MBAHCS

Semester 3

MH0052 – Hospital Organization, Operations and Planning (4 Credits)

(Book ID: B1213)

Assignment Set- 1 (Marks 60)

Q.1 a. Explain the differences between formal and informal organizations. [5 Marks]

b. What are the characteristics of a hospital organization? [5 Marks]

Formal organization:

A formal organization is one which consists of a group of people working together cooperatively, under authority, towards goals that mutually benefit the participants and the organization. In this system, well defined jobs bearing a clear measure of authority, responsibility and accountability are found.

Formal organizations have an intentional structure of roles in a formally organized enterprise. The structure must be flexible; there should be room for discretion, for advantageous utilization of creative talents, and for recognition of individual likes and capacities. The Structure should be organized in such a manner that the people involved and the resources are able to accomplish the purpose for which the organization was set up. That is why it is very important for a healthcare organization to set its organization structure based on its objectives. Hospitals however may share some of their objectives, but, there may be objectives that are unique to a particular organization only. The spectrum of objectives determines the organization structure, its scope and volume of activities, the required departments and their sizes, staff requirement, etc.

Informal Organizations:

Chester Barnard, author of The functions of executive, described informal organization as any joint personal activity without conscious joint purpose, even though contributing to joint results. Keith Davis of Arizona State University described the informal organization as a network of personal and social relations not established or required by the formal organization but arising spontaneously as people associate with one another. Thus in informal organizations, relationship that does not appear on an organizational chart, might include the machine-shop group; the sixth-

floor crowd; the Friday evening bowling gang; the morning coffee or tea club members etc. Both formal and informal types are found in organizations.

Table 1.1: Formal Organization Vs Informal Organization

Characteristics Formal Organization Informal Organization

Origin Deliberately created Formed spontaneously

Goal Reflects organizational goals

Individual and group goals

Structure Has definite hierarchy Structure less

Integrating mechanisms

Held together by rules, regulations and procedures

No rules, held together by feelings of friendship, mutual help and trust

Communication channels

Formal official channels of communication

No defined communication channels

Characteristics of Hospital Organization

Every organization has a head. In every organization there should be a clear line of authority for every individual. In a hospital, there are dual lines of authority. The Administrators are responsible for solving management problems while Doctors are involved in patient care.

Hospitals are characterized by having wide diversity of objectives and goals for different personnel, professional groups and subsystems. For example: The house keeping department works towards maintaining cleanliness and sanitation, the clinical team focus on patient care, the Administration team works on problem solving and hospital betterment, the marketing team works towards brand building and better marketing of services.

The hospital is in continuous operation which requires high operating costs and substantial personnel and scheduling problems.

The diversity of personnel ranges from highly skilled and educated administrators and doctors to unskilled and uneducated employees like the staff involved in sanitary functions.

The hospital organization is characterized by interdependence. Every person involved in patient care is dependent on other departments or individuals in order to accomplish their tasks or fulfill their responsibilities. For example: An orthopedic surgeon cannot perform an orthopedic surgery without the findings from the radiology department and the assistance of the nurses and technicians.

Hospitals deal with problems of life and death. This has psychological and physical stress on personnel at all levels in the hierarchy.

Measuring the quality of product (healthy and satisfied patient) is a problem because patient care delivered has no precise measurement.

Hospitals provide services. Unlike the production industry where productivity and quality may be easily defined, hospitals productivity and quality cannot be quantified easily.

Hospitals should always comply by the medical ethics. (eg: patient confidentiality).

Q2. Explain hospital administration. [10 Marks]

Hospital Administration

What is hospital administration?

Hospital administration is the management of the hospital business. Hospital administration is made up of many healthcare managers and executives who take care of individual departments. They are in charge of all the administrative or management functions of their respective departments. These various managers or assistant administrators will report to the Hospital Administrator.

Need for hospital administration:

A hospital like any other business entity may function for purposes of profits too. With the burgeoning numbers of private / corporate hospitals, private nursing homes, the need for specialized managers for hospitals become evident. The stiff competition necessitates specialists to handle difficult situations. Well informed decision makers have become a necessity. Gone are the days when a highly skilled physician would also take care of the administrative functions. With the enormous challenges pressing the healthcare industry people with special and specific education are required. Hence, the presence of hospital Administrators is the need of the hour. The primary function of a hospital administrator would be to manage the resources of the hospital. The resources of a hospital are: people, methods, measurements, materials, machinery and equipment, money, time and information. Some of these resources may be scarce, like the availability of specialist doctors, or nurses, availability of diagnostic equipment, etc.

A hospital organization may seem a lot like any other organization. It has many business features common to that of other businesses; however, there are certain qualities in a hospital that make it unique. These unique characteristics were already discussed in unit 1. You may read that again. Besides being an interdependent entity, a hospital is an organization of high accountability. The community looks up to the hospital for all of its healthcare needs. Hospitals deal with life and

death, making it all the more a sensitive place. Hospitals mostly intervene at the time of greatest mental agony. Its clients are a lot sensitive, therefore every service provided must ensure the utmost care. Hospital Administrators are people who have understood this situation very well. They should bear this in mind while taking decisions.

Who is a Hospital Administrator?

A hospital Administrator is the overall head of the business operation and managerial functions in the hospital. The Hospital Administrator is vested with the responsibility of running the hospital operations. He / she acts as a liaison between the Governing Board, medical staff and other management staff. They play a major role along with the Governing Board in making the hospital policies. They take up human resources function also such as, recruiting, staffing, evaluation, etc. They have an active participation in the hospitals public relations. He / she is also responsible for contributions during budgeting and allocation of resources. They are involved constantly in training programs that would enhance their managerial skills and helps them to know new management trends and techniques enabling them to be on the edge. The Administrators role is very crucial in the effective and efficient running of a hospital.

Roles and functions of a Hospital Administrator:

Hospital Administrator is the chief executive in the hospital. A hospital may have a number of executives in various departments to handle the administrative or managerial functions. All these executives are accountable to the Hospital Administrator. Figure 2.3 represents the various major duties of the Hospital Administrator.

The major functions of the Hospital Administrator are enlisted below:

Functions of the Hospital Administrator:

1. Acts as a legal representative of the Hospital. The Hospital Administrator is responsible to ensure whether the hospital is complying with the government rules and whether all the statutory requirements are met.

2. Is a part of the Governing Board. He / she has the responsibility of supervising all the activities in the hospital

3. Should ensure that all staff is aware of the hospitals mission, vision and objectives. He /she is instrumental in getting information on mission, vision and objectives down to all the staff.

4. Implements all the management decisions in the hospital

5. Formulates major rules, regulations and procedures and ensures their implementation

6. Ensures that the rules formulated are in line with the hospitals policies

7. Coordinates and participates in devising short term and long term plans for the hospital

8. Submits annual reports to the Governing Body

9. Ensures financial viability of the hospital

10. Acts as a link in between the management and the employees. Therefore participates in deciding the salary structure, benefits, etc.

11. Is responsible for a good employer employee relations

12. Works closely with other important executives in the hospital such as the Medical Superintendent, nursing Superintendent, etc.

13. Ensures that all the departments function smoothly and efficiently.

14. Is responsible for outsourcing services, contracts, hiring, etc.

15. Acts as an official representative of the hospital

16. Maintains contacts with the government, community and media.

Fig. 2.3: Duties of a Hospital Administrator

Characteristics of an effective Hospital Administrator:

An effective Hospital Administrator should possess all the managerial skills. Besides, he or she should also be outstanding in the following qualities:

1. Should show competence at work

2. Should be sensitive to organizations and staffs problems and needs

3. Should possess the ability to analyze, synthesize and integrate various information

4. Has the ability to foresee and plan

5. Has the ability to bring forth new and creative ideas

6. Has the ability to coordinate, organize, control and allocate resources

7. Should be able to delegate work and make efficient use of his or her own time

8. Ability to motivate and develop people

9. Should be able to introspect and evaluate

10. Should be an able communicator

Q3. Hannah Healthcare is planning to open a hospital in North Bangalore region. For this purpose they

have brought together a team of experts.

A. Who are the team of experts who constitute the hospital planning? [5 Marks]

B. What are the principles of hospital planning? [5 Marks]

The Hospital Planning Team

The hospital planning team should ideally consist of the following members:

1. Hospital Administrator

The Administrator is the chairman of the planning team. He is mainly involved in putting up hospital requirements to his team in terms of, facilities for the hospital, design consideration, orientation of interrelated departments and service facilities. He also oversees and coordinates the various activities involved in planning.

2. Hospital Engineer

The engineer appointed to prepare the plan of the hospital should have previous experience in constructing hospitals. He works in close coordination with the administrator and the architect.

3. Hospital Architect

The hospital architect should have knowledge of the work flow involved in a hospital setup so as to suggest the design considerations of the hospital. The experience and expertise of the architect and the hospital engineer helps in planning a good hospital.

4. Financial Expert

The financial expert helps the administrator to study the feasibility of the project. He can advice on the funds required for the project and the sources available for the same. The estimates given by the finance expert helps in drawing up a smooth plan.

5. Health Statistician

The health statistician also contributes to the study of the feasibility of the project. He helps the team by providing vital information on the demographic picture of the region, disease related statistics, socio-economic condition of the people, all of which helps the administrator in deciding the type of facilities required and charges to be levied.

6. Representatives of government or local bodies

The representatives of the government or local bodies help in the coordination of the project. They form a link between the community and the hospital

7. Nursing Director/Superintendent

The nursing director can give valuable inputs to the project team, especially in ward planning.

8. Social scientist

The social scientist helps in identifying the felt needs and real need of the community. His suggestions during the planning process helps in fulfilling the communitys expectations of the project.

9. Consultant representative from user department

The success of everything planned in the hospital depends on whether it is user friendly. It is therefore necessary for the planning team to take into consideration the suggestions of the consultant representative from the user department. The design and functioning should be user friendly.

Principles of Hospital Planning

High Quality Patient Care:

The hospital must be designed, staffed and equipped to meet the stated objectives in addition to providing high quality medical care. There must be a good organizational structure. The quality of patient care delivered should be strictly monitored through continuous review of existing facilities, services offered etc. The hospital should have adequate number of competent staff who would ensure a high quality patient care. The medical staff should be provided continuous medical education that keeps them informed about the latest trends and technology.

Community Orientation:

The needs of the population should be borne in mind while planning the hospital. The hospital should be located at a convenient and easily accessible location. While outlining the charges for the healthcare facilities, the following factors should be taken into consideration i.e. the population mix, social status, education and earning capacity of the target population. The hospitals Governing Board may have people representatives from the community. The hospital should also involve itself in community outreach programs that might not only promote the hospital services, but will also help in developing goodwill and helps in understanding the needs of the community.

Economic Viability:

The hospital may not be profit making at all times. Hence there should be a sound financial management system in place. The healthcare facility should be able to identify and adopt means to be self sustaining. Any renovation and expansions planned should be done rationally, taking the views of the community into consideration.

Sound Architecture:

The design adopted in putting up a hospital should consider efficient use of the facility and personnel. Flexibility should be adopted during designing, ensuring proper circulation space for movement of staff, patients, relatives and friends. The space should also accommodate movement of goods and materials used for patient care. Identifying areas prone to infection and adopting infection control measures at preliminary stage of planning contribute to a sound architecture. In short Design should follow function and not vice versa. Design should accommodate and consider future expansion. Disaster planning should be done simultaneously with the planning and design of the hospital structure.

Q.4. Explain the various ward designs. Explain them with diagrams. [10 Marks]

Design and Layout

Size: The size of the wards depends on several factors. It can vary from as low as 10 beds to as high as 90 beds in a single ward. Some of the parameters influencing the design and layout of the wards are:

1. Severity of the patient condition The more the severity, smaller the ward. E.g.: ICU, CCU, T.B Sanatorium etc.

2. Category of the ward General wards has more number of beds than special room or deluxe wards.

Location: The location of the wards depends on the activities taking place, services rendered, movement of patients, relatives of patients, doctors, nurses, paramedical staff, visitors etc.

Example: It is desirable to have the surgical wards close to operation theater and post op; ante-natal wards close to labour theater; ICU close to the Accident & Emergency centre etc.

Ward Areas: the various areas that need to be included while designing the wards are:

Patient space: it includes: Multibed bays, patient rooms

Day space: serves as a space for reading, writing, watching TV, etc.

Patient relatives area

Visitors waiting area

Corridor space that would allow movement of man, machines and trolleys, stretchers, etc.

Ward Design

Nightingale Ward:

The nightingale ward is named after Florence Nightingale. This pattern came into existence after the Crimean war during the 19th century. Each ward has a total of 40 beds. Schematic picture of this plan is given below. This arrangement has the following advantages; 1) excellent cross-ventilation, 2) good lighting, 3) clear and unimpeded view of all patients.

Fig. 4.1: Nightingale Ward

The disadvantages are: 1) No privacy for the patients, 2) Lot of traffic (food cart, patient trolley, ward stock etc) moving through the patient care areas causing inconvenience and disturbance to patients admitted, 3) Nurses/ other staff fatigue factor, due to the distance to be covered for rendering services located in separate areas.

Variant Nightingale:

To overcome some of the disadvantages faced in the Nightingale pattern, a variant of the same was created. Even in this pattern there are 40 beds. The Variant Nightingale pattern is also called Cruciform Shape. The length of the ward is 26 meters. This concept gave rise to the evolution of having single bed room/double bed room wards. A sketch of this type of layout is illustrated below.

Fig. 4.2: Variant Nightingale Pattern

Advantages of this design is: 1) Privacy for patients 2) Reduction in noise levels 3) Reduced incidence of cross-infection 4) Attached toilets making it convenient for patient attenders/visitors 5) Flexibility in usage of wards among different departments. This pattern was not free of defects as it had a few disadvantages; 1) Reduced view from the nursing station 2) Patients found it difficult to communicate to nurses and doctors 3) Cost of construction, maintenance, overheads etc was more with high capital costs 4) Maintenance also was difficult as this pattern increased the floor area.

Rigs Design:

The Rigs pattern of ward was first designed in 1910 and implemented in Denmark. The length was reduced and width was increased as compared to the Nightingale pattern. A schematic representation of this layout is given below.

Fig. 4.3: Rigs Design

Some of the special features incorporated in this design are as follows:

1. There was a major shift in the earlier concept of spacing of beds.

2. Privacy in general wards was enhanced due to wall partition of 5 ft height.

3. The distance walked by the nurses for rendering service was reduced

4. Patient beds are arranged parallel to the main corridor, in order to reduce traffic disturbances in the ward

Some of the other patterns worth mentioning are:

Nuffields ward:

A lot of research was done on hospital design during 1950s. Nuffields study (1949-1955) deserves special mention. Based on the findings, an experimental ward was constructed. The design is represented below.

Fig. 4.4: Nuffields Ward

Race track design/deep plan:

This concept arose during 1950s in the United States. Also called double corridor system, this design has 36 beds with two nursing stations.

Fig. 4.5: Rack Track Design Harness type ward:

Also known as the crossed type, this design is known to have different types of rooms with single, double, four and even eight beds.

Fig. 4.6: Harness type Ward

Other ward types:

Courtyard ward:

This type of wards makes provisions for natural light and ventilation. This also helps in saving costs and hence contributes towards the hospitals economy.

Q5. Write short notes on:

i. OPD [5 Marks]

ii. Accident and emergency services [5 Marks]

Out-Patient Department

Introduction

The outpatient services of the hospital are significant. It is the first point of contact with the hospital. The reputation of the hospital thus, depends on how good the out-patient service is. It is also considered as the window of the hospital. It helps in reducing inpatient admissions and facilitates day care services. This helps the hospital management in reducing managing costs and as for as the patient is concerned, it benefits in terms of convenience and also reduced healthcare expenditure.

Objectives:

After reading this section you will be able to:

Define outpatient facility

Explain the importance of outpatient services

Illustrate the work flow in the department

List the minimum facilities required in the outpatient department.

Definition:

The outpatient department is a part of the hospital with allotted physical facilities; medical and paramedical staff in sufficient numbers, with regular scheduled hours of work to provide care for patients who are not registered as in-patients.

Functions:

Provides wide range of treatment, diagnostic tests and minor procedures.

Eliminates the need for hospital stay/reduction in hospitalization rates.

Reduces the cost burden on both hospital and patients.

Imparting education to professional staff and patients.

Benefits medical students, physicians and other healthcare professionals in terms of diversified clinical experience.

Importance of Outpatient department:

The outpatient department is the first point of contact with the hospital.

Forms an entry point into the healthcare delivery system.

Inseparable link in the hierarchical chain of healthcare facilities.

Stepping stone for health promotion and disease prevention.

Contributes to the reduction in mortality and morbidity rates.

Reduces the number of admissions (IP), conserving hospital bed

Filters the inpatient admissions, ensuring admission to patients who necessarily require it.

Outpatients:

Outpatients are those persons who are given diagnostic, therapeutic or preventive services through the hospitals facilities, who have not registered themselves as inpatients the hospital.

Categories of outpatients:

1. Emergency outpatient:

Emergency care is given in case of sudden severe illness or accident

Emergency can be from the patient point of view or from the physicians point of view

2. Referred outpatient:

Generally referred from outside hospitals or general physician

For specific investigations or minor procedures

3. General outpatient:

Usually form the bulk of the outpatient attendance

For follow-up care rendered by the consultants in the hospital.

Source of origin of OP cases:

The various sources of outpatient case can be listed as

Direct walk in patients to the hospital

Referred case from outside hospitals, local doctors etc.

Attendance in casualty on an emergency basis

Follow-up cases or repeat visits

Flow pattern of work:

Reception and enquiry i.e. first point of contact in the hospital

Registration

Moves to sub-waiting area

Visits the doctor at OPD

Subjected to number of clinical investigations

Patient sent home based on clinical findings

Patient is admitted (if required) for further evaluation and treatment.

Planning of outpatient services:

It is important to note that the outpatient department which is a part of the hospital has functional and administrative links with the hospital. There are health centers, satellite clinics and dispensaries dependent on the outpatient services. As a matter of policy, preventive and

promotive care should be provided along with curative care. In short, better services attract more patients.

The demand for outpatient services depends on number of factors like, expenses to the patient; distance to reach the OPD; transportation facilities available; socioeconomic status of the target population; degree of urbanization in the population and quality of care provided at the hospital.

Planning considerations:

At the time of planning the outpatient department, the following points are worthy of consideration-

1. Range of outpatient services to be provided; defining the functions.

2. Number of staff required by rank and the tasks to be performed by them.

3. Possible service time per patient, depending on daily and hourly capacity.

4. Flow of patients

5. Requirement of furniture and equipment

6. Layout of the department.

Facilities available at OPD:

1. Public areas and administration

Trolley bay

Reception and Help desk

Registration counter

Lobby and waiting lounge

Toilet and drinking water facilities

Public telephone

Coffee shop, gift/flower shop

Bank extension counter

Security out post and fire alarms

2. Clinical facilities

General examination rooms

Special examination rooms i.e. for ENT, EYE, etc.

Treatment/procedure rooms

Nursing station

Injection room

Laboratory and sample collection area

Pharmacy outlet

Radiology services

Common problems encountered by patients at the OPD:

Long waiting time to consult the doctor

Non availability of lab investigation reports on time

Interruptions during patient consultations because of telephone calls to doctors

Poor designing of facilities

Breaking the queue in the appointment system

Accident and Emergency Services

Introduction:

The emergency department has become a key point in patient care in the healthcare delivery system, serving the market that demands modern, efficient facilities, trained staff and state-of-art healthcare. The volume of patients seeking routine care in emergency departments has grown considerably, since there is a large pool of mobile citizens who have no family physicians. Furthermore, the emergency department remains one of the few places where provision of healthcare unequivocally takes precedence over financial and legal considerations. Round the clock availability of services is another aspect that is characteristic of emergency departments.

The emergency department is required to render a comprehensive range of services right from the elementary first-aid and general outpatient services to sophisticated management of surgical and medical emergencies and full-scale trauma care. This service, like OPD has a lot of public impact and as a result helps strengthen the image of the hospital.

Maintaining a 24-hour service with its high fixed costs and periods of low utilization can be costly. A well designed and efficiently managed emergency department is an important source of revenue to the hospital. It can be noted that patients in emergency use diagnostic and supportive services of the hospital to a considerable extent and this brings in a lot of revenue.

Objectives:

At the end of this section you will be able to:

Define accident and emergency service

Describe the phases of emergency medical care

Explain the importance of accident and emergency services

Identify the planning considerations of an emergency unit

Factors contributing to increased demand:

Rapid urbanization and industrialization

Increased diagnostic facilities in the hospital

Team approach to medical care

Medico-legal cases not attended by general practioner

Increased recognition of the hospital as a place of healing

Definition:

A patient who requires immediate treatment, which if not given would mean loss of life/limb or result in any other disability.

An emergency as understood by the patient and his relatives is any illness/injury for which patient requires/desires immediate attention of the physician.

Phases of emergency medical care:

There are 3 phases of emergency medical care, they are-

1. Pre-hospital care:

Prevention i.e. by public education

Detection

Establishing communication network

Notification i.e. trained technical manpower

Rescue operation

Initial stabilization: The trauma team should reach out to the accident scene quickly as the treatment initiated during the first one hour also called Golden Hour is of importance in clinical outcome in such cases.

Transportation to hospitals

Continuous advance life support measures enroute the hospital.

2. Emergency department care:

The hospital accident and emergency unit is activated from the time the mobile unit arrives at the site of accident till the patient is transferred either to the in-patient area or to another hospital where facilities are available.

3. Hospital care:

This refers to general or specialized care received at the hospital in ICU/CCU/Burns/Trauma centre etc. This phase extends up to the rehabilitation stage of the patient.

Importance of A & E services:

The accident and emergency unit is a very sensitive area in public relations. Its services form the mirror image of the hospital and for some patients, the first point of contact with hospital care.

The promptness exhibited in attending to the patients by the healthcare personnel reflects the hospital services. It is often an area for criticism

Trauma and cardiovascular diseases are the two leading causes of sudden death.

India accounts for nearly 6-8% of total road traffic accidents in the world.

Location:

The ideal location for the accident and emergency unit would be the ground floor, with direct and easy access for patients and ambulance from the main road. There should be a separate entrance to this unit and there should be clearly visible sign boards directing towards the entrance, with proper lighting (during night).Parking area should be spacious with a drive in for vehicles and transferring of patients from the ambulance comfortably. Other services to be located near the accident and emergency unit is, the admission counter; medical records department; laboratory services; radiology services; blood bank; intensive care unit; operation theater etc.

Physical facilities

1. Administrative and public areas:

Reception

Entrance should be wide enough to move stretcher, trolley

Public waiting area with toilet; drinking water; public phone facilities

Room for security; police out post; ambulance driver; patient bystanders

Office for the night supervisor

Coffee shop and snack bar in the vicinity

2. Clinical facilities:

Trauma room

Examination/treatment room

Scrub room

Space for triage/observation room

Storage space for equipments

Room for duty doctors/nurses

Patients toilet

Soiled linen room; janitors closet

Locker room

Categories of staff:

The various categories of staff working in the accident and emergency unit include, casualty medical officer; consultants on call; nursing staff; attenders and orderlies; receptionist; medico-social workers; security staff; radiographers; laboratory and ECG technicians on call.

The hospital management should ensure that adequate security is provided to the various categories of staff from manhandling, as casualty is a highly sensitive and emotional area. Adequate measures to be taken in providing the staff with personal protective equipment to protect staff against infection.

Q6. If you are called be the infrastructural consultant for setting up a NICU in a 5 year old multispecialty

hospital, what are the planning considerations of NICU that you would present to the Managing Board?

[10 Marks]

Neo-natal ICU

Introduction

Childbirth is an occasion for joy. However, on some occasions this joy is tainted with concern about the health of the newborn. The threat of serious illness or death of a newborn places serious responsibilities on health care providers to respond appropriately with effective therapy. Disorders and diseases in the neonatal period pose a greater risk to life and health than which occur during any other period of postnatal life. This burden of illness is measured not only in terms of neonatal mortality and morbidity but also in terms of disability and handicap among survivors and in terms of high economic costs for acute and continuing medical care, special education and other supportive services. The recognition of the need for provision of intensive care to the newborn, led to the birth of the concept of Neonatal Intensive Care Units/ Special Care Neonatal Units/ Intensive Care Nurseries.

The idea of having a special intensive care unit for newborns represented a developmental milestone in the field of neonatology. The establishment of the first premature infant center at Sara Morris Hospital in Chicago in 1920s marked a new era of concern for the sick newborn. Dr. Louis Gluck established the first newborn center at Grace New Haven Hospital at New Haven, Connecticut in 1960. At the turn of the 20th century, a French physician named Pierre Constant Budin discovered that incubator care was associated with improved survival of premature infants. Martin Couney is credited with advances in incubator design as well as premature feeding techniques. The use of ventilators in infants with respiratory distress began in 1961. Much of what is now known as intensive care, the use of intravascular catheters; blood gas monitoring; arterial pressures; heart rate; temperature monitoring and a myriad of other facets of care were developed as a result of research, after the success of assisted ventilation.

Objectives:

After going through this section you will be able to:

Define a neo-natal intensive care unit

Classify the NICU

Explain the design considerations of NICU

List the policies and procedures followed in NICU

Definition

Newborn intensive care is defined as care for medically unstable or critically ill newborns requiring constant nursing, complicated surgical procedures, continual respiratory support, or other intensive interventions.

Neonatal Intensive Care Unit (NICU) is a special unit of the hospital set up to provide extraordinary surveillance and support of vital functions and definitive therapy for infants having acute or potentially reversible life threatening impairment of a vital system.

Classification of Neo-natal Intensive Care Unit

There is a lack of consistent definition of levels of care in neonatal care units. The advantages of having uniform definition would include the ability to compare outcomes, utilization, and costs among institutions; develop NICU standards; inform the public of NICU capabilities; minimize the perceived need for businesses to develop NICU standards.

The proposed levels of care are:

Level 1. Newborn Nursery

- Can perform neonatal resuscitation at every delivery

- Care for healthy term newborns and for infants 35-37 weeks gestation who remain physiologically stable.

- Other newborns would be stabilized and transported to a unit with the appropriate higher level of care.

Level 2a. Special Care Nursery

- Can provide Level 1 care plus can care for infants > 32 weeks gestation and > 1500 grams birth weight.

- Have physiologic immaturity (apnea, poor feeding, temperature instability), but not requiring mechanical ventilation or Continuous Positive Airway Pressure (CPAP)

- Have medical problems that are anticipated to resolve rapidly and not require urgent sub-specialty care

- Are convalescing after intensive care.

Level 2b. Special Care Nursery

- Can provide Level 2a care, and

- Can provide mechanical ventilation for brief duration (<24 hours) or CPAP.

Level 3a. Neonatal Intensive Care Unit.

Can care for infants > 28 weeks gestation and > 1000 grams birth weight.

Can provide sustained life support with conventional mechanical ventilation.

May perform minor surgical procedures, such as placement of central venous catheters or repair of inguinal hernias.

Level 3b. Neonatal Intensive Care Unit

Can provide comprehensive care for infants < 28 weeks gestation and < 1000 grams birth weight.

Can provide advanced respiratory support such as high-frequency ventilation or inhaled nitric oxide.

Can perform major surgical procedures on neonates (excluding ECMO and repair of complex congenital heart defects requiring cardiopulmonary bypass).

Requires prompt and on-site access to a full range of paediatric sub-specialty consultants, as well as paediatric surgeons and anesthetist.

Requires availability of advanced imaging support on an urgent basis, including CT, MRI, and echocardiography.

Level 3c. Neonatal Intensive Care Unit.

Has the capabilities of a level 3b NICU

Can provide ECMO and surgical repair of complex congenital heart defects requiring cardiopulmonary bypass.

The rationale for this three-tier approach is:

A reasonable geographic coverage is ensured.

A high throughput for the level III units enables the maintenance of clinical skills.

High levels of bed occupancy in level III units permits efficient use of expensive resources.

In our country, 80-85% of all babies need only primary or level I care, 15-20% needs level II care and only 5% need level III care. Level II and level III care are woefully inadequate, in both the government and non-government sectors and level I care, though available, is of very poor quality. If newborn care has to improve, all three levels of care have to be well developed and a good referral system should be in place.

Neonatal Intensive Care Unit Environment:

The environment within the NICU is completely new to the preterm infant, who until the time of birth, has been protected within an intra-uterine environment. Increasing amount of research shows a relationship between the NICU environment and the physiological and neurological development of the infants. An environmentally sensitive unit can enhance growth, shorten the duration of mechanical ventilation, lead to early oral feeding, reduce incidence of complications, shorten hospital stay and reduce hospital costs.

Giving birth to a premature or sick infant is not usually the familys expectation, and the intimidating environment of the NICU can provide reassurance to the shock and sense of loss that families feel. Therefore in planning and designing a neonatal unit, the goal should be to provide an environment which is conducive to family-centered developmental care of sick newborns, decreasing stress for the family and the healthcare providers, improving short and long-term outcomes.

Physical Facilities and Space Requirements:

Core physical requirements include, continuous supply of running water, uninterrupted power supply, central supply of medical gases and suction facilities.

Geographic access:

Level III neonatal intensive care services should be available within 2 hours by road, under normal traffic conditions for 90 % population in a district.

Location within the hospital:

The NICU should be in a distinct area within the health care facility, with controlled access. Movement to other services should not pass through this unit. It should be located close to the labour room and operation theatre, to facilitate prompt transfer of sick and high-risk infants. It is suggested that units receiving babies from other hospitals should have ready access to the

hospitals transport receiving area or hospitals ambulance entrance. NICU should be easily accessible from emergency room, laboratories and radiology suite.

NICU Unit configuration:

Hospitals proposing a level III NICU should propose a unit of at least 15 beds and should have 15 or more level II NICU beds. According to Putsep concept, a 28 bassinet unit might have 3 intensive care spaces (10.7%), 20 intermediate care spaces (71.4 %) and 5 transitional care spaces (17.9 %) for short-term observation. The unit should be in a square area so that open, unencumbered space is available. A split-unit, on either side of the hospital corridor should be avoided for ease of mobility and prevention of infections.

The NICU design may range from an open ward to an individual cubicle or room configuration. Open unit configuration offers maximum flexibility for patients, staff, equipment movement and better patient view; individual cubicles design gives less noise and patient movement and reduced cross-infection rate.

Size of the unit

The size of the unit planned, depends on the number of deliveries in the hospital per year; whether it is a referral maternity center or babies born in other hospitals are admitted. At present the recommendation is that 1.5-2 intensive care beds and 2 special care beds should be provided for every 1000 births (can be modified according to the workload of the unit). Extra provision has to be made for babies in other hospitals.

Infant care space

Each infant care space should contain a minimum of 11.2 square meters, excluding sinks and aisles. Intensive care beds may require 14 square meters per infant. An estimated 50 square feet of floor space is needed per patient bed, for intermediate care.

There may be an aisle adjacent to each infant care space with a minimum width of 1.2 meters in multiple bedrooms and 2.4 meters in case of single patient rooms or fixed cubicle partitions. This is to facilitate easy movement of all equipment, which may be brought to the babys bedside.

In multiple bedrooms, there should be a minimum of 2.4 meters between infant care beds. This is because the provision of less than 8 feet between beds limits the ability of a family to stay at a babys bedside without interfering with staff activities. Each room should have a minimum of one door of width 48 inches, for X-ray equipment.

Electrical, Gas supply and Mechanical Needs:

Mechanical requirements at each infant care bed, such as electrical and gas outlets, must be organized to ensure safety, easy access and maintenance. There should be a minimum of 20 simultaneously accessible electrical outlets for intensive care infants positioned to maximize access and flexibility. Standard duplex electrical outlets are not suitable, as each outlet may not

be simultaneously accessible for oversized equipment plugs. The outlets must be installed at a height of three feet. There should be a mix of AC power supply and UPS for all electrical outlets. At least fifty percent of the outlets should be connected to an uninterrupted power supply. All life support and monitoring equipment should be connected to UPS. In addition, the area needs a special outlet to power portable X-ray machines. The use of adaptors and extension boards should be discouraged. The electrical equipment must be checked, at least once a month for leakage of power supply and grounding adequacy. Voltage supply to the NICU must be stabilized with a voltage stabilizer.

Minimum number of accessible gas outlets recommended is: Air; Oxygen; Vacuum; 3 out lets per infant bed. In case of intermediate care infants, two oxygen outlets, two compressed air outlets and two suction outlets should be provided for each bed. A flow rate of 20 liters per minute, at a pressure of 3.5 to 4.0 bars is satisfactory for oxygen supply. Each vacuum point should allow free airflow of 40 liters per minute at vacuum pressure of 500 mm of mercury. The suction outlets should be equipped with a unit alarm to signal loss of vacuum. Installations should be at a height of 3 feet.

Airborne Infection Isolation Room(s)

It is desirable to have an isolation room for every 6-10 beds. In most of the cases, this is ideally situated within the NICU; but, in some circumstances, utilization of a similar isolation room elsewhere in the hospital (example, in a pediatric ICU) would be suitable. Infants with open sepsis should be cared for by different nursing and resident staff. A work-area for hand washing, gowning and storage of clean and soiled materials, may be provided near the entrance to the room. The room must have a minimum of 150 square feet of clean space, excluding the entry work area. Single and multiple bed configurations are appropriate based on use. Ventilation systems for isolation room(s) should be engineered to have negative air pressure with 100 % air exhaust. There should be a minimum ventilation of 12 air-changes per hour in the isolation room and 10 air-changes per hour in the work-area.

The walls, ceiling, floor must be sealed tightly so that air does not infiltrate the environment from outside or from other air spaces. An emergency communication system should be provided within the room and remote monitoring of an isolated infant should be considered. When not used for isolation, these rooms may be utilized for care of non-infectious infants and other clinical purposes.

Procedure room

A procedure room may be incorporated into the NICU but is preferably sectioned off to reduce patient traffic and to allow better control of techniques such as exchange transfusion, umbilical vessel catheterization. This room should be a minimum of 120 square feet in size, equipped with a hand washing section, oxygen outlet and vacuum outlet and about 4 electrical switches. The ventilation of the room should provide a minimum of 6 air-changes per hour.

Entrance

The entrance to the neonatal unit should be planned as a lobby with double doors; an airlock, which allows some control of the airflow within the unit. Corridors in NICU should be at least 1.8 meter wide.

Scrub area

At least 150 square feet of space at the main entrance, must be assigned as a scrub area with provision for hand-washing, hanging coats, stethoscopes and for leaving footwear. It should have hands-free sinks large enough to contain splashing. Blade handles at the sink should be minimum six inches long. Space must be provided, for donning of protective clothing and a bench to facilitate wearing of over-boots. About ten air-changes per hour are recommended for this area.

General support space

Storage areas A three level storage system is desirable. The first storage area should be the central supply department of the hospital. The second storage zone is the clean utility area for the storage of supplies frequently used in the care of newborns. It should be adjacent to or within the infant care area. There should be at least 0.22 cubic meters of space for each infant, for secondary storage of syringes, needles, intravenous infusion sets and sterile trays.

A medical equipment store should be provided; 1.7 square meters of floor space for equipment storage per infant in intermediate care and 2.8 square meters per infant in intensive care. Easily accessible electrical outlets are desirable in this area for recharging equipment. All supply and medical equipment rooms should have convenient access to at least one sink. A minimum of 4 air-changes per hour are recommended for the clean utility and equipment storage rooms.

The third storage zone is for items frequently used at the newborns bedside. There should be shelf space available for placing respirators, monitors, infusion pumps and feeding pumps. Bedside cabinet storage should be 0.45 cubic meters per infant in intermediate care area and 0.67 cubic meters per infant in intensive care area.

Family entry and reception area

The NICU should have a clearly identified entrance and reception area for families. Families shall have immediate and direct contact with staff when they arrive at this entrance and reception area. The design of this area should be impressive. Facilitating contacts with staff will also enhance security for infants in the NICU. This area should have storage facilities with a lock for families personal belongings.

Floor surfaces

Floor surfaces should be such that they can be easily cleaned, should minimize growth of microorganisms and should be highly durable to withstand frequent cleaning and heavy traffic. Floors should be slip resistant. Consideration should also be given to the density of materials used and acoustical properties. Materials suitable to these criteria are resilient sheet flooring

(medical grade) and carpeting with an impermeable backing, chemically welded seams with antimicrobial and antistatic properties.

Walls and surfaces

As with floors, the ease of cleaning, durability and acoustical properties of wall surfaces must be considered. Acceptable materials include scrub paint, vinyl wall covering, vinyl covered sound absorbing panels and sheet materials that have fused joint systems. Walls may also be made of washable glazed tiles. There should be protection at points where contact with movable equipment is likely to occur. Walls must be painted white or slightly off-white to permit prompt detection of jaundice and cyanosis.

Glossy finish create glare that is harmful to newborn eyes; matt finish in dark colors absorb too much light, increasing the need for artificial light sources. Doors should be provided with automatic door closers.

Ceiling

Ceiling should be cleaned easily and should prohibit the passage of particles from the cavity above the ceiling into the clinical environment. It should either be a monolithic ceiling or have ceiling tiles that are clipped down and washable. It should have a noise reduction coefficient (NRC) of at least 0.903. Standard hospital tiles have a NRC of 0.6519.

Ambient temperature and ventilation:

The NICU should be designed to provide an air temperature of 22-26oC and a relative humidity of 30-60 %. This is best achieved by air-conditioning with small package units rather than centralized air-conditioning. Portable radiant heater and infrared lamp can be used to provide additional heat to an individual infant.

Effective ventilation is essential to reduce nosocomial infections. The most satisfactory ventilation is achieved with laminar airflow. In a vertical type system, the air flows from above downwards and it is recommended for use in NICU. A constant positive air pressure should be maintained, to prevent contaminated air entry from the corridors into the NICU; the vertical flow of filtered air maintains positive pressure of 15 mmHg. Millipore filters (0.5m) or high efficiency particulate aggregate (HEPA) filter may be used (to filter out bacteria). Air delivered to the NICU should be filtered with at least 90 % efficiency. A minimum of 6 air changes per hour is required, with a minimum of 2 air changes from outside air. The ventilation pattern should prevent particulate matter from moving freely in the space; intake and exhaust outlets should be situated as to minimize drafts near infant beds. Fresh air intake should be located at least 25 feet (7.6 meters) from the exhaust outlets of ventilating systems, combustion equipment stacks, plumbing vents, or areas that may collect vehicular exhaust or other noxious fumes.

Noise abatement

The noise level in a NICU affects the infants, staff and families. Excessive noise may lead to hearing loss, physiological and behavioral disturbances like sleep disturbances, crying, hypoxia, tachycardia and increased intracranial pressure. Equipment should be selected with a noise criterion (NC) rating of 40 or less. However, once the unit is in operation, much of the transient sound in a nursery is under the control of personnel. Hence, the personnel should devise simple strategies to reduce noise in the nursery (no tapping / writing on incubator hoods, careful closing of incubator doors, soft shoes, etc.).

Communication system

The NICU should be provided with an intercom system. A direct external telephone is mandatory for parents to inquire about their infants.

Infant security

The NICU should be designed to minimize the risk of infant abduction. Care should be taken to limit the number of exits and entrances to the unit. Control station / clerical area should be located in close proximity and direct view of the entrance to the newborn area, so that all visitors will have to pass in front of the nursing station to enter the unit. In addition, for security reasons, parent-infant room(s) should be situated within an area of controlled public access.

Ancillary services

Distinct support space should be provided for respiratory therapy, laboratory, pharmacy, radiology and other ancillary services when these activities are routinely performed in the unit. Satellite facilities may be required to provide these services. Hospitals providing Level III neonatal intensive care services should provide at the site, X-ray and clinical laboratory services capable of performing micro studies. This requirement is essential in order to carry out investigations on blood samples in small quantity from preterm babies in whom, frequent biochemical investigations are needed, collecting venous blood is difficult and hazardous. Anesthetist should be available. There should also be access to ECG, EEG and blood bank services.

Equipment requirements

During the last decade, a large number of devices for diagnostic and therapeutic application for the high-risk newborn infants have evolved. The fundamental needs of the unit are availability of adequate space, presence of sufficient number of trained nurses and continuous in-service training. It should be ensured that company supplying the equipment undertakes to train all staff in the unit.

Maintenance of existing equipments in proper working condition is more important than acquiring new ones. After expiry of warranty period, yearly maintenance contract must be made for preventive maintenance and emergency repairs. Essential spares must be purchased and kept in stock. Photocopies of working and service manuals should be available in the NICU. Equipments must be charged when not in use. The in-charge nurse should maintain a register

with equipment name, company address and contact number, date of installation, warranty period, problems and repairs pertaining to all the equipments, along with record keeping of equipment quality assurance. There should be a budget for purchasing, maintaining, replacing and upgrading of equipments for neonatal care.

Equipments needed may be classified into following groups:

Supportive systems: incubator, open care systems, transport incubator, infusion pump, phototherapy unit, ventilator, nebulizer.

Monitors: The monitors with facility to display, heart rate, respiratory rate, blood pressure, oxygen saturation,

Laboratory and imaging equipment

The various equipments in the neonatal unit are listed below

Emergency tray( containing Ambu bag and mask, infant laryngoscope, oral airways and tracheal tubes of different sizes, connectors for tracheal tubes, sterile suction catheters, oral mucus suction, emergency drugs like epinephrine 1:10,000, naloxone hydrochloride, sodium bicarbonate, IV fluids and pediatric stethoscope); Bag and mask resuscitator; Suction equipment; Catheters, syringes and needles; Weighing machine; Bassinets; Incubators; Perspex heat shield; Oxygen head box / Oxygen hood; Oxygen analyzer/ambient oxygen monitor; Heart rate monitor; Respiratory rate and apnea monitor; Thermometers; Blood pressure monitor; Invasive blood gas monitoring; Non-invasive blood gas monitoring; Pulse-oximeter; Transcutaneous blood gas monitor; Capnography or End Tidal CO2 (EtCO2) monitor; Multi-channel vital sign monitor; Ventilator; CPAP (Continuous Positive Airway Pressure) apparatus; Infusion pump; Phototherapy unit; Transcutaneous bilirubinometer; Portable X-ray and ultrasound machine; Laboratory equipment; Feeding equipment; extra corporeal membrane oxygenator (ECMO)

Discharge policy in a neonatal unit

The discharge policy statement is put forward by the first formal statement of the American Academy of Pediatrics on the issue of hospital discharge of the high-risk neonate. It has been developed, on the basis of scientifically derived information.

Four categories of high risk neonate are identified:

Preterm infant

Infant who requires technological support

Infant primarily at risk because of family issues

Infant whose irreversible condition will result in an early death.

The unique home care issues for each are reviewed within a common framework. Recommendations are given for four areas of readiness for hospital discharge: infant, home care planning, family and home environment, community and health care system. The need for individualized planning and physician judgment is emphasized..

Semester 3

MH0052 – Hospital Organization, Operations and Planning (4 Credits)

(Book ID: B1213)

Assignment Set- 2 (Marks 60)

Note: Each question carries 10 Marks. Answer all the questions.

Q1. Explain about the Central Billing Department in detail. [10 Marks]

Central Billing Department

Introduction

The Central billing department plays an important role, as liaison office between the management and the patients, in addition to its prime duty of billing. The immense patience, human relations and hospitality is the need of the hour to alleviate the problems of patients who are in distress, as the words spoken and deeds undertaken by the staff working at this department project the theme of humanity. One of the commonest problems faced by the discharged patients at all hospitals is the delay in discharge due to slow bill generation. The same can be overcome or reduced to a great extent by computerization of billing system and having a user friendly hospital information system (HIS) in place.

Objectives:

After studying this section you will be able to:

Illustrate the workflow in billing activities

Explain the discharge procedure

Describe the policies and procedures followed in the billing department.

Admission records of patients

The admission records with complete details pertaining to the patients admitted are sent to the Billing Office from the Central Admission Office, which are filed alphabetically to serve as information to the patients party to locate their patients easily at the enquiry counter.

Volume of work

On an average, 120 to 140 patients are discharged in a tertiary care referral hospital with bed occupancy of 80 percent. The bills generated by the billing department per day are approximately 120 to 140.

Organization of billing department

The overall administration of the hospital is the responsibility of the Medical Superintendent. For the effective and smooth functioning, the Billing Office has been placed under the Finance Executive, who looks after the financial matters and accounts of the hospital.

Billing Section Organization

The fig 8.1 below explains the organizational chart of the billing section in a hospital.

Fig. 8.1: Organization chart of the Billing Section

Documentation Procedure

Compilation of Billing Data

The Billing Office receives statement of investigation charges from various wards, laboratories, operation theatre and other departments every day at a set time every day. The charges are immediately fed into the computers in the respective patient files. This system enables the Billing Office to issue interim bills and weekly reminders to patients so as to initiate payment.

Discharge procedure for inpatients

Ward Patient is advised discharge

File moves from billing section to the receiving counter

Discharge procedure initiated at billing office.

Print out of checklist generated

Checking and coding of charges which are not entered

Final entry of charges

Generation of Bills

Final Scrutiny and Re-entry if necessary

Cash collection

Patient is discharged

Dispatch of bills to accounts department

Procedure of Billing

The files of the discharged patients are received from the wards at the Billing Office after proper scrutiny and are entered in the daily discharge register. The file along with a print out of a check list of charges is made available for coding after recording the date, time and the condition of the patient in the computer, as indicated in the files.

Coding of Investigation / Procedure / Operation Charges

The patients bills are prepared according to the rate list provided by the management. With the help of a check list and inpatient file, proper coding of the charges are carried out to find out the discrepancies in charges and also for appropriateness of the charges as it is the most essential aspect in billing procedure. After codification of charges the files are passed on for final entry and then the bills are generated.

Scrutiny of the Bills

Bills are scrutinized thoroughly for accuracy of the charges to avoid short billing and omission of charges by referring the files and clarifying the doubts from the concerned department. The bills are then sorted out and distributed to the respective counters for the completion of the assigned job of discharging the cases admitted under free ward, camp case, family planning and corporate referral companies etc.

Paying Inpatient Bill

For the convenience of the general and special ward patients cash counters are functioning separately where the payments can be made according to the status of the ward.

Remittance of the Cash

The cash collected against the bills is remitted to the bank once/twice in a day. This depends on the policy adopted.

Dispatching of the Bills

The bills after payment are assembled serially and dispatched to the Accounts Section, usually on the following day, to enable the hospital to maintain the accounts and to preserve the bills. This is subject to the policy adopted by the organization.

Procedure of Billing of Investigations / Procedures

The bills of the outpatient are generated in computers on the basis of the investigations/procedure prescribed by the doctors. The charges are levied as per the rate list provided by the management.

Billing of Procedures at Various Outpatient Departments

In large hospitals for the purpose of convenience to the patients billing counters may be located floor wise, though this is not advisable. Cash memo raised by the concerned OPD against the procedures and the special consultation is sent to the outpatient cash counter for payment.

Ascertaining of the X-ray Bill

The x-ray bill along with investigation slip should be produced by the patient at the x-ray counter which is scrutinized by the technician for appropriateness of the charges before taking x-ray. For any discrepancies in charges the bill should be redirected to the Central Cash Counter by the Radiology department for ascertaining and rectification of the charges.

Q2. Mr. Arun kumar met with a road traffic accident in the Bangalore Chennai Highway. He was rushed

to many small hospitals where treatment was refused, and finally was admitted to Crancare Healthcare.

Crancare Healthcare took the patient into the emergency and for the first half an hour did not start any

treatment. The injured one’s relatives insisted and finally after so much persuasion the treatment

started. Mr. Arun Kumar was in the ICU for 5 days and eventually passed away. The patients’ relatives

filed a case against the hospital for medical negligence.

a. What is the name given to Mr. Arun Kumar’s medical record? [2 Marks]

b. According to the records retention policy in the MRD, how many years should they retain Mr.

Arun Kumar’s Medical record? [2 Marks]

c. Explain the method to retain files of Mr. Arun Kumar’s kind. [2 Marks]

d. What is the procedure for court attendance? [2 Marks]

e. What is the retention time of inpatient medical records that does not require to be produced in

the Court of Law? [2 Marks]

Records retention policy

There should be adequate storage space available. The total number of outpatient files in a tertiary setting is 75,000 85,000 and the total number of in-patient files 35,000- 40,000. The policy followed with large patient attendance at a teaching hospital ideally can be:

Outpatient files 10 years for patients having got admitted at least once. In case of patients not got admitted file is retained for 5 years.

Inpatient files Retained for 25 years.

Medico-legal files Forever. On an avg. the hospital makes 2500 medico-legal cases per year.

2. Medico Legal Cases (MLC) Record Maintenance

All MLC records are maintained under lock and key. Each MLC case has an MLC no. which is generated by the medical records department. All the records with in this file is numbered (including the nurses record) and stored. In case of files retrieved for issue to court, a tracer card replaces them, which is pink in colour. A register is maintained for documenting the issue of disability- certificate, treatment-certificate and injury-certificate.

3. Court Attendance

The MRD receives summons from the court through the Medical Superintendents Office for producing MLC files. One clerk from MRD attends the court in order to submit the records. Before submission, the number of pages in outpatient and in-patient records, investigation reports, no. of X-ray films is documented and made triplicate in a typed format. The court along with the MLC file retains two copies. The third copy is returned to the hospital signed by the court manager. This serves as acknowledgement.

4. Birth and Death Report

The MRD maintains a birth and death report book in duplicate. It also generates a birth/death report in vernacular language (Kannada), which is sent to the corporation through the Medical Superintendents office so as to enable the party to obtain birth/death certificate

Q3. a. Explain the objectives of hospital pharmacy. [5 Marks]

b. Write short notes on Drug Therapeutic Committee. [5 Marks]

Hospital Pharmacy

Introduction

The Hospital Pharmacy is the drug dispensing centre in the hospital. Purchase of drugs and maintaining the right inventory is an important function of the chief pharmacist. Nearly 20% of the hospital budget is spent on medicines. Availability of the right drug, at the right time and right place is the key to a hospitals existence. The pharmacy should be properly organized and the department should be under a professionally competent pharmacist.

Objectives

After going through this section you will be able to:

List the functions of the pharmacy

Explain the importance of hospital formulary

Describe on the activities of PTC

List the design considerations of the pharmacy

Explain the legal implications in running the hospital pharmacy.

Objectives of a Pharmacy:

Some of the objectives of the hospital pharmacy can be highlighted as:

Purchasing, storing and dispensing the drugs

Ensuring the potency of the drugs at the time of purchase and storage

Dispensing prescriptions to inpatients and outpatients,

Ensuring Quality control of the preparations made to be used in dispensing

Maintaining information regarding cost, quality and source of supply

Ensuring adherence to the laws, rules and acts applicable to hospital pharmacy

Promotion in the economy of use of medicines

To monitor the adherence by all concerned to hospital formulary

Drug therapeutic Committee

For efficient functioning of the pharmacy, it is necessary that the users of the service and its providers along with the top management meet together and have a committee to discuss on any decisions to be taken and any protocols to be formulated for the pharmacy.

The optimum composition of the committee will depend on the size and type of a hospital. For a general hospital of about 500 beds the committee composition will be at a minimum, Medical Superintendent who is the chairperson; one representative from the administration; Heads of departments (Medicine, Surgery, Pediatrics, Obstetrics & Gynecology); consultants from various specialties; Nursing Superintendent; the Chief pharmacist who is also the secretary and one pharmacist.

The frequency with which the committee should meet is a policy decision of the individual healthcare organizations

Q4. Explain CSSD and its activities in detail. [10 Marks]

General Stores

Introduction

Materials are essential resources to achieve the objectives of any health care organization and key to the development. In the hospital setting the expenditure on material and supply accounts to about 40%. In the absence of materials required for health care activities the manpower deployed becomes non functional. Therefore, it is of great importance that materials of right quality are supplied in right quantity at right time and place of use.

Objectives

After going through this section you will be able to:

Explain the concept of inventory control

Describe the concept of EOQ

List the coding system and storage systems

Storage System

The storage system in general stores may be broadly classified under 3 heads

Receipt system

Physical update & maintenance system

Issue system

In a growing organization / industry, the system should not only permit matching of present requirements with existing facilities but also take care of future growth potential & demands.

Objective of the general stores

The main objective of the stores function is to render service to the users.

They may be enumerated as follows

1. Receive the material, check them for quality, co-ordinate for inspection & quality checks & prepare the goods receipt notes.

2. Accept the past materials, prepare rejection notes & complete the formalities for payment of bills.

3. Take stock of accepted materials, store in pre-determined respective places.

4. Issue vouchers to be prepared, make actual issues as and when necessary.

5. Keep the purchasing department well informed through systematic indents & other reports.

Organizing the whole procedure is essential in order to have easy storage, prevent pilferage, proper identification & quick retrievals with minimum time & effort. To achieve this, stores location & layout must be considered & the job analysis of the personnel involved should be done.

Apart from this the following routine activities must be attended to-

Establish, maintain & update a rationalized system of codification.

Analyze the consumption & issues from stock records in order to establish norms.

Highlight abnormal consumption, accumulation, obsolescence & surpluses.

Arrange for periodic reviews, physical verification & ensure proper accounting.

Supervise for smooth functioning.

Stores Location and Function:

Storage system has to accommodate for the inputs of material, components brought in from outside sources, the in-process inventories & the outflow of finished goods to customers. The systems efficiency is assessed in terms of unit cost of moving goods through storage sites or storage over a given period.

The design, size & location of a storehouse must therefore be, an integral part of wider systems design & management strategy. It must be realized that, what happens in the storehouse affects the whole range of other activities.

Development of Storing:

The degree of mechanization affects layout, while scarcity of space affects height. The need for rapid over picking means an easy accessibility to stock, but it weighs against economy of space. Therefore any storage system is a compromise between the use of space & use of time.

There are three basic ways of storing:

1. Fixed location: This means that the stock can be found immediately without a complex system of recording, hence there can be considerable waste of space.

2. Random location: In this case space is better utilized but goods & elaborate records have to be kept about the location of materials.

3. Zoned location: In this case goods of a particular product group are stored in a given area. They may be randomly stored in a zoned location or according to fixed location.

In large mechanized/automated storehouses, fast moving & sometimes medium &slow moving are grouped together. This is to assign most suitable types of storage & materials handling equipment to different kinds of stock movement. Fast moving items are stored near to the input/output end so as to reduce travel time & speeding up throughout.

Centralization and Decentralization:

Though centralization has its own merits like, helps to ensure economy, better control & reduced manpower needs, it has its demerits like difficulty in rendering service to various work centers scattered in different locations.

Decentralized storehouse in advantageous to workshop, lying scattered in wide areas. However reversal of flow wastes money & counter flow is likely to result in congestion & accidents.

Classification and Coding:

The need for classifying & coding is essential in order to prevent unnecessary stocking of items, misleading nomenclature, faulty numbering & use of trade/brand names to describe the same item. A standard numerical coding is necessary for the purpose of use in purchase, stores and issue & other purposes in order to symbolize such fundamental & particular characteristics.

The Systems:

The following systems of codification are in common use:

Alphabetical system

Numerical system

Decimal system

Combined alphabetical & numerical system

Brisch system

Kodak system

Alphabetical system:

In this system alphabets become the basis & codes are allotted to each item in alphabetical order

Numerical system:

This system has numbers like, simple numbers, block numbers or dash/stroke numbers.

Decimal system:

Under this system of codification within the range of ten numerals 0-9 some significance is attached with every code, thus the whole range of items can be codified without difficulty.

X-Condition

X-Shape

X-Grade

X-Size

X-Type

X- Sub-group

X- Group

X- Class

Two-digit decimal:

X-Condition

XX-Shape

XX-Grade

XX-Size

XX-Type

X- Sub-group

X- Group

X- Class

Combined alphabetical & numerical system:

This system uses a combination of both alphabets & numbers. It allows the use of alphabets to a limited extent & then use of number codes.

Merits and Demerits of Codification

Merits

Helps in accurate identification, prevention of duplication and variety reduction.

Helps in mechanical recording, accounting, pricing and costing of materials.

Locating and indexing for inspection are also made easier.

Demerits

Codes are sometimes misunderstood & when this happens finding the exact code is difficult.

Large numbers of items are coded in one group, this leads to confusion.

Materials Accounting

The primary basis for material accounting is cost. Materials are ordered on a continuous basis & there is no prescribed procedure which is used in the determination of materials cost for accounting purposes.

For this purpose, the following records & documents are maintained:

1. Bin card

2. Stores ledger

3. Stock identification card

4. Materials received note

5. Materials requisition slip

6. Materials return slip

7. Materials transfer note

Bin card

It is a record of movement of materials against each kind of stock with respect to daily transactions. It shows daily receipts, issues & balance quantity in hand.

Uses

1. Exact position of materials is known, as against each receipt & issue.

2. Information regarding stock level & the quantity balance on hand is immediately known.

3. Code number and full description of the materials is given on the card.

4. Serves as a check on stock ledger & helps physical verification of stores

Stores ledger

When bin cards do not show the details of information, stores ledger is the alternative. It gives the following information as against the bin cards:

Supplier name & address

Quantity ordered each time, invoice no. & price

Expected delivery with due date in remarks column.

Stock levels.

Stock identification card

These cards are kept in the stores against each bin or rack. They contain the following information:

Material code no. & full description.

Respective stores ledger folio & bin card no.

Materials received note

When materials are passed on to the stores after proper verification & approval by inspection, the materials & supplies are taken into stock through material received note.

Materials requisition slip

Materials are requested by the user department through this document. Stores dept must check the following points:

1. M.R slip is signed by the authorized person

2. Proper code no. & description of the material required to be marked

3. Quantity issued is entered immediately, signed & verified by the stores.

4. The requisition is prepared in triplicate, one copy each for issuing authority/stores record/stock accounts.

Materials returned note

Materials are returned by the user department back to the stores through this document

Materials transfer note

This document is used when materials are transferred from one user department to another user department

Flow of Costs and Inventory Valuation

Inventory has both physical (i.e. goods flow) & financial (i.e. cost flow) characteristics. The former is factual & objective, the latter is a subjective estimate.

The following methods are in use for assumed flow of costs for accounting.

1. FIFO method (first in, first out)

2. LIFO method (last in, first out)

3. Average cost method

4. Specific cost method

FIFO Method

In FIFO method the assumption is that materials are issued from the oldest stock & their unit cost also represents the cost at time of purchase on the stock ledger. However when prices are subject to change this method does not match costs against revenue on a current cost basis. This causes distortion in the income statement.

LIFO Method

Under this method, the cost of inventory on hand represents the oldest inventory at purchase cost of old inventory, i.e. the current revenues represent the current replacement cost; the underlying purpose being to match the current revenues against current costs. During inflation, LIFO means lower profits. Such inventory income is unrealistic because it ignores the need for replenishment at higher prices.

Average Cost Method

In order to provide realistic basis for inventory valuation and the cost of goods sold, the Average cost method is used. Average cost methods commonly used are of three types, Simple Average, Weighed Average and Moving Average. It works on the principle of determining the average cost of each item during the period of a given time.

Specific Cost Method

It provides a more realistic valuation of ending inventory as well as flow of costs. It has the flexibility of being suitable for either a periodic inventory system or perpetual inventory system, the objective of which is to indicate inventory at all times through physical verification of inventories round the year in order to reconcile the current balances with stores ledger.

Inventory Control and Management

In simple terms inventory control means a stock of goods.

Definition

Inventories are materials or resources of any kind having some economic value, either awaiting conversion or use in future.

OR

It is also defined as an ideal resource of any kind having economic value.

Inventory involves money in terms of storage space, personnel, insurance, security, deterioration & obsolescence. Sometimes it may be economical to purchase an item on demand than to maintain an inventory. Conversely a certain minimum amount of each item must be held to minimize the chances of total stock-out.

The purpose of inventory control is to determine appropriate levels of holding inventory, the ordering sequence & the quantities so as to minimize the total cost incurred.

The management & control of inventories, incorporates certain concepts and technique as follows:

ABC analysis

VED analysis

Ordering cost

Inventory carrying cost

Economic order quantity

Lead time

Safety stock

Re-ordering cost

Stock turnover

ABC-Analysis

Economics of materials control is a matter of self-preservation in todays competitive environment. Since material control is a matter of rupee control, stringent control must be placed on higher value items.

Paretos law:

According to this law, The significant items in a given group normally constitute a small portion of the total items in the group and the majority of the items in the total will, in aggregate be of minor significance.

Principle

A small number of items represent a large percentage of the cost value. Conversely, large percentage of the items represents only a small portion of the cost value. The procedure adopted to determine varying levels of control is called ABC-analysis.

Procedure

The list of all items in the store & the current annual consumption of each item (in Rupees) are taken down from the records available in the Stores / Purchase dept. The items in the list are then re-arranged in the descending order of annual consumption cost (highest to lowest)

An analysis of this list will show that:

The first 10% of the items account for approx.70-75% of the annual consumption cost. These are categorized as A items.

The next 20% of the items account for approx. 20-30% of the annual consumption cost. These are categorized as B items

The remaining 70% of the items account for only 10-15% of the annual consumption cost. These are categorized as C items

Control

Low value items require low investment cost even to increase the level of safety stock. Hence large quantities can be purchased & because of higher stock the physical inventory can be lengthened. Conversely high value items require higher investment cost. Safety stock should be as low as possible and economical purchases should be made, close controls of these items should be ensured. Without ABC-analysis the ordering policy may be to order all items once in 3 months, in which case the stock position may become chaotic.

Summary of ABC-analysis:

Other Classifications

VED Analysis (Vital, Essential, Desirable)

HML Analysis (High cost, Medium cost, Low cost)

FSN Analysis (Fast, Slow, Nonmoving)

SDE Analysis (Scarce in market, Difficult to procure, Easy to procure)

Economic Order Quantity (EOQ)

Definition

It is that quantity at which, the cost of ordering the requirements of an item and the inventory carrying costs are nearly equal i.e. when the sum of the two costs is the lowest. In other words, it seeks to strike a balance between purchase costs and the cost of holding inventory.

Advantages of EOQ

1. Helps in finding appropriate levels of holding inventories.

2. Facilitates the function of ordering sequence and the quantities so as to minimize the total material costs.

In order to understand EOQ method two important costs must be considered and analyzed.

Ordering Cost

In most cases, ordering cost is hidden under overheads. Ordering costs include many variables and are not easily measurable.

They include salaries / wages of the involved personnel

Postal / Telephone / Telex and similar bills

Advertisements

Stationeries

Entertaining Vendors / Suppliers

Travel by Stores Personnel (staff)

In general the ordering cost per order may vary between Rs.15 to Rs.40, which is quite acceptable.

Inventory Carrying Cost

It is obvious that holding excess inventories will result in an increase in the cost of storage, space, maintenance, electricity, insurance and other holding charges along with money tied up in holding it. However there are tangible and intangible costs and problems in carrying too little inventory.

Some inventory carrying costs are as follows.

Cost of storage / Insurance

Salary / Wages of stores personnel

Stationary forms / Paper work

- Loss of interest on money deadlocked in inventory

- Deterioration and Obsolescence

- Losses due to pilferage

Inventory carrying cost is expressed as a percentage of the average investment in inventory. The total inventory carrying cost may range from 1% - 5% of the total inventory cost of a health organization.

EOQ Formula

TC = RP + (RC / Q) + (QH / 2)

Where,

Factors Influencing Order Quantities

Lead time

It is the period that elapses between placing an order and receiving the supplies in stores.

Administrative lead time: Time required for preparing purchase requisitions, obtaining quotations, initiating purchase order etc. It also includes checking and inspection of materials on arrival, recording and sending the material to the appropriate stores.

Delivery lead time: It is the time taken by the supplier in getting the materials ready, transport of materials from his warehouse and actual delivery to the user organization.

Minimum Stock Holding

The guiding principle is that high value items should have a very low stock (since orders are closely followed up). Low value items can have high quantum of minimum stock. Medium value items fall in between. Shelf life affects the minimum stock holding of an item to a great extent.

Safe Buffer Stock

This is the quantity of stock that is set aside as insurance against variation of demand and procurement period for unforeseen reasons and to avoid stock out.

Reordering Systems

Reordering Point: The reordering level is equal to the minimum stock plus requirement during lead time.

It is given by the formula B = RL / 12, where B = Reordering point;

R = Annual demand (units); L = Lead Time (months)

Cyclic System: In this system the physical position is reviewed at fixed intervals. Orders are placed depending on the stock in hand and rate of consumption, i.e. ordering interval is fixed but the quantity ordered varies each time. Ideal for A value items and high value B items.

Two-Bin System: In this case sufficient stock to meet consumption before placing of the next order is held in one bin and the other bin contains stock sufficient to meet probable consumption during the period of replenishment. Here, the order quantity is fixed but the frequency of the order varies. Fixed order quantity is suitable for C items and low value items.

Q5. Mr. Amithaab has been recruited as the Housekeeping manager of Vijayam Hospital. What are the

possible work that he need to allocate in the hospital. Outline the various housekeeping activities in the

hospital. [10 Marks]

Housekeeping Services

Introduction

The house keeping service has been developed for the purpose of maintaining the whole hospital clean and orderly. Recently the term Sanitation has replaced the term House-keeping service in

many large institutions. The objective of the housekeeping service is to maintain the environment (both external and internal) clean and hygienic, more for the purpose of health.

Objectives:

After going through this section you will be able to:

List the functions of the housekeeping department

Explain the contribution of housekeeping department in improving the image of the hospital

Objectives of housekeeping

The objectives of house keeping are many-fold. They can be classified as:

Physical structure:

In order to maintain a clean environment and facilitate the maintenance of the hospital building, it is essential to assess the need for change periodically.

Equipment of Material:

The housekeeping manager should ensure that adequate supplies of washing material are maintained; maintain equipments in working condition; and investigate into acquisition of new equipments/washing material.

Work process and methods:

This includes evaluation of the staffing pattern and their modality of operation; standardization of methods of cleaning and utilization of equipment.

Safety and education:

The house keeping manager should ensure that adequate safety training is provided for all housekeeping staff; conduct periodic educational programs for house keeping personnel and also other hospital staff; ensuring that the safety standards for equipments and work process are maintained.

Management and staff relation:

There should be good communication within the organization fostering an attitude of co-operation and co-ordination; Equitable and fair division of work; preparing and periodic updating of the housekeeping manual.

Functions of the Housekeeping department in the hospital

The overall functions of the house keeping department can be summarized as follows:

Sanitation function

This includes, dusting; mopping; sweeping; cleaning fixtures, curtains, blinds; toilet maintenance; elevator cleaning; waxing; trash removal; garbage removal; plants cleaning; environment hygiene; receipt and issue of supplies.

Stocking of supplies

This includes maintaining stock of toiletries; jug, mug etc; dustbins; stationeries; towels and linen.

Maintenance function

Cleaning, positioning, maintenance of all equipment.

Periodic oiling of trolleys/beds/wheel chairs etc.

Safety and security

Making the housekeeping and related staff aware of the detection of fire and fire prevention.

Detecting fire and operating the fire alarm.

Participation in infection control programs.

Rodent and pest control

Organize, supervise and execute rodent and pest control measures.

Public relation function:

By creating a pleasant and comfortable environment for patients and staff alike, the house keeping strengthens public relations.

By being in constant touch with patients, these people who render this particular service are the best spoke-persons of the reputation of the hospital.

Linen management:

The housekeeper along with his staff deployed at the floor level can effectively operate:

Daily linen exchange

Repair/mending

Linen condemnation

Issue of linen

Linen supply to various special rooms and wards

Safety stock with the house keeping section can also take care of exigencies if any at the same area or at other places in the hospital. Linen management by the housekeeper relieves the nursing staff of a non-nursing job, and gives them more time for patient care.

Productivity and efficiency:

By providing a clean, safe and pleasant environment, the housekeeping department promotes the productivity and efficiency of employees and in turn, that of the hospital as a whole.

By practicing safe and effective segregation at source, garbage collection transport and disposal, the housekeeping department plays a great role in controlling hospital infection. This in turn hastens patients recovery and thereby increases hospital bed turn-over rate, thus enhancing the number of patients in the hospital. The cumulative effect of all this is economical and quality hospital operations.

Q6. Ms. Margret is the executive secretary to the CEO . She is sending an e-mail to the following group of people for a meeting that is pre-scheduled.

i. Dr. Narayanan N - CEOii. Mr. Krishnamurthy P.K. – Hospital Administratoriii. Dr. Kiran Kumar – Medical Superintendentiv. Mrs. Lilly Ivan - Nursing Superintendentv. Ms. Ramya Kumari – Assistant Administratorvi. Mr. Robert Antony – CFOvii. Mr. Sathyanarayan Nair – HR Head

Answer the following questions, based on the details given above:

a. Find out the name of the committee that Ms. Margret is calling for. [2 Marks]

b. What is the purpose of this committee? [4 Marks]

c. What are the specific functions of this committee? [4 Marks]

Hospital Organizational Structure

An organization is a coherent combination of functions of a group or groups of people, who are united by a common purpose, by division of labour and function and through a hierarchy of authority and responsibility.

A hospital organization is a systematic medical, non-medical, administrative and human resources activity that would impact the satisfaction of all its stake holders. Therefore, organizing is a process of clustering the responsibilities and activities into workable units, determining the lines of authority and communication and developing patterns of coordination. And each of these workable units needs to have constant interaction for effective functioning of the hospital.

Organization structure in a hospital refers to the levels of management within the hospital. These levels will allow the efficient management of the individual departments. The structure will enable one to understand the chain of command. The organizational structure may vary from one hospital to the other depending on the goals and objectives and size of the hospital. The collective functions of the various departments work towards the ultimate goal of the hospital. Authority responsibility relationships should be clearly spelled. Clarity in the organizational relationship may contribute to increased productivity and reduced internal conflicts.

Functional Authority

Figure 1.3 represents a pyramidal organizational hierarchy. It is a traditional organizational structure that clearly depicts the flow of authority and responsibility which is essential for delegation and accountability.

Fig. 1.3: Pyramidal Organizational Hierarchies

Top management consists of: The Governing Board, CEO, and Management Team

Middle management consists of: Sr. Administrative executives, Department heads, Consultants, Nursing head, Managers

Supervisors consist of: Section heads, senior doctors, Nursing supervisors, Ward-incharges

Line workers consist of: Junior doctors, Staff nurses, Clerical staff, Housekeeping staff, and maintenance staff

An outstanding characteristic of a hospital is that it does not have a clear line of authority. Unlike other organizations, hospitals do not have a single line of authority, hence, the clutter. Sometimes it is a single line and sometimes it is a double or multiple lines. Since, hospitals have a medical line of authority and an administrative line of authority, devising an organizational chart for a hospital is significant and utmost care needs to be given. The medical services are headed by a Medical Director or Medical Superintendent and the administrative services are headed by the CEO / Administrator / General Manager based on the size of the organization. However, the ultimate authority in devising policies rests with the governing board or the policy making body. The dual lines of authority is clearly depicted in the figure 1.4.

Fig. 1.4: Lines of authority

The two important and distinct functions of the hospital are:

1. Provision of clinical care:

Treatment procedures

Diagnostic procedures

Nursing care

Clinical support services

2. Provision of non-clinical care:

Administration

Sanitation

Security

Stay facilities

The organizational structure of a hospital may vary depending on the goals and objectives and size of the hospital. Figure 1.5 is a sample organization structure of a hospital.

The organizational chart of a hospital may vary from one hospital to another depending on the following factors:

1. Classification and nature of the hospital

2. Objectives and goals of the hospital

3. It depends on the professional competency of the administration head. It might be different based on the fact whether the General Manager or the CEO has a medical background or not

4. Local community demand and needs, trends.

Central Billing Department

Introduction

The Central billing department plays an important role, as liaison office between the management and the patients, in addition to its prime duty of billing. The immense patience, human relations and hospitality is the need of the hour to alleviate the problems of patients who are in distress, as the words spoken and deeds undertaken by the staff working at this department project the theme of humanity. One of the commonest problems faced by the discharged patients at all hospitals is the delay in discharge due to slow bill generation. The same can be overcome or reduced to a great extent by computerization of billing system and having a user friendly hospital information system (HIS) in place.

Objectives:

After studying this section you will be able to:

Illustrate the workflow in billing activities

Explain the discharge procedure

Describe the policies and procedures followed in the billing department.

Admission records of patients

The admission records with complete details pertaining to the patients admitted are sent to the Billing Office from the Central Admission Office, which are filed alphabetically to serve as information to the patients party to locate their patients easily at the enquiry counter.

Volume of work

On an average, 120 to 140 patients are discharged in a tertiary care referral hospital with bed occupancy of 80 percent. The bills generated by the billing department per day are approximately 120 to 140.

Organization of billing department

The overall administration of the hospital is the responsibility of the Medical Superintendent. For the effective and smooth functioning, the Billing Office has been placed under the Finance Executive, who looks after the financial matters and accounts of the hospital.

Billing Section Organization

The fig 8.1 below explains the organizational chart of the billing section in a hospital.

Fig. 8.1: Organization chart of the Billing Section

Documentation Procedure

Compilation of Billing Data

The Billing Office receives statement of investigation charges from various wards, laboratories, operation theatre and other departments every day at a set time every day. The charges are immediately fed into the computers in the respective patient files. This system enables the Billing Office to issue interim bills and weekly reminders to patients so as to initiate payment.

Discharge procedure for inpatients

Ward Patient is advised discharge

File moves from billing section to the receiving counter

Discharge procedure initiated at billing office.

Print out of checklist generated

Checking and coding of charges which are not entered

Final entry of charges

Generation of Bills

Final Scrutiny and Re-entry if necessary

Cash collection

Patient is discharged

Dispatch of bills to accounts department

Procedure of Billing

The files of the discharged patients are received from the wards at the Billing Office after proper scrutiny and are entered in the daily discharge register. The file along with a print out of a check list of charges is made available for coding after recording the date, time and the condition of the patient in the computer, as indicated in the files.

Coding of Investigation / Procedure / Operation Charges

The patients bills are prepared according to the rate list provided by the management. With the help of a check list and inpatient file, proper coding of the charges are carried out to find out the discrepancies in charges and also for appropriateness of the charges as it is the most essential aspect in billing procedure. After codification of charges the files are passed on for final entry and then the bills are generated.

Scrutiny of the Bills

Bills are scrutinized thoroughly for accuracy of the charges to avoid short billing and omission of charges by referring the files and clarifying the doubts from the concerned department. The bills are then sorted out and distributed to the respective counters for the completion of the assigned job of discharging the cases admitted under free ward, camp case, family planning and corporate referral companies etc.

Paying Inpatient Bill

For the convenience of the general and special ward patients cash counters are functioning separately where the payments can be made according to the status of the ward.

Remittance of the Cash

The cash collected against the bills is remitted to the bank once/twice in a day. This depends on the policy adopted.

Dispatching of the Bills

The bills after payment are assembled serially and dispatched to the Accounts Section, usually on the following day, to enable the hospital to maintain the accounts and to preserve the bills. This is subject to the policy adopted by the organization.

Procedure of Billing of Investigations / Procedures

The bills of the outpatient are generated in computers on the basis of the investigations/procedure prescribed by the doctors. The charges are levied as per the rate list provided by the management.

Billing of Procedures at Various Outpatient Departments

In large hospitals for the purpose of convenience to the patients billing counters may be located floor wise, though this is not advisable. Cash memo raised by the concerned OPD against the procedures and the special consultation is sent to the outpatient cash counter for payment.

Ascertaining of the X-ray Bill

The x-ray bill along with investigation slip should be produced by the patient at the x-ray counter which is scrutinized by the technician for appropriateness of the charges before taking x-ray. For any discrepancies in charges the bill should be redirected to the Central Cash Counter by the Radiology department for ascertaining and rectification of the charges.