Sei sulla pagina 1di 27

Page 1 of 27

RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

STANDARD OPERATING PROCEDURES

FOR

HOUSEKEEPING

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 2 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

AUTHORIZED SIGNATORY

1. Approved By Medical Director

2. Issued By Incharge-QA

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 3 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

AMENDMENT SHEET

Sl. Page Clause No. Date of Amendment Made Signature of


No. No. Amendment Reasons approval
authority
1

TABLE OF CONTENT

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 4 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

Sl.
TITLE/CONTENT
No.

1. INTRODUCTION

2. PURPOSE

3. GOAL

4. SCOPE OF SERVICES

5. APPLICABLE AREA

6. ORGANOGRAM

7. JOB SPECIFICATION / REQUIREMENT

8. RESPONSIBILITIES

9. PROCESS FLOW CHART


DUTY ROASTER
10.
HOUSE KEEPING SUPERVISOR
10.1
HOUSE KEEPING PERSONAL PROTECTIVE EQUIPMENT
11.

12. CLEANING SCHEDULE

13. PROCEDURE & WORK INSTRUCTION

13.1 PROCEDURE OF BIO-MEDICAL WASTE COLLECTION AND SEGREGATION

13.1A DOS AND DONTS FOR WASTE MANAGEMENT

13.1C HOUSEKEEPING CLEANING FREQUENCY AS PER HIC GUIDELINE

13.1E ENVIRONMENTAL CLEANING PROTOCOL

13.2 WORK-INSTRUCTION FOR USE OF CORROSIVE / HAZARDOUS MATERIALS


Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 5 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

13.3 WORK-INSTRUCTION FOR CLEANING / SCRUBBING OF HIGH RISK AREA

13.4 WORK-INSTRUCTION FOR CLEANING/SCRUBBING OF LOW RISK AREA

13.5 WORK-INSTRUCTION OF LAUNDRY ACTIVITIES

13.6 WORK-INSTRUCTION OF WASTE MANAGEMENT IN THE HOSPITAL

13.7 WORK-INSTRUCTION OF MANAGEMENT OF PATIENTS LINEN

13.8 WORK-INSTRUCTION FOR SPILLAGE

13.8a INFECTED SPILLS -MANAGEMENT OF BLOOD OR OTHER BODY FLUID SPILL

14. WORK INSTRUCTION FOR HANDLING OCCUPATIONAL HAZARDS

15. LIST OF QUALITY INDICATOR

16. LIST OF QUALITY OBJECTIVES

17. ANNEXURE

18. ABBREVIATION

1. INTRODUCTION:

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 6 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

The House Keeping department has a good role to play in Hospital hygiene and image. All staffs in
house keeping department should be well groomed and clean. They should know the standards of
cleaning and hygiene to up keep the image of the hospital.

The House Keeping department has more than 30 staffs.

Hospital cleaning, outside cleaning, Bio-medical and General waste disposal etc. comes under the
supervision of House keeping.

House keeping has to ensure clean-linen in each department, as this directly reflexes the quality,
health and the image of the hospital.

2. PURPOSE:
a. To ensure cleanliness and hygiene throughout the hospital.
b. To prevent Hospital acquired infections.
c. Ensure proper segregation and disposal of bio-medical waste.

3. GOAL:
Cleaning and controlling infection in an around the hospital premises.

4. SCOPE OF SERVICES:

a. Bio-Medical waste collection & segregation

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 7 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

b. Waste Management
c. Hospital Cleaning
d. Environment Cleaning
e. Use of Corrosive / Hazardous Materials
f. Cleaning & Scrubbing of high risk area
g. Cleaning & Scrubbing of low risk area
h. Laundry Activity
i. Management of patient linen
j. Spillage Management
k. Handling Occupational Hazards

5. APPLICABLE AREA:

a. IPD
b. Toilets
c. Emergency
d. Radiology
e. Dialysis
f. Pharmacy
g. Mortuary
h. Roof
i. Maintenance

6. ORGANOGRAM:

Asst. Medical Director

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 8 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

Head-HR

HOD-Housekeeping

Housekeeping
Supervisor
Laundry Man

H.K Staff

7. JOB SPECIFICATION / REQUIREMENT:

Refer to Human Resource Department. RVMH/HRM/FM/05

8. RESPONSIBILITIES:
Refer to Human Resource Department. RVMH/HRM/FM/05

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 9 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

9. PROCESS FLOW CHART:

Activities

1. Sweeping
2. Mopping Output
Input 3. Dusting
4. Waste management 1. Hygienic environment.
1. Cleaning material 5. Use of Corrosive
2. Linen as per the patient Hazardous 2. Fresh and clean linen in
requirement /investigation Materials. each area.
area. 6. Cleaning /
3. Pesticide (Outsource) scrubbing of high 3. Waste disposal
Approved By: bins for waste
4. Colour coded risk area. Issue No. : 01
disposal. 7. Standard
Cleaning / Operating 4. Ambulance maintenance
5. Request
Issued By:for internal Procedure
scrubbing of low Rev.5 No. : 00
transport. risk area Support ward nurses in
8. Laundry Activity. patient care.
Issue Date: 25.07.2015 9. Management of
Rev. Date: 00
patient linen.
10. Spillage
Management.
Page 10 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

Control Parameter

Responsibility
Reference
1. Toilet cleaning checklist.
Work Instruction 1. HOD-Housekeeping 2. Room checklist.
3. Waste disposal policy
Related documents 4. Pest control rounds file

10. DUTY ROASTER

a. Patient Ward A Shift 1 GDA & 1 H.K. Staff

General Duty 9.00 to 5.00 1 GDA (Every Patient ward)

B Shift 1 GDA & 1 H.K. Staff

C Shift 1 GDA & 1 H.K. Staff

b. Floor OPD A Shift 1 GDA & 1 H.K. Staff

B Shift 1 GDA & 1 H.K. Staff

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 11 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

General Duty 9.00 to 5.00 1 GDA (Every Patient ward)

c. Other Areas In each shift 1 GDA

11. HOUSE KEEPING PERSONAL PROTECTIVE EQUIPMENT:

Critical Area - Gloves, Mask, Protective Cloth,

General Area - Gloves, mask

12. CLEANING SCHEDULE:

12.1. CLEANING SCHEDULE OF GENERAL WARD:

Landing Daily Shift Wise

Staircase Daily Shift Wise

Nursing station Daily Shift Wise

Corridors Daily Shift Wise

Rooms Daily Shift Wise

Toilets (rooms) Daily 4 times in a day

General ward includes Male /Female ward, Medical Male/Female ward, general ward, pediatric ward,
surgical ward, observation.

12.2. CLEANING SCHEDULE OF HIGHLY RISK AREA:

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 12 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

ICU Daily Every 4 hourly

OT Daily Every 4 hourly

Dialysis Daily Every 4 hourly

. Daily Every 4 hourly

. Daily Every 4 hourly

.. Daily Every 4 hourly

Pathology Daily Every 4 hourly

12.3. CLEANING SCHEDULE OF LAB, X-RAY, SCAN, BLOOD

U.S.G Daily Shift Wise (As Required)

Radiology Daily Shift Wise (As Required)

CT/MRI Daily Shift Wise (As Required)

Blood collection Daily Shift Wise (As Required)

Emergency Daily Shift Wise (As Required)

12.4. CLEANING SCHEDULE OF GENERAL AREA

Main porch Daily Shift Wise

Staircase Daily Shift Wise

Reception area Daily Shift Wise

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 13 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

Corridor Daily Shift Wise

Pharmacy Daily Shift Wise

Toilet (OPD) Daily Every 30 Mints

Report counter Daily Shift wise

Toilet (Report count) Daily Shift Wise

Lifts Daily Shift Wise

12.5. CLEANING SCHEDULE OF O.P.D

Maternity Daily Shift Wise

Billing Daily Shift Wise

Doctors chamber Daily Shift Wise

EEG Daily Shift Wise

Cardiology Daily Shift Wise

Dental Daily Shift Wise

Ophthalmology Daily Shift Wise

Health Checkup Daily Shift Wise

OPD reception Daily Shift Wise

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 14 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

13. PROCEDURE & WORK INSTRUCTION:


13.1 PROCEDURE OF BIO-MEDICAL WASTE COLLECTION AND SEGREGATION:

Bio Medical waste of our hospital after disposal is handed over to the RAMK group. As per
pollution control board recommendation. RAMK group has been given the contract to handle
the bio medical waste of RVMH Hospital.
Segregation & Dispatch of waste in Different color Bags. Covering all type of Hospital waste.
Responsibility: - Supervisor, Nursing staff

a. Yellow bag - For post operative body parts, dressing materials, blood or
body fluid, contaminated paper and cloth, mask, caps etc.

b. Blue bag - Syringe, I.V set, catheter, gloves, Urine bags, Blood bags
etc

c. Black bag - For food waste + All General Waste

d. P.P.C - One is for broken glass ampoules, slide etc.


Another one is for burned needles, blades etc.

A.DEPARTMENTAL FUNCTION:
a.As per pollution control board & our hospital policy we have to give our biomedical
waste.
b.Every shift wise the housekeeping staffs collect the biomedical waste from the each room.
c.They store the waste in the sulobin shift wise.
d.In the every night the housekeeping staffs collect entire waste from the floors.
e.Store the waste in the bio-medical waste segregation room.

B.DOS AND DONTS FOR WASTE MANAGEMENT DOS:


b. Do segregate waste at point of generation to
Infectious non-sharp
Sharp

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 15 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

General
Infectious plastic waste
c. Do collect in color-coded bags
d. Do train & educate all categories of staff in proper segregation & handling of wast.
e. Do decontaminate all sharps by chemical disinfectant
f. Do shred plastic waste
g. Do use syringes & needles destroyers
h. Do recycle decontaminated, shredded plastic through authorized manufacturers
i. Do cover the waste collection containers
j. Do secure storage area
k. Do transport through covered trolleys
l. Provide protective wear to transporters and handlers
m. Do clip and decontaminate rubber gloves
n. Do immunize all waste handlers

DONTS FOR HANDLING AND DISPOSAL OF HOSPITAL WASTE:


a. Dont mix the infectious with non-infectious waste.
b. Dont throw sharps in the trash or into non-puncture proof container/bags
c. Dont recap the needle or bend or break needles with hand.
d. Dont fill the waste containers more than 3/4th of capacity
e. Dont allow unauthorized persons access to waste collection/storage areas
f. Dont use open buckets for infectious waste or sharps

C. HOUSEKEEPING CLEANING FREQUENCY AS PER HIC GUIDELINE:

SL. NO. TASK FREQUENCY REMARKS


1 CURTAIN CHANGING MONTHLY
2 NEEDLE JAR CHANGING 48 hrs
3 MOP HEAD CHANGING WEEKLY

INTERVAL
4 MORTUARY CLEANING WEEKLY ONCE
5 DUSTER CHANGING WEEKLY ONCE
6 WARD AREA SCRUBBING WEEKLY ONCE
7 GENERAL PEST CONTROL DAILY THRICE
8 FLOOR DESINFECTING FOUR TIMES
Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 16 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

9 FAN MONTHLY ONCE


10 WASTE DISPOSAL DAILY THRICE
*Note Frequency can be changed as when required.

D. DEPARTMENTAL FUNCTION:
Housekeeping staffs clean there allocated area as per the schedule mention.

E. ENVIRONMENTAL CLEANING PROTOCOL

Area Disinfectant Used Exposure Time


Floor Critical Care & OT Virex 11 - 256 Every 4 hourly
Floor, ward and public area Virex 11 256 & Phenyle Shift wise (4 times)
Beds & surface Virex 11 - 256 Daily
Bed mattress Sodium Hypo chloride 1% Daily
Spill 1% Sodium hypo chloride As required
Cleaning of glassware Colin Daily
Cleaning of W.C bowl, Harpic Daily
urinals, pint measures.
Public toilet floor cleaning Phynile/ Harpic/Soap liquid Every half hourly
Toilet & bed pans washing Bacilocid special & Sodium Shift wise (4 times)
and disinfection -ward, ITU Hypo chloride
Fogging - ward Virex 11 - 256 OT Staff

Fogging critical care, OT Virex 11 - 256 OT Staff

F. DEPARTMENTAL FUNCTION:
Housekeeping staff clean the environment of this hospital according to the schedule.

13.2 WORK-INSTRUCTION FOR USE OF CORROSIVE / HAZARDOUS MATERIALS:


a. Protect yourself.
b. Approach the scene with caution.

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 17 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

c. Attempt to identify the hazardous material.

d. Obtain further information and assistance for equipment, etc.

e. Avoid contact with hazardous material and person.

f. TRY to contain the material as much as possible in one place. Try decontaminating the
person, as much as possible at the scene. Setting up the decontamination area should be
done.
With few exceptions WATER is the UNIVERSAL ANTIDOTE. For biological
(Infective) hazardous materials use BLEACH.

DEPARTMENTAL FUNCTION:
a. Before the use of the corrosive / hazardous material protect himself by the use of
personal protective equipments.
b. Identify the material before attempt that.
c. In the cleaning time very much alert to contaminated with the body save your body to
contamination with the hazardous material.
d. At the end of the work decontaminate the person as much as possible.

13.3 WORK-INSTRUCTION FOR CLEANING / SCRUBBING OF HIGH RISK AREA:


a. Perform the daily basis work as per work manual & collect the special instruction if any
from the supervisor for the day.
b. Collect the cleaning tools like broom, mop, bucket, scrubber, cleaning compounds,
disinfectants etc.
c. Sweep the floors carefully.
d. Dilute the cleaning compounds / disinfectants with water as recommended.
e. Mop the floor carefully.
f. Clean the bed railing, food trolley & other associated furniture/fixture with the
disinfectant.
g. Fumigate the area / room as per H.K plan. (As required)
h. Always collect the waste materials from designated container (colour coded bucket) and
place the fresh under liner.
i. Dump the entire collected garbage bag in the designated area.
j. Cleaning the furniture & fixture with Colin.
k. Cleaning of fixture as and when required.

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 18 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

l. Broom the floor


m. Preparation of liquid solution for floor scrubbing in 1-lit water 20 ml. After scrubbing
squeeze water and mop floor.
n. 3 times mopping & Weekly mop head changing.
o. Cleaning of bedpans & urinals with hot water and Hypochlorite solution and then
disinfected.
DEPARTMENTAL FUNCTION:
a. The allocated staff perform there daily work as per work manual.
b. Collect all the cleaning tools and disinfected before used them.
c. Dilute the cleaning compounds / disinfectants with water.
d. Sweeping & moping the floor carefully.
e. Clean the associated furniture/ fixture with the disinfectant.
f. Fumigation done by the high risk area as per the fumigation schedule.
g. Collect & dump the biomedical waste in the designated area.
h. Prepare the liquid solution for floor scrubbing.
i. 4times mopping & weekly mop head changing.
j. Bed pan & urinals clean with hot water & Hypochlorite solution & then disinfect.

13.4 WORK-INSTRUCTION FOR CLEANING/SCRUBBING OF LOW RISK AREA (ALL


CORRIDOR, OPD, BLOOD COLLECTION, WARDS DLX, TWDXL ROOM):
a. Report to the dept. & see the H.K work plan.
b. Collect the special instruction if any from the HK Supervisor for the day. Report to duty
on daily basis work as per work manual & collect the special instruction if any from the
Supervisor for the day.
c. Collect the cleaning tools like broom, mop, bucket, scrubber, chemicals (biodegradable)
etc.
d. The ratio of solution for furniture & fixture is Hypochlorite solution
e. Use appropriate PPE ( like mask, gloves)
f. Sweep the entire floor (room /corridor/ stair case etc) area and mop with the help of
cleaning materials, disinfectants duly diluted with water.
g. Clean & do dusting of the reception and other associate area, clean the glass doors by
Glass Cleaner Chemicals.
h. Change the under liner of all waste been and replace with new one.
i. Clean the inner/outer body of the waste been by soap solution.
j. Clean the OPD chambers through dusting, sweeping followed by mopping dusting,
scrubbing & wiping.

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 19 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

k. Broom the floor and preparation of solution with floor liquid soap (Floor soap) and
phenyl solution (1 lit water: 20 ml), after proper scrubbing mopping with phenyl
solution if required.
l. Floor mopping to be done on the basis of requirement.
m. Clean the water closets.
n. Mop and Make the toilet floor clean & dry
o. Clean, disinfect & dry the commot seat, wash basin.
p. Wipe the Mirror, water fixtures.
q. Check the necessary consumables
r. Finally check the air neutralizer machine / place air refresher.
s. Cleaning of urinals & bedpans with warm water and soap solution then disinfected or
Sodium Hypochlorite 1% after every use.
t. Check if all the H.K accessories (hand disinfectant solution, towel, patient couch linen
etc) are available or not. Change/Replace as necessary.

DEPARTMENTAL FUNCTION:
a. Collect the cleaning tools from the specific area.
b. Prepare the solution.
c. Used appropriate personal protective equipment.
d. Sweep & dusting the entire floor area, reception and other associated area, clean the
glass door by the glass cleaner chemical & mop with the help of moping materials.
e. Floor moping to be done on the basis of requirement.
f. Change the waste bin plastic & clean the entire bin with soap solution.
g. Clean the OPD chamber with the appropriate techniques.
h. Clean the water closer.
i. Mop & make the toilet, commot, urinal clean, disinfect & dry.
j. Wipe the mirror & water fixture.
k. Check the air neutralizer machine / place air refresher.
l. Bed pan & urinals clean with hot water & liquid soap & then disinfect.
m. Check all the H.K accessories change / replace as necessary.

13.5 WORK-INSTRUCTION OF LAUNDRY ACTIVITIES:


a. Treatment of soiled linen with disinfectant (0.1% hypochlorite) for 1 hour.
b. Collection of soiled linen of the same at the floor/units.
c. Transportation of soiled linen to laundry.
d. Handover soiled linen to vendor.

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 20 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

e. Receive clear linen from vendor.


f. Dispatch of washed linen to floor/units.
g. Monthly inventory at linen.
h. Indirect for new linen against condemned linen.
i. Replacement at linen/improperly washed linen to floors/units.
j. Random Quality check (Dust visible, stain, ironing, odour)
k. Swab testing of cleaned linen.
l. Dispatch at new linen to different floor/unit.
m. Rewashing linen.
n. Monthly linen Audit/Inventory checking
o. Monthly outsourced laundry audit on their performance.

DEPARTMENTAL FUNCTION:
a. Collect the soiled linen in specific time at specific place.
b. Prepare the soiled linen treatment and deep the linen about 1hr.
c. Transfer the soiled linen to the laundry.
d. Handover the linen to the vendor.
e. Received the clean linen from the vendor.
f. Check the condemned linen from the washed linen.
g. Send the condemned linen to the vendor.
h. Random quality check and the swap test of the washed linen.
i. Dispatch the clean linen to the floor.
j. Monthly rewash linen audit/ inventory checking.
k. Outsource laundry audit once in a month.
13.6 WORK-INSTRUCTION OF WASTE MANAGEMENT IN THE HOSPITAL:
a. Create consciousness through training among the user dept as well as H.K Staff.
b. Identify the different type of waste, medical or non medical & Segregated according to
their nature.
c. Use appropriate personal protective equipment (P.P.E) like gloves, musk, chemical etc.
while handling wastes.
d. Place the appropriate waste bins with proper liner (refer color code for collection of Bio
medical wastes) in convenient / designated places in public area /ward area for collecting
wastes.
e. Dump / Store all kind of wastes in the designated waste bins according to their status.
f. Finally transport the wastes ( from waste bins ) to hospital waste dumping area
g. Take weighment of the wastes before disposal.

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 21 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

h. Dispose the wastes through the approved agencies.


i. Inspect the waste site from time to time and keep it clean.

DEPARTMENTAL FUNCTION:
a.As per pollution control board & our hospital policy we have to give our biomedical
waste.
b.Every day in the morning the housekeeping staffs empty the biomedical waste bag.
c.Each floor wise yellow, blue, black and white container placed in a big container
according to there colour.
d. After collecting the waste send them in our basement.
e.The biomedical waste segregation area is located in the basement.
f.The housekeeping staff put the waste colour wise separate place.
g.Take the weight of individual waste and handed over the waste to the approved
agencies.
h.Note the data of the waste collection / disposal at the end of the month and it to the
commercial department.
i.Keep clean the waste side and inspect time to time.

13.7 WORK-INSTRUCTION OF MANAGEMENT OF PATIENTS LINEN:

A. IDENTIFICATION & SEGREGATION OF LINENS:


a. Before using the fresh linen, inspect the same for any discoloration, torn, heavy
stains.
b. If the linens are found not up to the mark segregate them and issue fresh linen.
c. In case it is heavily stained linen send it to the House keeping dept for Re wash.
d. If the linen is Torn, discolored etc, store it separately in the ward/ OT/ ICU and other
concerned area and once send to the housekeeping department in a week.

B. INSPECTION OF LINEN REJECTED BY THE USER DEPTS:


a. Once the discarded linens are received from the user dept, inspect the linen
thoroughly for any cut marks, holes, missing button, discoloration, etc and make
the necessary entry in the ward wise linen stock register.
b. Segregate them separately according to the nature of damage.
c. If the items are found repairable, send the items to the Tailor for repairs.
d. If some of the lines are found not usable, and need to be disposed, stack them
appropriately and make entry in the linen disposal register.

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 22 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

C. DISPOSAL OF TORN LINEN:-


a. Disposable linens to be placed to the Scrap committee in 6 months or earlier if
needed.
b. Evaluate and dispose the linen.

D. USAGE OF REPAIRED LINEN BACK TO USE:-


a. Once the linen is received from the tailor after repairing, inspect them appropriately
and examine if they are duly altered/ repaired and suitable for the purpose.
b. If suitable, make the necessary entry in the Torn Linen Register as re useable items
and send the linen for washing.
c. If unsuitable, depending on the condition of the linen, either sends the same to the
Tailor or to the bin where discarded linens are kept.
d. Maintain the records in the torn Linen Register.

E. COLLECTION OF SOILED LINEN:


a. Every day morning patients linen are to be changed and the soiled linen are to be
kept into the dirty linen hamper bag from where soiled linen are to be collected from
different departments.
b. All linens are to be segregated as soiled / none soiled.
c. Patients objects are to be returned to patients.

F. COUNTING & SORTING:-


First sort item wise and thereafter count.

G. PACKAGING & DISPATCH OF LINEN TO LAUNDRY:-


a. Bundle the linen while sending to laundry.
b. Conduct checking of the bundle with a hand held metal detector (HHMD) to identify
any metal objects be in the bundle.
c. If sounds positive conduct a thorough search for the metal object by checking the
individual linen packs.
d. If valuables (such as ornaments, watches, coins, rings) are found, deposit the same
with HOD Security.
e. HOD Security to enter the item found / recovered in the Lost / Found register.
f. Dispatch to Laundry under receipt.

H. RECEIVING THE LINEN FROM LAUNDRY:-

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 23 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

While receiving the linen from the laundry Count the linen item wise and compare the
same with the accompanied challan of the Laundry.

I. CHECKING THE LINEN:-


a. Conduct inspection of at least 1/2 packs from each bundle at random and check if the
linen is torn, stained, properly cleaned and odoure free.
b. If any of these are found conduct more checking and separate the non conforming
linens and return to the laundry.
c. Take possession of those linens which are usable.
d. Mention the no of linens received and accepted.
e. Arrange Repair & Alteration of the torn linen which can be used after repair.

J. STORING & DISTRIBUTION OF WASHED LINEN:-


a. Distribute linen to the departments / wards as per requisition.
b. Issue extra linens (depending on availability) if requisitioned by the departments/
wards.
c. Store the balance linens in the central Linen store.

K. APPROVING LAUNDRY BILLS:-


a. As and when the bills are produced by the laundry, check the bills thoroughly and
compare with the daily challan of the Laundry.
b. Certify the laundry bill and release for payment.

L. INSPECTION OF LAUNDRY:-
a. Conduct surprise inspection of the laundry once in 6 months with a team comprising
of a member from Nursing and housekeeping.
b. Check the facilities, methods of washing the linen, detergents / chemicals used,
disinfectant used, method of drying, pressing, water used, the disposal method of
waste water etc.
c. Remind the Laundry owner about the necessity for preserving the environment as
using unapproved chemicals and discharging the same into the draining system may
disturb the ecology.

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 24 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

d. Submit the report to the Asst. Medical Director.

M. LIST OF CHEMICALS / DETERGENTS / STAIN REMOVERS TO BE USED


FOR WASHING:
a. Prepare a list of detergents, chemicals, stain removers, disinfectants to be used by the
laundry which are safe for the environment as well.
b. Get the list approved by the Medical Director/ HOD Pathology as for the patients
health.
c. Issue the list to the Laundry operator under acknowledgement and obtain an
undertaking that he will not use any other chemicals/ detergents which are not
approved and will not release the washed water to any ponds/ water body directly.

13.8 WORK-INSTRUCTION FOR SPILLAGE:

A. HAZARDOUS MATERIALS
Hazardous material that contains ingredients those are harmful to health. These include
materials that are lethal and non-lethal, corrosive, toxic, irritant, sensitizing, mutagenic,
teratogenic or carcinogenic. The concentration level of each ingredient in a mixture is
taken in to account in determining whether the mixture is determined to be hazardous.
a. Purpose
In the event of a spill, competent and prompt action is necessary for immediate
clean up to reduce and eliminate the hazards present.
The handling, storage and use of hazardous materials are controlled and
hazardous waste is disposed off safety.

b. Type of Spills:
Spill

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 25 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

Infected Spills Non-Infected Spill


--Blood --Chemicals etc
--Body Fluid etc

DEPARTMENTAL FUNCTION:
a. At first identify the type of spillage is that.
b. According to the type of spillage hospital have there own policy.
c. Maintain the proper action as per the define policy.

14 WORK INSTRUCTION FOR HANDLING OCCUPATIONAL HAZARDS:

Cuts by Blade, Staffs are immediately attended to First Aid. Necessary items
knife /Sharp Edge are placed in the First Aid Box and it is placed in prominent
location. In case of serious injury, staff is rushed to the
emergency department.
Slippery floors Floors are kept dry by the staffs who keep on mopping
frequently, signages-Caution.
Eye irritation Hand showers are kept in the hand wash area where staffs can
(Bleaching powder.) go and wash their eye. In case of serious, staff is rushed to the
emergency department
In case of major spillage the staff is rushed to emergency
Oil spillage otherwise first aid is given silverex /burnol which is kept in
first aid box.
Electrical short circuit Provide first aid in case of accident. In case of fire,
extinguisher is used inform operator & task force team.
Harpic /Acid Gloves mask and goggles are used while handling the
corrosive materials.

DEPARTMENTAL FUNCTION:
a. At first identify what type of spillage is that.
b. According to the type of spillage hospital have there own policy.
c. Maintain the proper action as per the define policy.

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 26 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

15 LIST OF QUALITY INDICATOR:

a. No. of complaints should be less than 5%


b. % to adherence to safety precaution while handling Bio Medical Waste
c. Patient satisfaction rate on Cleanliness
d. No. of complaints should be less than 5%
e. Quantity disposed (group wise, in kg, in no. of bags)
f. % of linen stock out
g. % of linen sent for rewashing

16 LIST OF QUALITY OBJECTIVES:


a) No. of complaints should be less than 5%
b) 80 % to adherence to safety precaution while handling Bio Medical Waste
c) 70% Patient satisfaction rate on Cleanliness
d) % of linen stock out should be < 10%
e) % of linen sent for rewashing should not be < 10% of total washed.

17 ANNEXURE:
NIL.

18 ABBREVIATION:
a. HK House keeping
b. SOP Standard Operating Procedure
c. GDA General Duty Attainder.
d. P.P.E Personal Protective Equipment.

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00


Page 27 of 27
RIDDHI VINAYAK
CHAPTER NAME: ROM
MULTISPECIALTY
HOSPITAL

Housekeeping Document No.: RVMH / HK/ SOP/05

e. OPD Out Patient Department.


f. OT Operation Theater.
g. PCI Pest Control of India.
h. HOD Head of the department.
i. ANS Assistant Nursing Superintendent.
j. M S D S Material Safety Data Sheet.

Approved By:
Issue No. : 01
Standard Operating
Issued By: Procedure Rev. No. : 00

Issue Date: 25.07.2015 Rev. Date: 00