PLANNING AND ORGANIZING HOSPITAL UNITS AND ANCILLARY SERVICES (SPECIFICALLY CSSD, LAUNDRY, KITCHEN, LABORATORY SERVICES, EMERGENCY

DEPARTMENT)
INTRODUCTION: A hospital is a human invention, and as such can be reinvented at any time. Hospitals design has been subject to many changes over the past 100 years or so in both layout and size. In the early 20th century hospitals were basically places where the very sick spent their last days. But today, emerging concepts of a hospital are calling for designs that promote wellness and wellbeing rather than merely the treatment of diseases. Health care organization, medical and pharmaceutical advances and medical technology developments and patient expectations are continuously changing at a fast pace. The implications of these changes on the planning and design of health care facilities are direct and evident and the design response to them manifests itself in emerging planning concepts and ideas. Planning and organization of hospital units: A hospital is responsible to render an essential service. In fulfilling this responsibility, hospital planning should be guided by certain universally acknowledged principles. The principles are usually irrespective of the level of planning, i.e. whether at national level, state level or individual hospital level. Aims of hospital planning: To enlarge the existing hospital by introducing new facilities. To increase utilization of hospital facilities. To increase population coverage To increase productivity of hospital Modernization of the already existing facilities To reduce the cost of operations and maximize efficiency of services.

Guiding principles in planning: Patient care of high quality: it can be achieved by the hospital through adopting following measures: a. Provision of appropriate technical equipments and supplies. b. An organizational structure that assigns responsibility and requires accountability for various functions within the organization. c. A continuous review of adequacy of care provided by physicians, nursing staffs and paramedical personnel. Effective community orientation: this should be achieved by the hospital by adopting following measures:1

a. A governing board made up of persons who have demonstrated concerns for community and leadership ability. b. Policies that assure availability of services to all people. c. Participation of the hospital in community programmes to provide preventive care. Economic viability: this is achieved by adopting measures like:a. A corporate organization that accepts responsibility for sound financial management in keeping with desirable quality of care. b. A planned programme of expansion based solely on demonstrated community need. c. An annual budget plan that will permit the hospital to keep pace with times. Orderly planning: orderly planning should be achieved by the hospital by following:a. Acceptance by the hospital administrator of primary responsibility for short and long-range planning with support and assistance from competent financial, organizational and functional advisors. b. Preparation of a functional programme that describes the short range objectives and facilities, equipments and staffing necessary to achieve them. Sound architectural plan: it is achieved by the following:a. Selection of a site large enough to provide for future expansion and accessibility of population. b. Recognition of the need of uncluttered traffic patterns within for movement of staff, patients and visitors and efficient transportation of supplies. Medical technology and planning: development in medical technology is taking place so rapidly that now the use of sophisticated technology determines the professional status. Classification of hospitals: Hospitals in general are classified into two categories depending upon the agencies which finance them: 1. Government or public hospitals: they are managed by government services, either central or state or public, municipal or departmental bodies that are financed from the overall budget for public services. 2. Non-government hospitals: they are managed by individuals, charitable organizations, religious groups, industrial undertakings etc. On the basis of ownership patterns, non-governmental hospitals are classified as: Private (personal) Partnership Private (family) trust Public charitable trust Cooperative society Private limited company
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 Public limited company Hospital planning process: i. Conceptualization of hospital: here the imagination or idea of the originator takes into a practical shape, and compares his dreams with the existing hospitals of country or outside world, tries to fit dreams into any such project. Support groups: once the idea is developed, the entrepreneur, discuss project, and then finds support groups to join hands and complete the project. Temporary organization and securing funds: a group should be formalized called as a hospital trust, which must be registered under the societys act or companies act. The originator is the chairman and others are members who are assigned different tasks. A detailed work out as to how much capital will be required for establishing the hospital. Geographical, environmental and miscellaneous factors: Meteorological information: temperature, rainfall, humidity Geographical information: existing road and rail communications, susceptibility to quakes/floods, building height restrictions due to proximity of airports. Miscellaneous availability: trained manpower, water, sewage disposal. Hospital design: Bed planning: it should be realized that the hospitals are not only utilized by the population in the vicinity but also will constitute the indirect population in the larger catchment area. About 85% bed occupancy is considered optimum. Hospital size: as a very large hospital of 1000 beds or more becomes extremely unwidely to operate, and a small hospital of 50 or less are not profitable. From functional efficiency point of view, it is advisable to plan two separate hospitals of 400 beds, each with a scope of future expansion, rather than a single one of 800 beds. Land requirements: in rural and semi-urban areas, plentiful land may be available permitting the hospital to grow horizontally, whereas in urban areas there will always be great premium on land and only avenue will be a vertical growth.

ii. iii.

iv.

v.

No. of beds 50 beds 100 beds 200 beds

Land in acres 10 acres 15-20 acres 20-25 acres

Storey of building Single storey -doDouble storey

500 beds 700 beds 1000 beds

55-70 acres 80-90 acres 90-100 acres

3-5 storey 4-6 storey 6-9 storeys

Public utilities: the national building code of ISI suggests 455 liters of water per consumer per day (LPCD) for hospitals up to 100 beds and 340 LPCD for hospitals of 100 beds and over. Additional availability of water in case, staff quarters and nurses hostel are a part of hospital campus. The hospital sewage disposal is connected to the public sewage disposal system, otherwise it needs to build and operate its own sewage disposal plant. It is preferable that power supply should be available on a multi-grid instead of uni-grid system in general use, to ensure a continuous supply of electricity to hospital at all times. Electricity requirement is 1 KW per bed per day2. Approval of plan by the local authorities: once the detailed plan has been the local bodies are consulted and persuaded for approval of plans. vi. formulated,

vii.

Circulation routes: the utility and success of hospital plans depend on the circulation routes on hospital site and within building. there are two types of circulation in the hospital :Internal circulation: the circulation space involves corridors, stairways and lifts. Corridors with less than 8 ft. Width are not desirable in hospitals and protective corner beading is a necessity in hospital corridors. External circulation: only one entrance to the hospital for vehicular traffic from the main road is desirable. the entrance and exit points should be wide enough to take two lanes of traffic, one entry for clarity of all visiting traffic and one exit for security from administrative viewpoint. Distances, compactness, parking and landscaping: distances must be minimized for all movements of patients, medical, nursing and other staff, for supplies aiming at minimum of time and motion. Functional efficiency depends on the compactness of the hospital which is achieved by constructing multistoried as they are convenient due to compactness as compared to horizontal development of hospital which demands more land involving extra costs and installation of services, roads, water supply, sewage etc. One car parking space per 2 beds is desirable in metropolitan towns, lesser in smaller urban areas while much less in semi-urban and rural areas. Separate parking for 3-

wheelers and scooters, employees and staff parking areas separate from public parking should be considered. viii. Zonal distribution and inter-relationship of departments: the departments which come in close contact with the public (e.g. outpatient department, emergency and casualty) should be isolated from the main in patient areas and allotted areas closer to the main entrance. The supportive services like X-ray and laboratory services need to be located near the OPDs. From the main entrance should be main inpatient zone consisting of ICU, wards, OT and delivery suit. The other supportive and clinico-administrative department in the hospital consists of hospital stores, kitchen and dietary department, pharmacy etc. these departments should be preferably grouped around a service core area. Gross space requirements: gross total area (building gross)-780-1005 sq ft, add walls, partitions: 95-125 sq ft. a building gross square footage figure includes everything a buildings perimeter viz. stairs, corridors, wall thickness and mechanical areas. On average, space will be required for a reception and enquiry counter in the main waiting area near the OPD entrance. The bed distribution is calculated as: Bed:population= A x S x 100 365 x PO Where, A= number of in-patient admissions per thousand population per year S= average length of stay (ALS) PO= percentage occupancy Bed distribution among various specialties will vary from hospital to hospital and conforms to following range: Medical: 30-40% Surgical: 25-30% Obstetrical: 15-18% Pediatric: 10-12% Miscellaneous: 10-15% (including eye and ENT) x. Climatic consideration in design: in very hot climate buildings need to be cooled in summer by artificial means. Some natural cooling can be achieved by building orientation and design. The building should be open, and oriented in such a way that even a slight breeze can pass through the building to cool its insides. Another way is to keep thick walls and small windows where the thick walls absorb the heat during day and dissipates during night, and small windows minimize the amount of radiated heat entering the building.
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ix.

xi.

xii.

Equipping a hospital: hospital equipment covers a broad range of items necessary for functioning of all services. the universal application of equipment in the hospital can be classified as: Physical plant: it includes lifts, refrigeration and air-conditioning, incinerators, boilers, kitchen equipments, mechanical laundry, central oxygen etc. Hospital furniture and appliances: beds, stretchers, trolleys, bedside lockers, movable screens, operation tables, instrument trolleys etc. General purpose furniture and appliances: it includes office machines (typewriters, calculators, filing system, and computers), office furniture, crockery and cutlery. Therapeutic and diagnostic equipments: it includes equipments for general use (BP instruments, suction machines, glassware washers etc.) and equipment interacting with patients during diagnostic and therapeutic procedures ( defibrillators, X-ray machines etc.) Cost evaluation of construction of hospital: the most common method of estimating the cost is on the basis of per bed cost. It will also vary in type of facilities the hospital provides, like teaching, training and research facilities.

Outpatient department: Outpatient department is the one where all patients except those who require emergency treatment, come for service in the hospital. Planning and organization of the OPD: Location: it should be easily accessible to those who come for outside, and should be a separate wing for OPD attached to the hospital accessible from the main entrance to the hospital with direct approach from the main road. Space: the space requirement will depend upon the land available and location of the hospital. Generally 0.66-1 sq ft area per annual outpatient attendance should be provided for OPD. If there are 3 lakhs visit in a year, the total space requirement for OPD will be 2-3 lakh sq ft or 4.5-6.8 acres. Size: the size of OPD depends upon the volume of attendance, clinics provided and extent of facilities like blood bank, emergency department. Zones of OPD: FUNCTIONAL ZONE: this zone is mainly used by the patients attending the OPD, attendants and relatives. This area includes parking area, entrance hall, waiting space, enquiry and registration, and medical social services. ADMINISTRATIVE ZONE: this zone is required in a large hospital to plan, organize, supervise, evaluate and co-ordinate the facilities being provided. the various functional units of this zone are Office of the OPD in-charge
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 Administrative control nurses station Cash counters Medical record room DIAGNOSTIC AND SUPPORTIVE ZONE: the various functional units in this area are: Clinical laboratory Imaging section AMBULATORY ZONE: This is a zone where the patients come in direct contact with the doctors and paramedical staff for consultancies, advice and treatment. it includes units like: Clinics for various medical disciplines Pharmacy Treatment room Minor OT STAFF ZONE: this zone is used exclusively by the staff members only. It includes duty rooms, stores, housekeeping and conference room. Functional management: OPD timings: it is recommended that OPD shall work 6 days in a week with facilities of morning and evening clinics. The morning timings is usually from 8am-12 pm, whereas the evening hours shall be from 3pm to 5 pm, and specialty clinics from 2 pm to 4pm. overcrowding and waiting time of the patients and relatives must be minimized. Records: a unit record system combining both in-patients record and continuous out patient record is recommended. Public relations: public complaints can be minimized and defused through public relations, the entire staff of OPD including public relations persons should act as agents. Facilities in OPD: The waiting lines should have enough furniture so that patients dont have to stand in queues but can sit comfortably. The general procedure and rules should be painted on boards or walls for the public. The registration area should be easily recognized and reachable. Health education messages can be promoted through TV-VCR system, closed circuit TV and also to reduce the boredom of the waiting patients and their relatives in OPD. Staffing of OPD: It includes the medical staff (consultant, professor, senior lecturers, medical officers, residents, junior and senior should be available), nursing staff (usually one nurse/OPD/clinic), paramedical staff (for injection room, dressing room, registration and MRD), receptionists and medico social worker.

Planning and organization of Wards:

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A ward is the most important part of hospital where the sick persons are kept for supervised treatment. It is also a nodal point for research in medicine and nursing field, training and teaching of medical, nursing and paramedical personnel. Types of wards: a. General wards: in these wards, patients with non-specific ailments, requiring no life saving care are admitted. The nurse patient ratio of 1:5 in big wards, and catering to the patients routine investigation, treatment and care needs. b. Specific wards: these include patients admitted for specific care due ti illness or social reasons. It includes: Emergency ward Intensive care unit Intensive coronary care unit Nursery Special septic nursery Burns ward Post operative ward Post natal ward c. Units with specialist nursing, treatment and equipment: wards like burn ward, transplant ward functions at national or regional centers where particular service skills are concentrated. Ward planning: Physical facilities: it includes: Size of ward: size of the ward depends on- types of patient (an area of 100-120 sq ft/bed is required and smaller rooms of 2-4 beds are preferable), requirement of ward staff (a small ward will have same requirement throughout the day, helped by a head nurse and a clerk for administrative and clerical responsibilities) Patient housing area: this is an area where patients are kept for treatment. The area per bed within the ward is 80 sq ft/bed but in acute ward it is 100 sq ft/bed Space left between two rows of bed is 5 ft.distance between two beds is 31/2 to 4 ft. Clearance between wall and side of bed is 2ft. Length of bed is 66, width of the bed is 3. Size of rooms: Single bed room should have a size of 125 sq ft/bed 2 bed room 160 sq ft/bed 4 bed room 320 sq ft/bed 6 bed room 400 sq ft/bed
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ICU 120-150 sq ft/bed Obstetrics and orthopedics 120 sq ft/bed

support service area: this section of ward includes: Nursing station/duty room: it should be located at such a place that the time taken by a nurse for moving from one place to another is limited. Centralize location is desirable. Treatment room: the room is meant for examination of patients and should be equipped with examination table, spotlight, dressing material, hand washing facility etc. Clean work room: it is a working room for staff nurses in nursing unit, contains work benches for preparation of trays, care of materials, equipments and supplies etc. Pantry: it is a place where the dishes are cleaned, washed and stored. Unit store: it is meant for storing the supplies and linens. Sanitary area: it includes baths and toilets, dirty utility room, store for sweepers etc. Auxillary areas: this section includes duty room for doctors, clinical side room, seminar room, attendant room, locker room for staff. Ward design: the primary objective of a ward design is to facilitate the nurse to hear and see everything in the ward and to enable the patients to easily call the nurse when need help. I. open ward: in an open hall, beds are placed in rows facing each other and nursing station in the center of the hall. II. Riggs ward: in this design, 3-4 beds are placed parallel to the windows in open bays separated from each other by low partition. III. Unilateral riggs ward: side beds are placed in each bay separated from nurses station with its standby services by a common corridor. IV. Bilateral ward: it has been accepted as most suitable and workable conditions, two unilateral riggs wards are on either side of a central nursing station. V. T-shaped ward: bed bays are placed in front of the nursing station and critical patients bays are in front of nursing station. Isolation bays are at both sides and ancillary and other service areas are behind the nursing station. Open ward

Open ward

Rigg,s ward

Riggs unilateral ward

Riggs bilateral ward

Ward management: it is the optimal utilization of the ward resources to produce maximum output, namely care and comfort of patients. It includes: Strategic management: responsibility of giving a strategic direction to a ward lies within the nursing unit set up in each ward. Strategy formulation for ward has to
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be done in the context and parameters defined by the strategy, direction, resources and constraints of hospital. Operational management: whereas strategic management gives an anchor and direction, operational management works towards the strategy. The responsibility of operational management of a ward rests with the ward head nurse/ nursing unit with the help of other ward personnel like ward clerk. It includes objectives of providing comfort and good care to the patients and long term objective of improvement and establishment of systems in functioning of the ward.

Central Sterile Supply Department (CSSD): Definition of CSSD: A CSSD is a department that furnishes all supplies required for the nursing units and departments of a hospital- theatres, wards, out-patient and casualty departments with complete, sterile equipment ready and available for immediate treatment of patients. These supplies include sterile linens, sterile kits, operating room packs, needles, syringes and other medical surgical supplies. In addition, the personnel in this department clean, inspect, repair, assemble, wrap and sterilize special treatment trays for various nursing units. Planning and organizational consideration of CSSD: Planning of CSSD: the CSSD should be planned in all hospitals above 100 beds. Theatre sterile supply unit (TSSU) is to meet emergent and large requirement of OT and is established inside OT complex. In large hospitals like 500 beds and above, TSSU is established in addition to the CSSD in service area. Bed size of the hospital Up to 100 beds 100-500 beds Above 500 beds Location of CSSD In operation theatre CSSD centrally located in service area CSSD in service area and a separate unit for OT to be called theatre sterile supply unit ( TSSU).

The following areas are to be provided in CSSD: i. ii. iii. iv. v. vi. Equipment storage room Receiving counter and clean up room Needles and syringes processing room Gloves assembling room with rubber goods processing room Clean work area including sterilizers Sterile storage area and issue counter
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vii.

gauze and dressing assembly area

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

Layout: Location should be where the most rapid means of transportation of supplies and equipment is possible. There should be avoidance of back tracking of sterile goods. There should be a continuous flow of equipment from the receiving counter to the dispensing counter. The contamination of sterile goods should be avoided. Sterilizing area should be the last area before the sterile storage and dispensing counter. The receipt and issue counters are separated by a corridor to avoid contamination.
Counter of receipt of used items

Decontamination and cleaning area Processing Packing of items

Separation of sterilized items by a partition or corridor

Distribution point

Sterilized items store

Sterilization

Area requirements: It is recommended that the area of 1.64 sq.m/bed for a CSSD would be appropriate up to 400 bedded hospitals, and for more than 400 beds an area of 1 sq.m/bed would be sufficient. The manual of IGNOU has recommended following functional area for a 100 bedded hospitals: Facilities entrance lockers In sq.meter 10.50 7.00
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Staff change room Dirty receipt and disassembly Washing, disinfection and decontamination assembly Linen processing sterilization Sterile storage distribution Trolley wash Trolley bay Bulk store Duty room toilet Total per 100 bed hospital

7.00 7.00 17.50 10.50 10.50 14.00 21.00 10.50 7.00 10.50 17.50 3.50 3.50 164.50

Staffing pattern: One CSSD worker per 30 beds plus one supervisor is recommended. In 200-300 beds hospital, you need 10-15 persons. Staff for 1000 bedded hospitals is: Supervisor 1(senior most and trained technician) Asst. Supervisor- one of the senior technician Technicians 6 (promoted attendants) Sweepers- 15 Clerk- 1 Equipments and materials required: Hot and cold running water Cleaning brushes and jet water gadgets Ultrasonic washers Hot air oven for drying instruments and sterilization Globe processing unit Instrument sharpener like needle sharpening machines Stem sterilizers and boiler for steam Autoclaves of various sizes including gas autoclave Testing equipment Chemicals to clean materials
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 Wall fixtures like sinks, taps Trolleys for supply of sterilized items and separate trolleys for collection of used items are needed Methods of sterilization: Sterilization is a process of freeing an article from all living organisms including bacteria, fungus, using dry or wet heat, chemicals or irradiation. a. Steam sterilization: autoclaving is the commonest method b. Hot air sterilization: Vaseline and oils cannot be sterilized with steam. these items are exposed to hot air to 160-1800c for 40 minutes. c. Gas sterilization with ethylene oxide d. Sub atmospheric pressure sterilization with formalin: it is meant to disinfect instruments like endoscopes. the temperature required is 900c for 10-30 minutes. e. Chemical sterilization with activated glutaraldehyde f. Gamma irradiation sterilization: it is used for disposable goods but is a costly method. g. Formaldehyde steam sterilization Inventory management: i. Stock: to ensure the availability of sterilized items to the hospital units, five times the average daily requirements. The replacement and procurement of condemned items should be laid out so that situation of stock out can be avoided. Issue of materials: the principle of first in- first out ensures proper rotation of supplies in CSSD and prevents any item from being kept for longer time so that its sterilization date expires. Distribution of sterile items: the method that can be used for distribution of sterile items are: Grocery system: in case CSSD is open 24 hrs, wards and departments can send requisition to CSSD and stock is supplied accordingly. CSSD is open for limited hours: Clean for dirty exchange system: one clean item is provided for each item in the ward used. Milk round system: it includes daily topping up of each ward/ department stock level to a pre determined level decided by users. Basket system: a basket with daily requirement of ward is changed everyday irrespective sterile items used or not, and the items of the whole basket is sterilized every day. In case the items are to be stocked in wards, the date of sterilization is written on each item so that the unused items are returned to CSSD for re-sterilization after 72 hrs.
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ii.

iii.

iv.

Quality control methods: Routine temperature/pressure and holding time testing of each autoclave. Steam clox is also very handy and reliable. Changes color from brown to green Heat/time, moisture sensitive tapes may be used in same way as that of steam clox Random samplings of sterilized items are also tested in laboratory Culture of wall/floor and scrapings.

Laundry services: Functions of laundry: Control of cross infection: it reduces the chances of cross infection. Patient satisfaction: the patient likes to have clean linen which is changed and washed frequently and has a psychological effect on patient. Public relation: the image of hospital also depends on clean look of linen as it instills confidence in patients and relatives. Types of laundry: a. In-plant or in-house laundry: in this system, the hospital has its own linen and laundry and all activities of the hospital laundry services are done in hospital premises. A hospital with more than 100 beds can run this type of laundry services. b. Rental system: this system is used in advanced western countries. The owner of the linen is also the supplier of linens to the hospitals and is also responsible for the replacement as well as the laundering of patients and staff linen. c. Contract system: in India, all hospitals have their own linen, majority of the hospitals get the laundering done by contract dhobis. In some cases, a subsidized contract type is prevalent and in some cases, the hospitals provide water and washing area within the hospital premises. d. Co-operative system: it is most beneficial to the smaller hospitals than the large hospitals as they share the service of highly qualified laundry services. Planning and organization of laundry services: Location: if possible, the laundry should be in the same building as the hospital, and should have separate entrance and exit areas. It is recommended to have a mechanized laundry in the basement, with proper drainage arrangements. Space requirements: The requirement for any laundry services has been worked out to be approx. 10-15 sq.ft./bed. No.of beds Space

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200-300 beds 300-500 beds 500-600 beds >650 beds

3750 sq.ft. 5670 sq.ft. 6460 sq.ft. 8210 sq.ft.

Floor area/space requirement: According to Dr. Mc Gibony, the area for a laundry for a teaching hospital in India should be at least 5800 sq.ft. Physical layout: 1. Straight through flow: the planning of the building and installation of equipment in a straight flow from the dirty end to the clean end. 2. U-flow: where the dirty and clean ends are in the same direction. 3. Gravity flow: this takes advantage of the underground, with dirty end at the top and clean end at the bottom. Laundry is divided into two distinct areas: Dirty area: it comprises of Reception of solid linen Sorting of soiled linen into suitable quantities for processing Clean area: it comprises of drying finishing discharge a barrier wall between the clean and dirty area is desirable

Schematic design of functional areas:

Reception of dirty linen and storage room Toilet Decontamination and sluice room Washer Boiler room

Laundry manager

Staff room

Store of detergent

Store of spare linen

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Linen mending

Hydro extractor

Issue area

Storage of clean linen

Pressing and laundering

Drier

Ancillaries: Laundry managers office Stores Tailoring bay Workers rest room Toilet Boiler room Material and decor: The route of soiled linen from the using points to the laundry and the flow of clean linen from laundry to the using points should be planned as to minimize the possibility of contamination of clean linen. The laundry should be grouped into specific separate areas. Laundry managers office should be located as centrally as possible to properly supervise the entire laundry operations. The walls should have large vision panels to allow full view of each area. A toilet, locker and shower facilities should be provided in the soiled linen receiving, sorting and washer loading room and clean linen processing room. Supply storage room should be adjacent and connected to the soiled linen receiving, sorting and washer loading room. Sufficient space should be provided for the storage of one weeks supply of detergents, bleaches and others. The floor for the laundry should have smooth, slip resistant and water proof surface, the walls should have a smooth washable surface free from all corners, edges or projections which create maintenance problems. Utility services like piping, electrical wiring should be designed and sized with appropriate consideration for future expansion. The steam supply system should be designed to deliver steam to the equipment in right quantity at a desired temperature.

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Hot water should be available at 1800F by the pipeline to the laundry at the required temperature from the boiler room. The power supply to the laundry is usually 220 or 440 volts in three phases , four wire alternative system and must be accessible Lighting should be free of glare and shadows. Fire extinguishers should be located in the laundry near the clean linen and the processing areas. There is a need for flow of drains in the sorting and washing areas. Ventilation system must be able to provide a comfortable environment for the workers. Sewing and mending room should be located near to the clean linen and pack preparation room.

Laundry management: The management of laundry contributes to morale of the staff and patients with fresh laundered linen: a. Sequence of operation: Collection of laundry by laundry staffs in trolley with clean and dirty linen separately and is sorted out as soiled, infected and foul linen to avoid nosocomial infection. Disinfection is done using disinfectants for infected linens. Sluicing and washing: sluicing is done for foul linen in sluice machine and then the linen along with those that are disinfected are put in washer for cleaning. Hydro-extractor: it is then put in extractor for removing extra water. Drier tumbler: the linens are put for drying. Pressing: the linens are pressed Mending: the torn linen is sent for repair or condemnation and replacement. Repaired linen is again washed in washer and washing cycle after that is to be completed. Distribution to ward is done by laundry staff after it is ready for use. b. Linen distribution system: Topping up: in this, the ward is given certain number of stock of linen based on 24 hours requirement and shortfall of linen due to use is topped up by the laundry staff everyday and used ones are collected. Clean for dirty exchange: the issue of clean linen to exchange number of pieces of dirty linen. Exchange trolley system: this is expensive and not used in India. In this, total trolley is supplied which has 24 hours requirement and next day fresh trolley is supplied with same number of pieces and old trolley is taken back to laundry irrespective as how many pieces have been used and linen is brought and washed.

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c. Quality control of laundry services: the quality assurance of laundry should be developed since laundry is important from where infection can be transmitted to other patients, which should be seen by the hospital infection control committee. d. Policies and procedures: Collection and distribution system of linens with periodicity to each ward and department. Detailed instruction about handling infected and foul linen. Charter of duty of each person handling laundry and training schedule of staffs. Sluicing and disinfection procedures. Operation of laundry machines. Maintenance and service contracts of machines. Provision of detergents Procedure for condemnation of linen and procurement of new linen Fire safety drills and fire extinguishing measures Record of distribution, collection, inventory of detergents and linen procured/condemned. Security arrangements for laundry. Regular physical verification of linen and fixing responsibility of any type of loss. Kitchen services: A hospital dietary service includes most importantly a production unit that converts raw material into palatable food. The preparation and distribution of food from store to spoon has many challenges for the administration such as proper preparation, cost accounting, pilferage and wastage. Functions of dietary services: The dietary services cater for the following: therapeutic diet in-patient catering diet counseling education and training

Staff requirements: Category of employees Beds 100 200 300 500 750

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Chief dietician Senior Dietician Dietician Asst. dietician Steward Storekeeper(ration) Storekeeper(general) Clerk/typist Head cook Therapeutic cooks Cooks Asst. cook Cleaners, waiters Store attendants Sweepers

1 1 4 6 4 1

2 1 6 14 4 1 1

3 1 1 2 8 20 6 1 2

1 5 1 1 1 1 2 2 10 28 8 2 2

1 1 1 7 1 1 1 1 2 3 16 32 10 2 3

Fig. 1 shows staff requirement Location and space requirement: Location: the dietary department should be located on the ground floor near wards where the diets need to be taken and also accessible to road as supplies are to be carried to storage area. Space requirement: Hospital kitchen is divided into number of divisions which have a particular activity. The broad areas are supplies receiving area, storage area, cooking area, pots and pan wash, garbage disposal, LPG stove and refrigeration facilities, housekeeping, dietician, steward offices and circulation area. Following space requirements are recommended for different size of hospitals: 200 beds or less: 20 sq ft per bed
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 200-400 beds: 16 sq ft per bed or 18 sq ft per bed 500 beds and above: 15 sq ft per bed Functional areas in department: a. Recipient area: this is the place where all provisions are off loaded. these are checked for right quality and quantity, hence area should have unloading points, ramps, trolleys and weighing scales. b. Storage area: this area where the provisions are categorized and stored in separate areas. the areas should have enough shelves and bins: Dry provisions like flour, dal, sugar, oil etc. Fresh provisions like vegetables, milk, butter, meat etc. They are further divided based on temperature requirements: items to be stored at room temperature like onion, potato etc Items require cool temperature (8-100c is maintained) for which walk-in cooler can be provided to store milk, eggs, butter etc. Deep fridge where temperature is below 00c fish and meat should be stored. Day store: it is an area where provisions for one days cooking issued to the cooks are stored. Preparation area: it is an area where provisions are cleaned, washed, soaked; meat is chopped, cut and sliced etc. the items like kneader, weighing scale, slicer etc has to be provided. Cooking area: it should have pressure cooker, cooking range oven etc. Service area: the food is put in service pots in trolleys and if it is a centralized distribution system, it is put in service trays, with specifying the name of patients. Washing area: this is meant for washing cooking and service pots, hence should have liberal hot and cold water. Disposal area: the area where all garbage and left over food is collected for disposal.

c. d.

e. f. g. h.

Fig 2. - The figure explains the layout of kitchen

Recipient area of provisioning Office store keeper Walk-in cold store Dry store Fresh store

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Dry store

Preparation area

Dietician Supervisor Staff room Staff toilet

Cooking area

Trolley+ pot wash area

Distribution area and service Wards

Distribution of diet: a. Centralized service: the food is set in individual tray centrally at dietary department including therapeutic diet of patients and are transferred to wards in trolleys and served to the patients. b. Decentralized service: the food is sent to wards and served as per the need of the patient. Dietary store management: Storage of food items: for dry storage, the temperature should be 700c, with adequate ventilation has to be insured. The storing shelves, bins should be placed 10 above the floor. Purchase of food products: the items can be purchased from open market or through calling tenders. The items to be purchased should have AG MARK OR IDI. For this, an internal purchase committee may be constituted by the hospital administration. Equipment planning: equipment purchase depends on the objectives and basic functions of the department, workload and availability of the personnel, and quality standards. Modern gadgets like mixer grinders, pressure cookers, dish washers etc. Should be a part of hospital kitchen. Financial control: The first thing to be done for an effective financial control is to control the labor costs. Menu planning should be done in such a way that it reduces the inventory, selection of items common to many areas of patient care, reduced handling, wastage, use of automation or more equipment requiring less operational staff are some measures that can be put to practice for an effective financial control. Laboratory services: The basic function of laboratory services is:

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 To assist doctors in arriving at or confirm a diagnosis and to assist in the treatment and follow-up of patients. The laboratory not only generates prompt and reliable reports, and also functions as store house of reports for future references. It also assists in teaching programmes for doctors, nurses and laboratory technologists. It carries out urgent tests at any part of day or night. Functional divisions: The hospital laboratory work generally falls under the following five divisions: a. b. c. d. e. Hematology Microbiology Clinical chemistry/ biochemistry Histopathology Urine and stool analysis

Functional planning: It covers the following activities: Determining approximate section wise workload. Determining the services to be provided. Determining the area and space requirement to accommodate equipment, furniture and personnel in technical, administrative and auxiliary functions. Dividing the areas into functional units i.e. Hematology, biochemistry, microbiology etc. Determining the number of work stations in each functional units. Determining the major equipments and appliances in each unit. Determining the functional location of each section in relation to one another, from the point of view of flow of work and technical work considerations. Identifying the electrical and plumbing requirements for each area/ work station. Considering utilities i.e. lighting, ventilation, isolation of equipments or work stations. Working out the most suitable laboratory space unit, which is a standard module for work areas. Organization: Location: it is preferable to have hospital laboratory planned on the ground floor and so located that it is accessible to the wards. In large hospitals, the entry of outpatients to the laboratory can be obviated by opening a sample collection counter in the outpatient service area itself. Outpatient sample collection: it should be located in the outpatient department itself. The design of this area should include waiting room for patients, venepuncture area and specimen toilets separately for male and female patients, along with provision of containers with appropriate preservatives and keeping record of each patient.
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 Area/space: in a small hospital, the laboratory facility consists of a room in which all the routine urinalysis, hematology and clinical chemistry investigations are carried out. As the hospital size increases, the requirement of technical and administrative services also increases with the necessity for departmentalization of the laboratory. The requirement of space for the laboratory consists of : Primary space: this space is utilized by technical staff for the primary task of carrying professional work. Secondary space: it is utilized for all supportive activities. Administrative space, i.e. Offers for the pathologists and others, staff toilets etc. Circulation space: it is the space required for uncluttered movement of personnel and materials within the department between various technical work stations, rooms, stores and other auxiliary and administrative areas. Laboratory space unit (LSU): it is a module of space and all calculations for technical work areas and some auxiliary area are based on LSU. For allocation of primary space, one of the most suitable sizes of a LSU is one measuring 10 x 20 giving a LSU module of 200 sq. ft. a rectangular module is functionally more efficient because in the same overall space, it can accommodate longer runs of benching due to its longer perimeter. Layout: structural flexibility should be achieved by use of movable or adjustable benching systems in association with an installation of service mains that has been designed to permit the repositioning of outlets. Administrative and auxiliary areas: the administrative area (the area is the central collection point for receiving specimens and is the reception and interaction area for patients and hospital staffs) is separated from the technical work area so that the nonlaboratory personnel need not enter the technical areas. Reception and sample collection: this is the area should be well ventilated and lighted, should have a chair where the patient can sit in comfort and where his arm can be stretched for the phlebotomy, a bed where the patient can lie down for pediatric collection or aspiration cytology. Bar-coding system for samples: this system is used to trace the samples. The sample is received and then bar coded, and then sent to processing area. This protects patient identity. Specimen toilet: it is provided for the collection of urine and stool specimens. Pathologist office: it is so placed that the pathologist can have an easy access to the technical areas particularly histopathology unit. Glass washing and sterilizing unit: small labs collect blood in bottles that are washed and reused. This is partitioned into washing and sterilizing area, containing sterilizer, pipette washer and sinks. Report issue: the reports should be issued in printed format. The hospital lab software can be made as per the requirement of the hospitals.
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 Utility services: it includes water, gas and compressed air systems. Piping systems should be easily accessible for maintenance and repairs with minimum disruption of work. For safety purpose and to facilitate repairs, each individual piping system should be identified by color, coding or labeling. Internal design and fitments: a. Work benches: the height of the work bench on which the technicians sit while working (revolving stools) vary from 75-90 cm depending upon the height of the workers. b. Lighting: natural light should be used to the fullest. Each work bench should be provided with adequate electric points especially fluorescent fixtures that give uniform illumination and minimize heat. c. Storage: each laboratory bench length should have storage space for reagents, chemicals, glass wares and other items, provided in the form of under bench drawers, cupboards etc. d. Partitions: it may be required between some laboratory spaces. e. Air conditioning: whole or at least histopathology section of the laboratory should be air conditioned due to accumulation of formalin vapors or else a powerful exhaust system should be installed. f. Working surface/ flooring: the surface of work benches should be resistant to heat, chemicals, stain proof and easy to clean. Floor should be easy to clean, and not slippery. Flexible vinyl flooring is preferred for laboratory floor coverings. Staffing: the hospital laboratory services should be under the control and direction of a doctor with qualifications in pathology or a PG degree in the new discipline of laboratory medicine. Number of personnel: staff requirement of laboratory technicians can be worked out empirically on the basis of generally accepted norm which is about 30 tests per day per technician. Equipment: Some of the core instruments that are needed are: Colorimeters/ spectrophotometers: they were used in old days, are now replaced by new auto-analyzers these days. Auto analyzers: it is used maximum in biochemistry works. Cell counter: it gives a more complete blood picture. The principle of the instrument is to pass the cells through a thin capillary. Centrifuge Refrigerators Pressure sterilizers Pipette washers Analytical balance
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Semi auto analyzer ELISA reader Blood gas analyzer PCR instrument Flow cytometer

Policies and procedures: Laboratory samples: samples to be examined falls in two categories: Samples collected by nursing staffs in nursing units Samples obtained by lab. Personnel. All requests for lab. Examinations must be in writing. Sample receiving: in the reception area, all samples of blood, urine, body fluids etc should be received at the reception counter. Sufficient racks and hand washing facility should be provided in this area. Request forms: all request forms should be uniform in size and contain only pertinent information. Time for accepting specimens: a time schedule for accepting certain types of specimen will facilitate the operations of the laboratory. Containers: all specimens sent should be in proper containers. Instructions on the time of taking specimens, minimum volume required, type of container etc. Should be posted at the nurses station in wards. Identification of specimen: the lab. Personnel should be responsible for proper disposition of all specimens and requests within the lab. to identify the specimen received, the specimen and request form should be numbered with same number and is also entered in the request register. Reports and records: lab. Personnel should give reports only to authorized ward/ OPD personnel and never directly to patients. A daily record register should be kept of all examinations performed in the lab. In order to maintain a monthly and yearly account of the work done. Blood bank services: it should be controlled by the officer in charge and the technical supervisor, to ensure that all are aware of the establishment of written procedures for identification of blood samples, storage facility etc. Outpatient samples: it is necessity in large hospitals where the volume of workload from outpatient department is considerable. HIV: necessary safety precaution should be clearly understood by all concerned while drawing blood samples from suspected HIV and hepatitis patients. Liaison with clinicians: differences between the patients lab. reports as compared to their clinical status arises which should be discussed in the medical audit committee. Motivation and cross-training: the in charge should discuss professional, technical and administrative matters concerning the laboratory during periodical meetings with staff.
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The lab. Policy must lie down that all staff is cross-trained to work in all the different sections of the laboratory. Waste disposal: histopathology and microbiology laboratory waste be considered as hazardous waste and should be disposed accordingly. Optimal utilization of laboratory services: to better utilize the laboratory services, a constant emphasis is needed on ordering only the appropriate tests required for diagnosis or prognosis based on clinical judgment and filling the required form s completely. Quality control: as a part of quality control function, standard operating procedure should be laid down by the in charge pathologist for each function and each functionary in the laboratory. Emergency services: An emergency department must be developed as a mini hospital within a hospital i.e. Independent and self sufficient in day to day working. Planning and organizational considerations: 1. Location: there are two essential location requirements: It must be on ground floor and easily accessible to both ambulatory and ambulance patients, and there should be minimal separation between it and radiology department. Secondly, the emergency department should have ready access to the acute patient care areas, eg. Operation theatre, ICU, blood bank etc. Emergency department must be designed; usually 1000 sq.ft is required for daily patient load of 100 patients. 2. Stretcher, trolley, wheelchair store: a store for stretcher, trolley and wheelchairs should be located adjacent to the entrance. 3. Ambulance attendants, police, mass media room: an equipped room of about 10 m2 near the entrance hall with attached toilet serves the needs of above personnel. 4. Work area: it should be spacious with enough room for personnel and patients. 5. Waiting area for emergency department patients: the main function of this is to be the passageway to patient examination and treatment area. 6. Waiting area for relatives: patient relatives should not be allowed in the work areas of emergency department. Waiting room with recreational facilities may be provided. 7. Visitors toilet: it should be provide near the main waiting space. 8. Nurses station and administrative office: this should be next to the entrance and manned on 24 hr. basis. It should be provided with multiple telephones, bulletin board with duty roster of doctors on call and directive pertaining to the emergency department should be displayed. Nurses work room should be well stocked with drugs, IV fluids. 9. Examination and treatment area: this area should always be in readiness to receive patients at all times, and should consist of a large room and number of separate smaller rooms for examination and treatment. It should be well illuminated space with oxygen

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supply, resuscitation equipment, suction, portable X-ray, electrocardiographs, and Boyles apparatus. 10. Equipment: Stretchers On-the wall oxygen unit On-the wall suction unit BP apparatus, otoscope, stethoscope, opthalmoscope etc. Spot lights Utility table Airways and resuscitation bags 11. Resuscitation room: the patient is to be stabilized in this room before shifting to treatment or recovery room, or to ICU or nursing unit. It should be well equipped with resuscitation equipment, ECG machine and X-ray viewing screening with facility for performing minor operative procedures. 12. Operation room: a self sufficient operation room to serve patients who need minor surgery and no admission or who are critically ill etc. in emergency department. 13. Fracture room: a separate fracture room equipped similar to OT and additional facilities for reduction of closed fractures under local anesthesia can be planned with hospitals with turnover of emergency patients in excess of 15,000 per annum. 14. Plaster room: it is needed for treatment of fractures and application plasters. 15. Care of burns: a separate room with 20 m2 area should be reserved for immediate care of burn patients. An observation ward of about 6-8 beds for patients to be kept under observation overnight or 24 hrs. 16. Isolation room: for obstetric patients, pediatric patients. 17. Other rooms: these should be planned based on the local needs: Room for dead bodies Pantry-7 m2 Storage space Utility and soiled linen room-7 m2 Cleaners room-house keepers room 4m2 Change room duty rooms 9m2 Conference room and reference library 8m2 Staffing pattern: Full time emergency physicians, especially trained in emergency medicine A well staffed emergency department needs 8 nurse shifts of 8 hours each per 100 daily patients visits. Additional staff nurses is required if there is observation ward attached. For registration and records, usually 3 clerks work in day and afternoon shift, and one during night. Security should be available round the clock
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 Public relations and social worker should be available to take care of the anxious and disturbed patients and their relatives. Medico-legal aspects of emergency department: a. Negligence: it is the breach of duty owed by a doctor to his patients to exercise reasonable care/skills resulting in some bodily, mental or financial disability. b. Duty to treat all: according to the recent supreme court decision, no doctor can refuse giving first aid treatment to accident victims or any other patients. c. Problem areas in emergency department: Consent to treatment: a written consent must be obtained from the patient to treat him, with the patients knowledge regarding procedures. Medical records: medical records and proper record keeping are high priority in any hospital. Proper documentation of patients case history with informed consent is necessary. Reporting to authorities: all medico-legal cases e.g. Assault and battery, child abuse, accidents etc. Should be reported to proper authorities e.g. Police. The cases of AIDS and venereal diseases should be reported to health authorities. JOURNAL ABSTRACT: A well managed outpatient services ensures not only a good relation, but also enhances the patient flow to the hospital. It also results in cost reduction and helps the hospital to become more economical. It also ensures patient satisfaction and satisfaction of the patients relatives. And it is also effective in reducing the load of in-patients services in the hospitals. It reaches out to the community through curative, preventive and promotive activities, and helps in rehabilitation of the patients. -The nightingale times

BIBLIOGRAPHY: i. ii. iii. iv. A.G Chandorkar. Hospital administration and planning. 2nd edition. Paras medical publisher. New Delhi. 2009. pg no. 67-72,153-166,167-179,181-195. B.M.Sakharkar. principles of hospital administration and planning. 2nd edition. jaypee brothers medical publishers ltd. 2009. pg.no-195-207. D C Joshi, Mamta Joshi. Hopsital administration. Jaypee brothers medical publishers pvt ltd. New Delhi. 1st edition. 2009. pg. no. 186-208. The nightingale times. volume II. pg. 32

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