Multidisciplinary IC committee
Evidence based, facility –based SOPs
Policy for all components of SP
Transmission based precautions
IPC training for all front-line clinical staff
and cleaners ( Induction & In-service
Functional HAI surveillance , timely
dissemination of data
Regular and timely feed back to the end
users
IPC activities must be implemented using
multimodal strategies to improve practices
and reduce HAIs & AMR
A person should be responsible to conduct
periodic or continuous monitoring for certain
process or structure indicators according to
facility or national priorities
12 | P a g e

7. Workload staffing and bed occupancy
( ONLY AT FACILITY )
1.Bed occupancy should not exceed the
standard capacity
2.Healthcare worker staffing assigned
according to the workload
Primary facility-Reduce overcrowding,
follow triaging and referral according to
guidelines
Secondary/ tertiary facility-
1.Standardize bed occupancy-1 patient /
bed; 1 meter space between edges of two
beds
2.Reduce overcrowding / optimize staffing
level

Clean hygienic environment including all

8. Built environment , materials
elements of WASH
equipment's for IPC,( ONLY AT
Infrastructure and services
FACILITY )
All materials and equipment's for IPC
including HH

Local solutions

 Local tools
 Local modules
 Networks
 Guidelines & policies
 Local monitoring tools
aligned to WHOs core
components

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The Key approach for IPC Implementation

1. Build it – System Change

2. Teach it – Training & Education
3. Check it – Monitoring & Feedback
4. Sell it – Reminders & Communications
5. Live it – Culture Change

Impact of Effective IPC in patient care

 30% reduction in HAI rates
 Surveillance contributes to 25-57% reduction in HAIs
 Improving Hand hygiene practices may reduce pathogen transmission by 50%
 IPC plans across USA between 2008-2024-reduction of CLABSI by 50%;
 SSI by 17% and MRSA bacteraemia by 13%
 By 2010 to 2015 Australia achieved nationwide HH compliance by 80%

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Infection Control Programme at CMC Vellore
Infection control Committee Structure
Multidisciplinary Support Team

Representation From Administration, High Risk Areas, Labs, CSSD

Chairperson Of HIC-Infectious Disease Specialist/ Physician Or Surgeon

Responsibilities
 Lay down policy and procedures
 Put guidelines and policies which are evidence based, best practices and
customized to Healthcare facility
 Laydown on the frequency of meeting
 Quorum for each meeting
 Minutes

Frequency of meeting – once in 2 months

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Infection control team

Sub Committees
 Bio-medical Waste Handling and Management Committee
 Needle stick-Injury Review Committee
 Safety Steering Committee
 Quality Steering Committee

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Activities of hospital infection Control Team

Responsibilities of HIC

Surveillance of HAIs
Establish the ongoing evaluation and review of all techniques in asepsis, isolation, and
sanitation employed in the hospital.
Develop written Isolation policies
Ensure proper conduct of CSSD, housekeeping, laundry, engineering maintenance,
Dietary and BMW are in conformity with the hospital infection control policies.
Education and orientation of all new employees

 Plan audits, monitor KPIs in IPC

 Act upon recommendations related to infection control received from the
administration, departments, services and other hospital committees
 Outbreak investigations
 Revisions and updating HIC policy and guidelines & antibiotic guidelines
 Notification of notifiable infections

Functions of IPC officer

 Surveillance of HAIs – evaluates, analyse, feedback
 Monitors BMW management & segregation and handling
 Reporting notifiable diseases
 Organize and conduct regular audits
 Leading Outbreak investigation
 Training and education
 Maintain all meeting minutes
 Supervise ICN’s
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Infection Control Nurses
 Surveillance of HAIs, data entry
 Assist HICO in preventing, investigating and controlling outbreaks
 Regular audits
 Infection control rounds
 Education and training of HCWs

Antibiotic Stewardship Pharmacist

 Attend ICU round advise proper storage of sterile products
 Participate in clinical care plan collaborating with the multidisciplinary
departments during or after the (ward / ICU) clinical rounds to ensure that
prophylactic, empirical and therapeutic uses of antimicrobials result in positive
patient outcome.
 To liaise with the clinical microbiology department and follow up culture reports
 Carry out regular surveillance of antibiotic usage in the ICUs
 Surgical prophylaxis audits
 Stewardship rounds with HIC team

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19 | P a g e
Surveillance
 HAI Surveillance
 Environment Surveillance
 Antibiotic Resistance Monitoring
Infection Control Nurse using a Tablet for Surveillance

Analysis and Dissemination

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Environmental Surveillance
X represents a positive culture

Model Report

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Standard Precautions
Standard Precautions are the minimum infection prevention practices that apply to all
patient care, regardless of suspected or confirmed infection status of the patient, in any
setting where health care is delivered.

Cardinal Rules
01. Consider all patients as potentially infectious
02. Assume all blood, body fluids and tissues to be contaminated with blood borne
pathogens
03. Assume all unsterile needles and sharps to be similarly contaminated

22 | P a g e
 Pitter et al, 2000 Switzerland

Source of Microorganisms

Survival of Germs depends on Humidity, Pathogen, Skin Factors etc

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Hand Hygiene….WHEN?

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Hand Hygiene Technique

Remove extraneous items e.g. rings, watches turn on tap, use comfortable temperature.
Apply soap, rub hands together vigorously for at least 15 seconds covering all surfaces
of hands and finger
Dry hand with towels
Turn off taps with wrists or elbows

Steps of Hand Hygiene

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Most Commonly Missed Areas

Other Occasions of Hand Washing

26 | P a g e
Personal Protective Equipment

Purpose:
1. To protect the skin and mucous membrane of HCW from
exposure to blood and body fluids
2. Prevents contamination of clothing
3. Reduces the opportunity of cross-infection

Selection of PPE depends upon-

 Splash/spray verses touch
 Category of isolation precaution
 Durability and appropriateness of the task
 Correct sizes
 Selection of PPE
Immediately dispose after use in a appropriate bin

27 | P a g e
Donning & Doffing of PPE

Remember

 Ensure proper selection and use of PPE.

 Wear gloves whenever there is potential for contact with blood, body fluids,
mucous membranes, non-intact skin or contaminated equipment.
 Do not wear the same pair of glovesfor the care of more than one patient.
 Gloves cannot be reused.
 Keeping hands away from face when using PPE
 Limiting surfaces touched.
 Perform hand hygiene immediately after removing gloves.

Transmission Based precautions/Isolation Precautions

 Infection control measures in addition to Standard Precaution to prevent
transmission of highly transmissible or infectious pathogens
 Designed for patients who are known or suspected to be infected with such highly
transmissible infectious pathogens.

Contact Precautions

 Colonization or infection with MDROs (MRSA,CRO,VRE),C.difficile, Hep A,

Scabies etc

28 | P a g e
  Patient Placement:
-Single room or cohort
 Precautions:

-Hand hygiene, dedicated equipment, Limit

transport unless medically necessary
-PPE-Gown and gloves
Don & Doff PPE after use

Droplet Precaution
 Diphtheria, Measles, Mumps, Rubella, SARS,
 Droplet deposited on the host’s conjunctivae,
nasal mucosa, or mouth

Patient Placement:
-Single room/ Cohort
Precautions
-Hand Hygiene
-Patient and attender follow Respiratory Hygiene
 Limit the movement unless medically needed
 PPE-surgical mask, face shield.

Airborne Isolation Precautions

Tuberculosis, Measles, Chicken Pox, SARS
Patient Placement-
AII room with Negative pressure
At least 6ACH(old setup)/12ACH (new set)
Direct exhaust of air outside/HEPA filters to air
handling unit
Keep the door closed
-Triage signs-ambulatory patients
-surgical mask for known or suspected patients
-limit the personnel from entering the room
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 -limit transport of patients
PPE-

Respiratory Etiquette

Sharps

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Sharps and Needle stick Injuries

Sharps are devices that puncture or cut skin
They are a potential hazard when contaminated with blood or body fluids and cause
puncture or cut wounds
Handle with care at all times

Risk of transmission for Blood borne viruses

Prevention

 Hepatitis B Vaccination
 A primary course of hepatitis B vaccination is
mandatory for all staff and students
 HBsAb titers appear 4-6 weeks after the last dose
 A booster dose is required only if the HBsAb levels is
< 10miu/ml

Handling and disposal of sharps

Plan your work
Must be disposed at the point of generation, in a leak-proof and
puncture-resistant sharp container

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In case of needle stick injury / splash

•Do not panic

•Wash the wound thoroughly with soap and water
•Eyes to be irrigated with water, splashes on nose,
mouth or skin should be washed with water
•Report to immediate supervisor
•Report to SSHS duty doctor / Casualty within 2
hours
•Identify the source patient, who should be tested
for HIV, hepatitis B, and hepatitis C

Prevention while handling sharps

Post exposure prophylaxis recommendations in CMC Vellore based on

index case status

Index Case Status Recommendations

HBVpositive Test the health care worker for antiHBs antibody titres
•Antibodies >100mIU/ml –Reassure
•Antibodies 10 to 100mIU/ml–One booster dose of vaccine
•Antibody negative or <10mIU/ml –HBV immunoglobulin and
full course of vaccination

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HCV positive
•HCW tested for viral load, HCV antibody and liver function
test (LFT) on day 0, every month till 1 month, 3 months and 6
months;
•If viral load is detectable then, post exposure prophylaxis
(Sofosbuvir and Velpatasvir)will be started

HIV positive PEP–Triple drug regimen for 28 days (Tenofovir + Lamivudine

+ Dolutegravir) –to be started with 2 hours, if not at least within
72 hours of exposure.

Handling patient care equipment & environmental cleaning

Clean and disinfect all frequently touched surfaces in patient-care areas

Biomedical Waste Management

“Bio-medical waste” means any waste that is
generated during the diagnosis, treatment or
immunization of human beings or animals or
research activities pertaining thereto or in
production or testing of biological or in health
camps including the categories mentioned in
Schedule I of Biomedical waste management rules
2016
Does not include general waste

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  The Health Care Waste generation ranges between 0.5 to 2.0Kg per bed per day.
 60% of it is infectious, often disposed improperly.
Poorly managed bio-medical waste –
 Potential danger to patients
 Community
 Great risk to health care providers

Laws Concerning Biomedical Waste Treatment


 Safe disposal is the legal requirement in our country.
 The Government of India enacted the Environment (protection ) Act in 1986.
 The Government of India Notified the rules for the management and handling
of Biomedical waste on 20thJuly 1998
 Guidelines was revised in 2016 and amended in 2018

Tamil Nadu Pollution Control Board


 Implementation of rules in Tamil Nadu is through State Pollution Control
Board
 Common Bio medical Waste Treatment Facilities (CBWTF) is authorized by
TNPCB.
 The Common Bio medical Waste Treatment Facilities (CBWTF) for Vellore is
Ken bio links.

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Life Cycle of Hospital Waste

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Segregation of Biomedical Waste

Facilities for IPC & Training

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AUDITS
Audits done by IPC
Hand Hygiene
IV Line Audit
HAI care bundle audit
PPE audit
Surgical prophylaxis audit
BMW audit
Donning & Doffing

Employee Health Programme

Staff Students Health Services (SSHS)
 Placement evaluation
 Health & Safety education
 Health Counseling
 Work restrictions for staff
 Health check up
 Pre and post prophylaxis

Outbreak Investigation
Reporting Notifiable infections
 TB
 Malaria, Filaria, Scrub Typhus
 Influenza
 Chicken pox
 Typhoid
 Dengue
 Cholera
 Fever Surveillance

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38 | P a g e
 Hospital Operations Management HHSM ZG614

Quality, Role of Quality Manager

and Implementation of
Quality Management System
Dr. Lallu Joseph
Quality Manager & Assoc. GS, CMC Vellore
Secretary General, CAHO

Quality
• “Doing the right things, for the right patient, at the right time, in the right way to
achieve the best possible results” - AHRQ
• Quality is meeting or exceeding the stated and implied needs of the patients every time

Quality Management in Healthcare – differing views…

1. Quality management is accreditation

2. Accreditation should solve all problems
3. Documentation and documentation- How can documentation improve quality??
4. Unnecessary expenses
5. Its for nurses and support staff, not for doctors
6. It’s a show on the day of assessment
7. Not my job, leave me alone…
8. Who are these fellows to tell us what to do and how to do…
9. Waste of time..

Reasons……….. for this

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• Lack of proper understanding of the principles of quality management
• Implementing without understanding the right intent and spirit
• Not evidence driven
• Trying to copy, paste
• Policing rather than facilitating
• Trying to be prescriptive
• Short term benefits

Who is this? Why is he like this?

1. Little kingdoms
2. Territorial
3. Intrusion into the autonomy
4. Threat
5. Unnecessary

Who are these Super Heroes???

Quality Manager…
1. Knowledgeable
2. Team player
3. Team leader
4. Assertive
5. Listener
6. Perseverance
7. Learner

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8. Work around people
9. Communicator
10. Trainer
11. Presenter
12. Manipulator
13. Always smiling
14. Should remain calm
15. Public relations
16. Impartial

Joker??

Unnecessary, Expensive, Intrusion into autonomy, Waste of time, Who are they
to tell us?

It boils down to …. Leadership

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Four absolutes of Quality Management
• Quality is simply conformance to requirements.
• The system for causing quality is prevention.
• The performance standard must be zero defects, not “that’s close
enough.”
• The measurement of quality is the price of nonconformance.

Cost of Quality
The American Society for Quality defines the cost of quality as “a methodology that
allows an organization to determine the extent to which its resources are used for
activities that prevent poor quality, that appraise the quality of the organization’s
products or services, and that result from internal and external failures”.

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5
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Patient Safety ?????

We can all agree the practice of medicine was simple, maybe relatively ineffective but
safe.
TODAY…..The practice of Medicine IS HIGHLY COMPLEX but effective
Way Forward…

Accreditation
Best possible tool for achieving quality and patient safety.
• Accreditation is a process in which certification of competency, authority, or credibility
is presented to an organization.
• A self-assessment and external peer assessment process used by healthcare
organizations to accurately assess their level of performance in relation to established
standards and then to implement ways to continuously improve it.

Focus of Accreditation Standards

Patient Safety
• Staff and employee safety

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 • Environment and community safety
• Information Education and Communication
• Measurement of Performance
• Organized around important functions

A doctor’s tool kit for quality care and patient safety…

Simple measures saves lives…..
Patient Identification
 ID Bands
 UHID

Use of WHO Surgical Safety Checklist

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Safer Medication

NATIONAL ACCREDITATION BOARD FOR HOSPITALS AND

HEALTHCARE PROVIDERS (NABH)
NABH is a Constituent Board of Quality Council of India
(QCI)

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HCO and SHCO
 Health Care Organization (HCO) - More than 50 beds
 Small Health Care Organization (SHCO) - Up to 50 beds

• Entry level accreditation – HCO & SHCO

• Full accreditation – HCO & SHCO

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NABH Standards

COP.3
Ambulance services ensure safe patient transportation with appropriate care
Objective elements:
a) The organization has access to ambulance services commensurate with the scope of
the services proved by it.
b) There are adequate access and space for the ambulance(s)
c) The ambulance(s) is fit for purpose and is appropriately equipped
d) The Ambulance(s) is operated by trained personnel
e) The ambulance(s) is checked daily.
f) Equipment is checked daily using a checklist.
g) A mechanism is in place to ensure that emergency medications are available in the
ambulance.
h) The ambulance(s) has a proper communication system.
i) The emergency department identifies opportunities to initiate treatment at the earliest
when the patient is in transit to the organization.

Chapter 1 - AAC (Access Assessment and Continuity of care)

Scope of services- Define and display
• Documented registration, admission and discharge
• Established Initial Assessment
• Regular Reassessments
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 • Lab services as per scope and safety requirements
• Imaging services as per scope and radiation safety
• Discharge process and discharge summary

Chapter 2 - COP (Care of Patients)

As per accepted norms- time, dated, signed
• Emergency services- as per law and statutory requirements
• Rational use of blood and blood products
• Management of ICU and HDU patients
• Management of OBG patients as per scope
• Management of paediatric patients as per scope
• Administration of anaesthesia
• Theatre and surgical patients management

Chapter 3 - MOM (Management of Medication)

Documented policies- Purchase, storage, prescriptions and dispensing.
• Implantable prosthesis
• Storage of medications
• Prescription of medication
• Safe dispensing of medications
• Administration of medication
• Monitoring of adverse drug events
• Usage of radioactive drugs

Chapter 4 - PRE (Patients rights and Education)

Patient rights- Documented and displayed
• Information and education about healthcare needs

Chapter 5 - HIC (Hospital Infection Control)

Infection control manual
• Conducts surveillance activities
• Prevent or reduce the risks of HAI
• Biomedical waste management as per norms

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Chapter 6 – PSQ (Patient Safety and Quality Improvement)
Structured quality improvement
• Continuous monitoring programme
• Key indicators to monitor the structures, processes and outcomes (5 Indicators)

Chapter 7 - ROM (Responsibilities Of Management)

• ROM – Defined
• Leaders in an ethical manner
• Multidisciplinary committees to oversee

Chapter 8 – and (Facility Management and Safety)

Ensure safety of patients, their families, staff and visitors
• Clinical and support service equipment management
• Safe water, electricity, medical gas and vacuum system
• Plans for fire and non-fire emergencies

Chapter 9 - HRM (Human Resource Management)

Staffing with patient care needs
• Professional training and development of staff
• Disciplinary and grievance handling procedure
• Addresses the health needs of the employees
• Personal record for each staff member

Chapter 10 - IMS
(Information Management System)
Complete and accurate medical record for every patient
• Medical record reflects continuity of care
• Maintaining confidentiality, integrity and security of records, data and information.
• Retention time of records, data and information

Challenges in implementation
Lack of awareness of standards
• Fear of the unknown

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 • Fear of exposing their vulnerabilities
• Old infrastructure and licenses
• Manpower requirement
• Standard Operating Procedures and Manuals
• Training of all categories of staff
• Inadequate resources

MANTRA
DO IT YOURSELF
DO NOT DELEGATE

1. Strong Management Commitment

Top management should actively involve
• Prepare the strategy for implementation
• Responsibility for implementation should lie with the top management

2. Quality Coordinator

Choose the right person

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 3. Quality Team
Multi-disciplinary Team

4. Training on the Standards

Attend in-depth training program on NABH Standards
• Nominate three members atleast to attend the program – doctor, nurse and
administrator
• Understand the intent of every objective element

5. Form Committees

Multidisciplinary team for NABH implementation

 Form Committees
• Quality Committee
• Safety Committee
• Infection Control
• Pharmacy
• Transfusion
 Form sub-committees depending on issues

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6. Baseline assessment to identify gaps

7. Assign Responsibilities

8. Ensure Involvement of Staff

 Identify Key Personnel in each area
 These individuals can be made as quality champions
 Train on the requirements of their areas

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 9. Prepare Implementation Checklist

10. Statutory and legal requirements

 Identify which are the relevant licenses to be obtained/renewed
 Hospital Registration
 Biomedical Waste authorization, Air, Water Consent
 AERB licenses
 Pharmacy licenses
 Blood bank licenses
 PC PNDT
 MTP
 Transplant licenses (if applicable)
 Identify what are the requirements to be fulfilled as per prevailing laws
 Assign responsibilities

11. Identify Infrastructural requirements

 Adequacy of fire detection, alarms and fire fighting systems
 Patient and material flow in CSSD and OT
 Special provisions like baby care room, play room,handicapped toilet as per the
scope of the hospital

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  Adequacy of equipments as per scope
 Prepare the plan for addressing them

12. Documentation

13. Training
 Prepare the Training Matrix and Training Calendar
 Identify and implement training requirements
 Identify Faculty
 Plan training calendar, roll out training
 Interact / educate the end users regarding the same
Including doctors
Train, Train, Train

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 14. Initiate Audits

15. Continuous Follow up

By Quality Manager
Quality Team
Committees
Documented
Presented to the Top Management
Follow up, Follow up, Follow up
16. Capture Indicators
 Start capturing basic and relevant indicators
 Explain the indicators and their relevance to the stakeholders
 Involve the stakeholders and analyze the data

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17. Keep updating the champions and all staff
 Continuous update to all staff on overall progress- through meetings, newsletters etc.
 Keep them engaged
 Update the departments and stakeholders on the levels of compliances
 Celebrate successes

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18. Do an internal assessment/ invited external assessment

Submit Your Application

Points to Remember
 Every Non-Compliance is an opportunity for improvement
 Accept NCs and improve on them
 Do not close NCs for the sake of closure
 Never get disheartened - Change in culture/ practice takes years
 Always remain positive – “Never give up”
 Continue to learn
 Establish the system for continuous monitoring and Sustainability

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