virtual hospital updated

8/4/2019 Virtual Hospital UPDATED

1/113

REPORT ON VIRTUAL HOSPITAL

FRAMEWORK

Department

Hospital Administrator/CEO

Presented

To

Dr Faisal Haq

Faculty Hospital Administration

Institute of Business management

By

Dr Shahida Mirza

ID-9636


2/113

Table of ContentsCEO/HOSPITAL ADMINISTRATOR ................................................................................................................... 3

Administrator ............................................................................................................................................. 5

POLICY ............................................................................................................................................................ 5

Objectives ....................................................................................................................................................... 6

Procedures ..................................................................................................................................................... 7

Programs ........................................................................................................................................................ 7

Standards ........................................................................................................................................................ 8

Duties & Responsibilities ................................................................................................................................ 9

Logistics............................................................................................................................................ 11

Long-Term Planning ......................................................................................................................... 11

Policies ............................................................................................................................................. 11

Organogram ................................................................................................................................................. 12

Hospital Environment ................................................................................................................................... 13

Macro Environment ................................................................................................................................. 13

Micro Environment .................................................................................................................................. 13

Objectives ................................................................................................................................................. 14

POLICIES ................................................................................................................................................... 14

Fire Safety Services ................................................................................................................................... 15

Environment Management Services ........................................................................................................ 16

Occupational safety & Health services ..................................................................................................... 17

By-Laws in general ........................................................................................................................................ 20

Departmental By-Laws ................................................................................................................................. 21

BY-Laws Directly Related to Patient Care ..................................................................................................... 21

AIR-CONDITIONING OF HOSPITAL ................................................................................................................ 23

OBJECTIVES ................................................................................................................................................... 25

POLICIES OF FINANCE DEPARTMENT (FD) .................................................................................................... 26PROCEDURES OF FINANCE DEPARTMENT .................................................................................................... 27

HOSPITAL'S ANTI-FRAUD BYLAWS ............................................................................................................... 28

DEPARTMENTAL WORK FLOW ..................................................................................................................... 30

INTERDEPARTMENTAL HIERARCHY .............................................................................................................. 31


3/113

STAFFING ...................................................................................................................................................... 32

SOURCES OF REVENUE (FUNDING) ................................................................. Error! Bookmark not defined.

HOSPITAL BUDGETING ................................................................................................................................. 33

Hospitals Budget Calendar .......................................................................................................................... 39

HUMAN RESOURCE DEPARTMENT.................................................................. Error! Bookmark not defined.

INTER DEPARTMENTAL HIERARCHY ................................................................ Error! Bookmark not defined.

Medical Department .................................................................................................................................... 40

Summarized History Of Nursing: .................................................................................................................. 53

RADIOLOGY DEPARTMENT ........................................................................................................................... 82


4/113

CEO/HOSPITAL ADMINISTRATOROne of the most important assets of any community is a hospital. A hospital is a

resource for anyone needing emergency medical attention or care beyond what a

physician's office can provide. A hospital is staffed by a multitude of employees,

and in such a busy, complex environment, there must be someone who canorganize and coordinate all of the people and services that are required. This role

is fulfilled by a hospital administrator, the person who oversees everything that

goes on in a hospital.

Our Hospital Administration Classis committed to building an exemplary patient

care community that offers a nurturing and challenging intellectual climate, a

respect for the spectrum of human diversity, and a genuine understanding of the

many differences-including race, ethnicity, gender, age, socio-economic status,

national origin, sexual orientation, disability and religion that will enrich theVirtual Hospital community.

Hospital is an organization that mobilizes the skills and efforts of widely divergent

group of professionals and semi-professionals, so as to provide highly personalized

services to individual patients.

It is therefore essential to bring together the various components to a unified

whole to achieve the objective through the authority of central co-ordination. This

warrants a systematic functioning of a hospital as an institution.

The Word HOSPITAL is self explanatory as it is given below:

H - HEALING

O - OBSERVATION

S - SUPERVISION

P - PERSUATION

I - INVESTIGATION

T - TREATMENT

A -ASSURANCE

L -LIESURE


5/113

AdministratorIn addition to the care provided to the patients by the physicians and nurses, most

medical facilities require a significant amount of behind-the-scene administrative

support. Hospital Administrators are the professionals responsible for managing

hospitals.

The hospital administrator plays a vital a role in saving lives, without having to

take scalpel in hand.

Hospital administrators manage hospitals, outpatient clinics, hospices, and drug-

abuse treatment centers.

In large hospitals, there may be several administrators, one for each department.

In smaller facilities, they oversee the day-to-day operations of all departments.

The doctors strive to keep the blood flowing and the heart beating,

BUT

The hospital administrator is doing his job in keeping the hospital alive and

healthy.

POLICY To make sure that hospitals are operating efficiently& providing

adequate medical care to the patients.

To act as Liaison between Governing Boards, Medical staff, &

Department head.

To integrate the activities of all departments so they function as a whole

Toplan, organize, direct, control & co-ordinate medical & health services

following policies set by a governing board of trustees.


6/113

To recruit, hire and sometimes train doctors, nurses, interns & assistant

administrators to develop a stable staff.

To develop strengths and neutralize workers weaknesses.

To develop procedures for medical treatments (in collaboration with

consultants), quality assurance, patient services, and public relations

activities such as community health.

To attendstaff meetings & participate in health planning councils.

They need to keep up with advances in:

- Medicine,

- Computerized diagnostic & treatment equipment,

- Data processing technology,

- Government regulations,

- Health insurance changes

- Financing options

ObjectivesDirecting hospital activities according to governing boards overall

objectives & policies.

Reviewing departments reports and activities

Settlingpatients complaints.

Assembling competent workers to direct & undertake given activities & to

develop them useful environmental and medical teams.

Preparing& operating sound financial structure& effective control & safety

of funds.

Submitting a long term plan for hospital and growth & a periodic, annual

financial budget to the Governing Boardfor its approval or otherwise.


7/113

Studying advances in hospital practices in order to advise the Governing

Board.

Studying the means to meet the communitys changing hospital needs.

ProceduresWriting proposals for government grants.

Preparing periodic budgets.

Allocating scarce funds & other resources.

Determining patients fee Schedule.

Determining space, equipment, materials & human resource needed to

provide services.

Convening conferences.

Determining on-duty schedule for Administration Department.

Makinga formal inspection round.

ProgramsFire Prevention and Fighting:

Prevention of fires by documented regular inspections of facilities and fire-

fighting equipment, and drills.

Disaster:

Expeditious care of mass casualties from a catastrophe and maintenance of

services during disrupted utility supplies, workers strikes, and guerilla

attacks


8/113

Safety:

Documents periodic inspections of facilities and job procedures to prevent

accidents which may cause death, injury, loss of time, lowered morale, and

increased accident insurances

Noise : reviews outside unwelcome sound about which little can be done

and inside excessive television and radio volume, door slamming, and

equipment squeaking wheels about much can be done

Time Conservation:

Involves prompt and accurate information, managers delegation of routine

tasks and elimination of indecision and orderly arrangement of items at

work place to obviate searching

Quality Patient Care:

Documents periodic review of patients needs for good care and evaluation

of departments coordinated activities and resources to meet such needs

Patients Suggestions:

Invitation, acknowledgement, consideration with appropriate department,and acceptance, if suitable, of patients suggestions for service importance

StandardsFor the Administrators periodic report

- To ensure uniform presentations,

- Prevent omission & duplications

- Facilitate comparison with previous reports.


9/113

For the quantity of patient care,

- Total patients days

- Outpatient Attendances

- Social Service Visit

For Quality of Care

- No. of clinical tests performed

Resources used

- Staff man-hours paid

- Pounds of soiled linen processed

For Quality of Resources Used

- By workers qualifications and secretaries shorthand and typing speed.

Duties & ResponsibilitiesThere are many duties of an administrator, but regardless, they are just as vital to

patients lives as regular doctors and nurses are.

Supervision

The main responsibility of hospital administrators is to supervise and oversee the

daily operations of the hospital facility or the department(s) for which they are in

charge. They must be sure that the facility in which they work is operating in an

adequate and efficient manner to provide the best care possible to patients.

Communication

It's a large responsibility of hospital administrators to hold good communication

skills. Because they act as the main communicator between medical staff, medical

governing boards, and the heads of other medical departments, communication is

vital to the success of all involved, so all departments within a facility can function

together.


10/113

They must also be sure to follow all policies and guidelines that are set by the

medical board of trustees, and they must be sure that the medical staff they are in

charge of supervising follows these policies as well.

Staff Hiring

Hospital administrators are responsible for the hiring of most staff, including

physicians, nurses and support staff. For elite positions, such as surgeons or other

kinds of specialists, the administrator may work to recruit top candidates.

Co-ordination of Business Functions

Most hospitals have a variety of business and support functions, and the hospital

administrator coordinates and oversees these functions. In a small hospital, the

administrator may handle these tasks directly. In a larger hospital, assistants and

managers may be appointed to handle various business and support functions, but

the hospital administrator will still oversee their work.

Policy Development & Implantation

Every hospital has its own set of policies that govern employees, procedures and

services offered to patients. A hospital administrator may be required to develop

policies and procedures and ensure that they are followed, or he may implement

policies created by a governing board or body. Short-range and long-range plans

for a hospital's development and overall growth are also usually handled, or at

least supervised, by a hospital administrator.

Managing Patients records

A large part of the hospital administrator's job concerns managing patient records.

The administrator must make sure that medical histories, current health

information, and billing, insurance and legal documents are all being handled

appropriately. Keeping all of this information organized and up to date is an

essential role that a hospital administrator must fill.

Employee Evaluation

As part of their hiring duties, hospital administrators must perform regular

evaluations of employees, rating them for competency and performance. This can

lead to promotions, demotions, transfers and firings.


11/113

Public Relations

Hospital administrators will often act as the public face of a hospital, appearing at

professional conventions, meetings, public events and health planning councils.

They must present the hospital in a good light and facilitate interactions with the

community.

Program Development

Hospital administrators are also responsible for various kinds of program

development. Programs can include different approaches to treatment, as well as

ones that relate to the hospital's organizational and managerial structure. Most

programs begin by identifying a need, either among patients or health-care

providers, and developing solutions to address it, which can then be formalized

into a new or designed program or initiative.Budget

Hospital administrators are responsible for helping to prepare the hospital's

budget, assessing priorities and allocating resources to various departments and

programs. After the budget has been prepared and approved, administrators must

supervise its implementation.

Logistics

Hospital administrators are also responsible for overseeing a hospital's logisticalconcerns. This includes organizing the hospital's supply chain to ensure that

physicians and nurses consistently have resources, such as medical supplies, to

provide appropriate patient care.

Long-Term Planning

Hospital administrators are also responsible for planning the hospital's future in

the long term. This includes outlining the hospital's future goals, identifying likely

challenges, and making sure that financial and logistical resources are in place to

accomplish the facility's mission.Policies

Hospital administrators must help develop and implement hospital policies,

making sure they meet the needs of patients and staff, and that they are

consistent with the requirements set forth by the hospital's board of directors.

They should also ensure that all policies comply with applicable laws.


12/113

Organogram

CEO/Administrator

Chief Operational Officer

Manager Nursing Chief Medical OfficerAssistant Manager

Operation

Dietary Services Maintenance

House Keeping Social Services

Pharmacy Laboratory

Radiology

Chief Financial Officer

Assit. Manager Income

Assit. Manager Expense

Accountant

Human Resource

Manager Recruitment

Manager Appraisal

Manager Training

DepartmentSecretary


13/113

Hospital EnvironmentHospital Environmental Service is about more than just cleanliness. A hospitals

appearance is the first opportunity to make an impression on patients and

visitors.

Creating a clean and safe facility builds confidence in services and translates into

improved patient satisfaction

Environmental Services is an integral part of the hospital team, and its work

directly impacts not only the daily operations of the hospital, but also the most

important deliverables: satisfaction and outcomes

Environment affects hospital functioning in two aspects

Macro Environment

- Overall Law & Order situation of city.

- General Economics and paying capacity of the population of Catchment area

of hospital.

- Disturbance in the community declines productivity of staff, e.g Riots,

strikes & transportation difficulties.

- Industrial noise and vibration disturbs delicately balanced scientific

equipments.

- High humidity, intense heat and desert dust bearing winds permeate

equipment mechanism.

Micro Environment

- Hospital itself (Shell, building, & physical assets)

- Segmentation of Climate

- Split of room categories

- Environment of LR, OR, ER, ICU, NICU etc


14/113

Special emphasis on:

- Air conditioning

- Zoning

- Interior decoration

- Cross functional team with collaboration with other units

- Hygiene Standards

- Fire Safety

Objectives

The Department of Health & Safety Provides:

Programming

Processes

Training

As required by the Regulatory Standards & Regulatory agencies of Hospitals

EH&S staff serves as consultants to identify and resolve health & safety issues, aswell as Specialists on Hospital committees & provide Expertise in such areas such

as:

- Fire Safety

- Environmental Management

- Occupational safety & Health

- Radiation safety


15/113

POLICIESTo Communicate & Facilitate all new program requirements & regulatory

initiatives.

To provide regulatory driven safety training.

To perform internal self audits and minor workplace hazards to insure

compliance.

To assess program compliance through

- Hazard surveillance rounds,

- Environmental rounds,

- Review of illness & injury reports

- Observation of staff knowledge during actual activities & planned drills

Following summarizes those services by program area:

Fire Safety Services

Regulatory Inspections

Conduct general inspection of facilities, life safety surveys, and compliance

surveys for compliance with applicable regulation and standards.

Fire Extinguisher Inspections

- Complete monthly inspections of all fire extinguishers.

- Annual maintenance of all extinguishers and hydrostatic testing of all of

them per code.

Fire Drills

Conduct quarterly drills covering all three drills.


16/113

Emergency Response

Provide emergency response to fire alarms, accidents, medical emergencies

and hazardous materials incidents, as well as routine responses to requests

for assistance.

Fire Detection & Suspension System

Monitor and service Hospitals fire detection and suppression systems that

have more than 15,000 components, such as smoke detectors, heat

detectors, bells, manual pull stations and fixed extinguisher system.

Plan Review

Review, as requested, proposed Hospital rehabilitations or new facilities to ensurecompliance with all applicable codes and standards.

Special Events

Provide safety supervision at various large events and public assemblies, including

carnivals, concerts, and special activities.

Safety Training

Provide Fire Warden, Interim Life Safety and general Fire Safety training to

Hospital staff. General Fire Safety training is provided to the off-site facilities.

Accommodation for the Disabled

In accordance with the Americans with Disabilities Act, activities include the

retrofitting of Hospital facilities to incorporate visual fire alarms and evacuation

guidance for the visually impaired.

Environment Management Services

Hazardous Waste Collection and Disposal

Coordinate and guide Hospital staff on proper collection and disposal of chemical

hazardous waste, asbestos waste, PCB waste, including sampling and identification

of unknown waste substances.


17/113

Recordkeeping

Maintain manifest and track waste disposal from Hospital operations.

Safety Training

Provide hazardous waste management training online, during orientation, andrecertification trainings.

Waste Minimization Program

Assist generators with regard to waste minimization. This may include training and

assisting in waste reclamation, conservation of raw materials, and less hazardous

product substitution. Identify strategies to recycle, reduce and reuse Hospital

resources.

Occupational safety & Health servicesHazard Surveillance

Hazard surveillance rounds are performed to ensure compliance with occupational

health and safety requirements, and Joint Commission, plus safety audits of all

operations and areas for potential occupational hazards and risks to employees.

Rounds at off-site facilities are performed by the Off-site

Safety Training

Conduct employee health and safety training on topics such as hazardcommunication protection, hearing conservation, and other specialized health and

safety topics.

Recordkeeping

Occupational injury and illness recordkeeping and reporting, including maintaining

injury and illness log and the summary.

Hazard Assessments

Hazard Assessments are performed to developed safety procedures for various

operations.

Injury and Illness Investigations

Conduct investigations to determine root causes and recommend corrective

action.


18/113

Occupational Exposure Monitoring

Conduct chemical exposure monitoring for formaldehyde, ethylene oxide, waste

anesthetic gases, and other airborne contaminants.

Indoor Air Quality

Conduct indoor air quality surveys, including sampling, identifying and developing

appropriate remedial actions to eliminate potential sources of airborne

contaminants. At off-sites, sampling is performed by the Off-site EC Coordinator.

Noise and Hearing Conservation

Conduct personal and area noise monitoring, as needed.

Lab Safety

Implement the Hospitals Chemical Hygiene Plan and Laboratory Safety Plan,

including lab inspections and chemical fume hood inspections.

Asbestos Management

Manage the Hospitals asbestos abatement activities. Perform air and bulk

sampling. Perform operations and maintenance asbestos abatements.

Radiation Safety Services

Radiation Protection Services provide the health physics support services that

are mandated by the New York State Bureau of Environmental RadiationProtection in the University's Broad Radioactive Materials License.

Licensing Management for the Academic and Medical Programs

Manage the Hospital Radiation Protection Program and maintaining compliance

with mandated licensing conditions.

Radiation Surveys

Perform radiation protection surveys for all sources of ionizing radiation. Maintain

lead apron quality control monitoring program.Personnel Monitoring

Provide personnel monitoring services, including provision of monitoring devices,

interpretation of personnel monitoring exposure and maintenance of all records

of internal and external radiation exposure.


19/113

Radiation Safety Training

Instruct personnel in the safe handling procedures of all sources of ionizing

radiation in accordance with University and State requirements.

Emergency Response

Respond to emergencies involving radioactive material.

Room Design and Decommissions

Participate in lead shielding design. Decommission and decontaminate authorized

radiation control areas to non-control area status.

Non-ionizing Radiation

Maintain the non-ionizing radiation safety program for lasers and microwaves, as

requested.

Hospital Radiation Protection

Provide full employee and patient protection services for radioactive materials

and ionizing radiation producing devices.

Radiation Waste Management

Manage low level radioactive waste management program

A.Off-site Facilities the services are provided to the off-siteEnvironmental services focal Points

Increase focus on patient care

Guarantee service outcomes

Maximize staff productivity

Improve revenue stream Ensure consistently high levels of cleanliness

Raise patient and staff satisfaction

Employ environmentally conscious cleaning practices

Prevent hospital-acquired infections


20/113

By-Laws in general

1. Copy of policy available in all departments and senior in charge of the

department must be well acquainted with the document

2. Smartly dressed, respectful staff at reception area with all theinformation regarding the services available and the personnel

departmental designations.

3. Reception staff should have all the records of the out-patient & in-

patients attendance for visitors facilitation.

4. Strict compliance of visiting hours is mandatory.

5. Visiting of children under 7 years not allowed in the hospitals due to risk

of carrying the infections.

6. Childrens companions are requested to attend properly to visiting

children cautioning them to noisy and unruly behavior of the hospital.

7. No attendants should be allowed with the patients accept the visiting

hours.

8. Display of sign Boards of all facilities at the visible points.

9. More prominently placed FIRE EXIT sign boards

10.Fire drill schedules on weekly/ fortnightly basis

11.Daily round by day/ night supervisors to all departments.

12.Special emphasis on the decoration of the departments, waiting areas

and corridors to create the patient-friendly environment and easy

transfer of the patients.

13.Special emphasis on the cleanliness of the hospital shell is the

responsibility of the departments as well along with the hospital

supervisors.

14.Make a cleanup day as a fun activity.

15.Compliance of Security guards to clearly written instructions for thesafety of the patients, hospital staff and the important assets of the

hospital.

16.Complete awareness of the disturbances in the community surrounding

the hospital and the city in general which can affect the smooth

functioning of the hospital and their corrective measures.


21/113

Departmental By-Laws

1. Duty roaster should be displayed at the soft board provided in the

department

2. Punctuality of duty time and the timely medication to the patients is

appreciated

3. Timely schedule of the Consultants appointment/visits for in-patients

4. Proper documentation of the in-patients regarding medication &

investigations or any scheduled procedure on the patient.

5. Preparation of patient and handing- taking from ER,OR as per requirement

of the procedure.

6. Timely disposal of the patient as per requirement of the medical record

office and billing department.

7. Proper documentation of the services availed by the patients to avoid extra

burden of cost for patients billing.

8. Proper management of all types of inventories and their turnover times

9. Quality assurance in patient care

10.All equipments should carry a tag with clearly written operating and

maintenance instructions

11.All the requisitions for lab, radiology and pharmacy should be online

(Provided the excellent HMIS is available), otherwise on properly designedforms with dispatch and receipt record.

12.Proper waste disposal by the department in collaboration with waste

disposal management department.

13.Requisition of the material according to the P &P of the MM department.

14.Billing of patients services strictly on their actual utilization by the patients.

BY-Laws Directly Related to Patient Care

1. A general consent form, signed by or on behalf of every patient admitted to

the hospital, must be obtained at the time of admission.

2. Documented evidence of such informed consent shall be included in the

patient's medical record.

3. All orders for treatment and medication shall be in writing.


22/113

4. The practitioner's orders must be written clearly, legibly and completely.

Orders which are illegible or improperly written will not be carried out until

rewritten or understood by the nurse.

5. All previous orders are canceled when patients go to surgery.

6. All drugs and medications administered to patients shall be those listed inthe latest edition of Pharmacopoeia and National Formulary.

7. Consultations shall be obtained at the discretion of the attendingpractitioner.

8. The attending practitioner is primarily responsible for requesting

consultation when indicated and for calling in a qualified consultant. He will

provide written authorization to permit another attending practitioner to

attend or examine his patient except in an emergency.

9. In an effort to ensure an environment conducive to the delivery of quality

patient care, it is imperative that both Medical Staff and Hospital Staffconduct themselves in a professional, collaborative manner which is not

abusive or harassing. Any behaviors inconsistent with this goal should be

reported and addressed immediately.

The following behaviors are not acceptable in the workplace which, if exhibited,

will result in disciplinary action:

Breaching patient confidentiality;

Creating a hostile environment (by offensive language or other behavior)for patients, staff or Medical Staff members;

Stealing or other forms of dishonesty;

Threats or intimidation;

Violation of Hospital Business Conduct and Code of Ethics;

Violation of Patient Bill of Rights;

Violation of Sexual Harassment Policy;

Violation of the Drug Free Workplace Policy;

If not exhibited, then liable to disciplinary action


23/113

AIR-CONDITIONING OF HOSPITAL

As all the hospital building cannot be set at the same temperature, it is imperative

to provide the air-conditioning on the priority of services, departmental

requirements. It is considered on the following basis.

i. Less air conditioning is required in corridors which have multiple entry

and exit areas.

ii. Operation theaters, labor rooms, ICU, NICU and other procedure rooms

require constant air- conditioning according to the season or the

departmental requirement.

iii. Radiology department needs different temperature for its equipments.

iv. Pharmacy needs different temperature for the storage of different typesof drugs.

v. Laboratorys needs for air-conditioning should be according to the

performance of test and the desired temperature.

vi. Information department (HMIS) may need different temperature grades

for their electronic equipments to maintain their efficacy.

vii. Conference rooms and training departments are not operative for 24

hours so these departments should have controlled air- conditioning

systemviii. Similarly, consultants clinics air-conditioning should be controlled

according to their operational timings.


24/113

FINANCE DEPARTMENT

Submitted to Dr. Faisal Haq

By

Dr ZahraSana Makarram


25/113

OBJECTIVESFront Office:

To provide appropriate information to the patients and their attendants.

To establish sound public relationship and to keep basic details of patients.

Admission Department:

To admit, or register all individuals when they enter a hospital for tests,

treatment, scheduled surgery or emergency treatment.

To serve the dual functions of getting information required for hospital

records, and giving information, advice, encouragement, and reassurance to

the patient.

Health Information Management System:

Processing the information that results in the data record for each patient

encounter.

Ensuring that the medical record contains the required documentation

(content).

Data processing Department:

To manage the computerized information that is collected from various

departments in the hospital.

To assist surveillance staff by accessing birth defects information that is

stored in computer format.

Accounts Department:

To Keep track of transactions and recording revenue and expenses are

important business processes.

To record, analyze and retrieve critical financial information that can be

used to determine the hospital's financial status and provide reports and

insights needed to make sound financial decisions.


26/113

Department of Treasury (Cash and Credit Management)

To maintain a booth for the purpose of receiving patient payments and

departmental deposits.

To performs daily rounds to collect payments from hospital departments.

To Post departmental charges to hospital patient system on daily basis.

To provide daily reports to Accounting on cash collections.

To Locate and notify customers (who were patients at the hospital) of

delinquent accounts by mail, telephone, or personal visit to solicit payment.

To receive payment and posting amount to patient's account.

To prepare statements if customer fails to respond.

To initiate repossession proceedings or service disconnection.

To keep records of collection and status of accounts.

POLICIES OF FINANCE DEPARTMENT (FD)Finance staff should complete a training program on fraud and abuse issues,

which is designed to ensure compliance with the requirements of anti-fraud

regulations, including, without limitation, adherence to proper coding and

billing procedures.

Payment must be for tangible services.

Any complaints should be followed up.

Where CFOs (Chief Financial Officers), or an external fraud team, undertake

an investigation on behalf of the Hospital, it is the Hospital's policy to

ensure that they are given unrestricted access to all personnel and

documents as required.


27/113

When fraud has been discovered the Director of Finance is also responsible

for ensuring that the appropriate sanctions are taken and that financial

redress is sought. Redress will always be sought where possible.

FD must have written procedures for each position in the Department,detailing the employees' responsibilities.

Employees should maintain the highest standards of professionalism. The

reputation of the Hospital is paramount and officers must not bring it into

disrepute by any of their actions.

All work should be conducted applying proper standards of fairness and

without discrimination in accordance with the current Equal Opportunities

Policy.

Employees should undertake all work with an open mind. Information

obtained should be assessed without preconceptions.

PROCEDURES OF FINANCE DEPARTMENT

FD creates Department policies.

The Finance Department advises the CEO (Chief Executive Officer) on

financial policy and long-range planning.

FD provides financial counseling and assistance to patients.

Thefinancial managementteam support managers within the Hospital,

providing reports and analysis on expenditure and income throughout the

year, setting budgets and providing financial information and support.

Corporately, the team provide Hospital wide reports on the financial

performance of the hospital to the senior management team and theHospital Board.

Thefinancial accountsteam manages the hospitals cash, and deals with the

payment of creditors, collection of income, internal controls and production

of statutory accounts. The section also manages the hospitals charitable


28/113

funds and undertakes the administration relating to the private patient and

overseas patients work done in the hospital.

The sales ledgerteam section ensures that the income due to the Hospital is

received. The initial stage is the production of an invoice, and then creditcontrol procedures are instigated if the debt is not paid within the agreed

timescales.

The accounts payable team is responsible for ensuring that the invoices that

the Hospital receives are entered onto the finance system. Invoice payment

is processed within this department, together with any supplier enquiries.

The general office is the public face of the Finance Department. The office

itself is the point of contact for patients travel claims and property, as wellas providing services to staff.

Theperformance managementteam assists in negotiation, pricing and

monitoring of the Hospital's contracts. They also produce reference costs

for the Hospital, which identifies the Hospital's costs for all procedures

performed in the previous year.

A member of the Finance Department sits on every planning board; this

affords the Department a great opportunity to infuse the financial

perspective into every operation.

HOSPITAL'S ANTI-FRAUD BYLAWS

Separation of duties. No employee should be responsible for both

recording and processing a transaction.

Access controls. Access to physical and financial assets and information, as

well as accounting systems, should be restricted to authorized employees.

Register accountability. Only a few employees should be assigned to one

register simultaneously, and only one at a time if possible.

All employees should log in their employee number when entering a

transaction.


29/113

Tracking cash variances. All cash overages and shortages should be posted

so trends can be determined. If no patterns are apparent, a shotgun

shortage exists, and a manager or head clerk with access to all registers may

be responsible.

Bad debts, where appropriate, must be written off after being approved by

the CEO.

General journals should be sequentially numbered, supported by narration

and proper authorization

Local Counter Fraud Specialist (LCFS), whom staff may contact confidentially

if they suspect a fraudulent act. The LCFS will be responsible for liaising with

the Human Resources Directorate, on behalf of the Director of Finance,when an investigation into suspected fraud commences. This is to ensure

that existing Hospital policies and procedures in relation to disciplinary

matters are followed.

The Director of Finance and the LCFS are responsible for investigating

suspected frauds in line with the operational directions included within the

Fraud and Corruption Manual

Hospital will use patients' personal health information to monitor or

prevent fraud or any unauthorized receipt of services or benefits.

Different types of sanction can be applied to a proven case of fraud,

including criminal, civil and disciplinary action. Sanctions will always be

taken where fraud is proven. Where fraud is proven this will be reported

internally within the Hospital so as to raise the awareness of fraud and to

assist in the attempts to deter fraud

Employees must follow fraud and abuse avoidance programme, encoded in

Fraud and Corruption Manual. Access to the Fraud and Corruption Manual is

restricted to the Director of Finance and the LCFS, so as to prevent staff

from knowing how to commit fraud.


30/113

DEPARTMENTAL WORK FLOW


31/113

INTERDEPARTMENTAL HIERARCHY


32/113

STAFFING

S.No Hierarchal Level No. ofStaff

01. Departmental Heads 03

02. Managers 06

03. Supervisors 04

04. Clerks Admission Clerks

(4+3+2) Front Office Clerks

(3+2+2) Account Clerks (6) Cashiers (3+2+1) Recovery Team Staff

(6) HMIS Clerks (4) Data Processing

Clerks (4+2+2)

46

Working Shifts:

1st

Shift: 08:00am - 04:15pm

2nd

Shift: 04:00pm - 2:15am

3rd Shift: 12:00am - 08:15am

Office Closing Time:

Daily

1:00pm -2:00pm (lunch break)


33/113

SOURCES OF REVENUE (FUNDING) Operating Revenue: delivery of patient care

Gross Patient Service Revenue (GPSR)

Net Patient Service Revenue (NPSR)

Other Operating Revenue: non patient care activities

Cafeteria sales

Gift shop sales

Parking garage fees

Space or equipment rentals

Research grants

Gains/Losses: peripheral business activities.

Investment Income (marketable securities or donations).

Unrestricted Donations.

HOSPITAL BUDGETING

Types of Budgeting

5 types of hospital budgets:

Expense Budget

Revenue Budget

Operating Budget

Capital Budget

Cash Budget


34/113

Expense Budgeting

The expense budget is the amount of money each department expects to

payout.

These expenses include salaries, supplies, and other various expenses.

There is the monetary resource departments must stay within.

Revenue Budgeting

The revenue budget is a forecast of the income a hospital expects to receive

for the budget period.

The preparation of the revenue budget entails the projection of patientservice revenues, other operating revenues and non-operating revenues.

Total patient service revenues are calculated by multiplying the expected

service volume in each revenue center by the charge per unit of service.

Finance department needs to decide what percentage of price increase will

be needed to produce the desired "bottom line".

Non-operating revenues are included contributions and interest from

investments.

Contributions are sometimes difficult to project while interest on

investments is an important part of the non-operating revenues.

Operating Budget

The operating budget is composed of the expense budget and revenue

budget.

It lists, for the upcoming fiscal year, anticipated income by source, and

anticipated expenses by natural classification such as salaries, supplies, and

utilities.


35/113

Administration always pursues a larger revenue budget than expense

budget, therefore projecting a profit on the bottom line.

The profit is used to finance the capital budget.

Capital Budgeting

The capital budget summarizes future plans for acquisitions of plant

facilities and equipment.

Hospital determine how much of its' capital plan has to devote to renovate

and to expand the project.

Management also examines the hospital's operating performance and

current financial status to see whether future financing is needed.

Capital budgeting is done in three steps:

Identify capital needs

Regarding financial allocations, prioritize the equipment

Managing capital needs

Cash Budgeting

The petty cash is essential for any business or organization to run its

errands.

Cash flow is reviewed on a monthly basis to enable administration to

foresee cash shortages and seek possible financing if necessary.

The cash flow statements basically indicate the difference in the balance

sheet accounts.

The reader focuses on how the debt is being used. For example, if the

hospital shows operating losses, working capital increases, and increases in

capital expenditures the funds will probably have been generated by long-

term or short-term borrowing.


36/113

The cash flow statement helps determine how debt is being used by the

hospital.

Financial managers make sure that they do not spend too much time on

deciding how to get cash rather than how to invest and manage what theyhave.

Higher interest rates will also generate extra funds.

Budgeting of Finance Department

Departments Required Expense BudgetAllocation of Required

Expense Budget

Front office 15% Salaries 12%Supplies 3%Admitting 17%

Salaries 14%Supplies1%Equipment 2%

Health management

information (HIMS)25%

Salaries 16%Supplies2%Equipment 4%Utility 3%

Data processing 14%Salaries 10%Supplies2%Equipment 2%

Accounting 15% Salaries 13%Supplies 2%Cashier

Credit/Collector15%

Salaries 11%Supplies1%Other Expense 3%

Allocation of Budget by Department

Department Expense Budget Revenue Budget

Governing

board/authority

Salaries

2.7%Supplies

0.3%Subtotal

3%

Subtotal 0%

Medical committee Salaries

4.7%Supplies

0.3%Subtotal

5%

Subtotal 0%


37/113


Finance Salaries

13%Supplies

1%Subtotal

14%

Subtotal 0%

Nursing Equipment 2%

Salaries 9%

Supplies 2%

Medicine 1%

Education 2%

Subtotal 16%

Patient service revenues 47%

Other operating revenues 0%

Subtotal 47%

Support services -

general

administration

Equipment 2%

Salaries 13%

Supplies 2%

Education 2%

Subtotal 19%

Subtotal 0%

Ancillary Depts Equipment 4%

Salaries 9%

Supplies 1%Medicine 2%

Education 2%

Subtotal 18%



Subtotal 20%

Medical Staff

Depts

Equipment 3%

Salaries 13%

Supplies 2%

Medicine 1%

Education 2%

Subtotal 21%



Subtotal 33%


38/113


Marketing Salaries 3%

Supplies 0.5%

Training 0.5%

Subtotal 4%

Subtotal 0%

Total 100 % 100 %

Allocation of Costs between Departments

Department Percentage of costs Sub-departments & percentage of costs

Governing board/authority 3% -

Medical committee 5% -

Finance 14% Data processing 1%

Accounting 2.38%

Admitting 2.38%

Front office 0.15%

Cashier /Credit/Collector 2.38%

Health management information(HIMS) 3.5%

Nursing 16% Nursing education 2%

Inpatient 5%

Central Sterile Supply Department 2%

Operation Room 2%

Outpatient department 3%

Emergency Department 2%

Support services - general

administration

19% Medical Records 4%

Human Resource 5%

Environmental 2%

Maintenance 2%

House Keeping 2%

Social Services 2%

Dietary 2%


39/113

Department Percentage of costs Sub-departments & percentage of costs

Ancillary Depts. 18% Radiology 6%

Pharmacy 4%

Laboratory 8%

Medical Staff Depts. 21% Medicine 7%

Surgery 6%

Obstetrics/Gynecology 5%

House Staff 3%

Marketing 4% Marketing plan 4%

Hospitals Budget Calendar

January 2011Jan 16-22 Budget information & training sessions

February 2011

Feb 8 Top down FY12 Operating Budget forecast and Ten Year Models are

completed

Feb 11 Last day for departments to edit and submit budget requests

Feb 18 Populate Operating Budget tools with historical data

March 2011

March 4Budget Team holds initial meeting

April 2011

April 9 Departments complete submission of Operating Budget revisions

determined during reviews

May 2011

May 1 Hospital completes compilation of budget requests and comparison

to Operating Budget Forecast

June 2011

June 16 CEO approves Budget and departments are notified

August 2011Aug 29 Evaluate budget process and follow-up on recommendations

September 2011

Sept 12 Salary recommendations for management staff are completed


40/113

Medical Department

Prepared by

Komal Daredia

Talat Nur


41/113

Medical Department

Objectives:

1. To diagnose and treat disease or injury for healing, curing or relief2. To educate staff for maintenance of professional standards

3. To conduct research for new medical techniques

4. To provide preventive health care

Policies:

1. To emphasize ambulatory instead of in-patient care

2. To detect diseases as early as possible for optimum recovery

3. To use the least resources consistent with effective care

4. To give patients with common ailment equal consideration

5. To involve patients with medical teaching and research without

discrimination

Programs:

1. General Practitioners Continued Education

2. Community practitioners participation in medical staff seminars and

conferences, doctor rounds and library use.

3. Development of community Health Officers and Medical Assistants

4. Training of patients to live with life term conditions.

Rules:

1. Staff appointments2. Staff engagement in private practice and disciplinary action

3. Confidential nature of medical records information

4. Routine laboratory work needed for patients on admissions

5. Personal use of hospital equipment


42/113

Constraints:

1. Physicians accept a code of conduct respecting human life

2. Medical and Surgical procedure consents (such as for blood transfusions

and interventional procedures)

3. Only registered nurses can receive physicians telephoned orders for

treatment

4. Constraining ethical issues e.g. sterilization

Standards:

1. Regulatory agencies requirement for current membership

2. International standard nomenclature of diseases and operations

3. Standards of staff performance

1. Death rate

2. Average length of patient stay

3. Evaluation of work performance

Environment:

1. Temperature control for scientific equipment

2. Physicians need to work with confidence and a reasonable degree of

freedom

3. Excessive concern on malpractice suits

Physical Facilities:

1. Medical Staff Offices include:

1. Office for Medical Officer

2. Office for Specialists

3. Office for Assistant Administrator


43/113

2. Lounge

1. For medical staff and visiting specialists

3. Conference Room

4. Medical Library

Records:

1. Medical Record Includes:

1. Signed and witnessed consents for medical procedures

2. Administration Record Includes:

1. Staffs completed applications for appointments

2. Professional staff register

3. Minutes and reports of meetings and conferences

4. Medical library card catalogue by subject and matter

Committees:

1. Staff Appointments Committee

1. Reviews applications for staff positions and for annual re-

appointments and make recommendations to Executive Committee

2. Infection Control Committee

1. Implements aseptic measures and remedies deviations from them

2. Responsible for isolation of infectious patients

SWOT Analysis

1. Strengths

1. A diverse pool of qualified specialists

2. Weaknesses

1. High turnover of nursing staff


44/113

3. Opportunities

1. Increased demand of quality care and private sector hospitals

4. Threats

1. Uncertain political conditions of the country


45/113

Organogram

Interdepartmental Hierarchy


46/113

Procedures:

Protocols:

General Guidelines

1. Procedures should be in black and white

2. Should be grouped according to body systems

3. Administration procedures include:

1. Appointment to medical staff, obtaining specialists opinion,

conveying meetings, arranging conferences, withdrawing library

books

4. Each procedure may include:

1. Equipment/Instruments and material needed, preparation of patient,

place of performing procedure and staff, length of time needed.

Pre-Anesthesia Assessment

1. The pre-anesthetic evaluation is defined as the process of clinical

assessment that precedes the delivery of anesthesia care for surgery and for

non-surgical procedures.

2. Involves the assessment of information from multiple sources e.g. medicalrecords, patient interviews, physical examinations, and findings from

preoperative tests

3. At a minimum, a pre-anesthetic physical examination should include:

1. 1) An airway examination

2. 2) A pulmonary examination to include auscultation of the lungs and

3. 3) A cardiovascular examination

Pre-Anesthesia Assessment

1. Timing

1. Guided by considering combinations of surgical invasiveness and

severity of disease


47/113

Surgical Invasiveness Severity of

Disease

Timing of Evaluation

High surgical invasiveness Any severity of disease Prior to day of surgery

Any surgical invasiveness High severity of disease Prior to day of surgery

Low/Moderate surgical

invasiveness

Low severity of disease On/Before day of

surgery

Informed Consent

1. Informed consent is the process by which a fully informed patient can

participate in choices about his/her health care. It originates from the legaland ethical right the patient has to direct what happens to his/her body and

from the ethical duty of the physician to involve the patient in his/her

health care.

Elements of a full Informed Consent

1. The nature of the decision/procedure

2. Reasonable alternatives to the proposed intervention

3. The relevant risks, benefits, and uncertainties related to eachalternative

4. Assessment of patient understanding

5. The acceptance of the intervention by the patient

What is adequate information?

6. Reasonable physician standard: what would a typical physician say

about this intervention?

7. Reasonable patient standard: what would the average patient need

to know in order to be an informed participant in the decision?

8. Subjective standard: what would this patient need to know and

understand in order to make an informed decision?


48/113

Where is informed consent needed?

9. Surgery, anesthesia, and other invasive procedures

10. For a wide range of decisions, written consent is neither required or

needed e.g. a man contemplating having a prostate-specific antigenscreen for prostate cancer should know the relevant arguments for

and against this screening test, discussed in layman's terms

What happens when a patient cannot give informed consent?

11. A surrogate decision maker consents if patient is determined to be

incapacitated/incompetent to make health care decisions

What is presumed /implied consent?

12. The patient's consent should only be "presumed", rather thanobtained, in emergency situations when the patient is unconscious or

incompetent and no surrogate decision maker is available

While the principle of respect for person obligates you to do your best to

include the patient in the health care decisions that affect his life and body,

the principle of beneficence may require you to act on the patient's behalf

when his life is at stake.

Sterilization & Disinfection


49/113

1. Contamination1. The soiling or pollution of inanimate objects or living material with

harmful, potentially infectious or other unwanted material

2. Decontamination1. A process which removes or destroys contamination so that

infectious agents or other contaminants cannot reach a susceptible

site in sufficient quantities to initiate infection or any other harmful

response

3. Cleaning1. A process which physically removes infectious agents and the organic

matter on which they thrive but does not necessarily destroyinfectious agents. Cleaning is an essential prerequisite to ensure

effective disinfection or sterilization

4. Disinfection1. A process used to reduce the number of viable infectious agents but

which may not necessarily inactivate some microbial agents, such as

certain viruses and bacterial spores

5. Sterilization1. A process used to render an object free from viable micro-organisms

including viruses and bacterial spores


50/113

Classification of infection risk associated with the decontamination of

medical devices

Risk Application of item Recommendation

High 1. In close contact with a break in the

skin or mucous membrane

2. Introduced into sterile body areas

Sterilization

Intermediate 1. In contact with mucousmembranes

2. Contaminated with particularly

virulent or readily transmissible

organisms

3. Prior to use on immune-

ocompromised patients

Sterilization/Disinfection

Low 1. In contact with healthy skin

2. Not in contact with patient

Cleaning

1. Devices designated for single-use only must never be re-processed

2. Packaging and dispatch of contaminated items

1. double package the device in appropriate packaging

2. give prior warning to the intended recipient

3. clearly label equipment to indicate that it is contaminated


51/113

3. Receipt of contaminated items in decontamination area

1. Items will be received into the designated dirty items section of the

decontamination area

4. Choice of decontamination method

1. The manufacturers instructions

2. The nature of the contamination

3. the ultimate use of the item

4. the heat, pressure, moisture or chemical tolerance of the item

Safe handling and disposal of sharp items

Type of equipment ________________ Manufacturer _________________

Description of equipment____________________

Other identifying marks _____________________

Model No _______________ Serial No __________________

Fault __________________

Is the item contaminated? Yes* No Don't know

*State type of contamination: blood, body fluids, respired gases, pathological

samples, chemicals (including cytotoxic drugs), radioactive material or any other

hazard: ________________________

Has the item been decontaminated? Yes No Don't know

What method of decontamination has been used? Please provide details

Cleaning ______________________

Disinfection ______________________

Sterilization ______________________

Please explain why the item has not been decontaminated:


52/113

______________________

Procedures

Approximate Time

Procedure Surgery Time Recovery Time

Caesarean Section 30 minutes to an hour 1-2 hours

Laparoscopic

Appendecetomy

45 minutes to an hour 1-2 hours

Laparoscopic Gallbladder

Surgery

An hour 1-2 hours

Cardiac By-pass Surgery 4-5 hours 1-2 days in ICU

Joint Replacement Surgery 3-4 hours 2-3 hours

Staffing Norms

Efficient OR Staffing

Maximize OR Efficiency by minimizing hours of over-utilized OR time1. Under-utilized OR Staff

1. Staffing is planned from 7 AM to 3 PM

2. An ORs last case of the day ends at 1 PM

3. There are 2 hrs of under-utilized OR time

2. Under-utilized time is from 1 PM to 3 PM

3. Over-utilized OR Staff

1. OR staffing is planned from 7 AM to 3 PM

2. ORs last case of the day ends at 6 PM

3. There are 3 hrs of over-utilized OR time

4. Over-utilized OR time is from 3 PM to 6 PM


53/113

VIRTUAL

HOSPITALFRAMEWORK:

NURSING IS..

The use of clinical judgment in the provision of care to enable people to improve,

maintain, or recover health, to cope with health problems, and to achieve the best

ossible quality of life, whatever their disease or disability, until death.(Royal College

Nursing)

We who are nurses are inheritors of a great tradition. It is ours toguard, to strengthen, to enlarge where needed, and to equip ourselves

worthily for so doing. M. Adelaide Nutting (1939)

Nursing is both an art and a science and this is evident in the application of

scientific knowledge and principles, in the assessment of patients' needs, in the

development and implementation of a care plan, and in the evaluation of patient

and family responses.

By ;

Dr Sheikh Sajjad Ali.

10102

Hospital Administration.


54/113

SUMMARIZED HISTORY OF NURSINGNightingale developed and used her coxcomb diagrams, which are credited with

having spawned the use of pie charts, to identify the differences nurses care

made in the lives of British soldiers during the 18541856 Crimean war. However,

what was most unusual and unique was howshe presented her data to demonstrate the number of preventable soldier deaths

before and after the advent of nurses care. Trained nurses, indeed, did make a

quantifiable difference in the lives of the British soldiers.

Accordingly, the death rate of soldiers, resulting from disease and infections,

decreased from 47% before the introduction of trained nurses to 2% after their

arrival (Florence Nightingale Museum, 18541856).

NURSING DEPARTMENT:

We believe nursing is concerned with the wellbeing of the total person.

Through its unique contribution, nursing can and must be an effective

social force in promoting the quality and availability of health care services

for all persons and worth.

OBJECTIVES:

To provide path to nurses to ensure delivering of high quality of nursing

care.

To collaborate with other paramedical staffs to ensure the integrated and

holistic care to the patient.

47

2

-100

-80

-60

-40

-20

0

20

40

60

No Train Nurses Trained Nurses


55/113

To provide assistance to physician to carry procedure as prescribed by

them.

To promote leadership in nursing practice, education, administration, and

research. To establish and implement the philosophy, standards, policies, rules and

procedures for the nursing service.

To ensure appropriate distribution of duties and responsibilities among the

nursing staff at various levels.

To periodically appraise the performance of nurses and carry out regular

nursing audits.

To estimate the requirement for nursing personnel, appointment of

competent nurses and establishes policies and programs for their

orientation, placement, on the job training and supervision.

POLICIES:

To achieve the highest level of individual's health.

To encourage families to participatein the patients care. E.g. hygiene care,

wound care, nutrition etc.

To accommodate patient with same problem in the same areas.

To focus on evidence-base practice. To ensure healthy work environment

MISSION:

Partnership with the people to ensure equity, quality, leadership in providing

compassionate focuses on the unique needs of patients and their families.Service commit to:

Treating patients with compassion andrespect for their human dignity,individual valuesand religious beliefs.

Being responsive to the customer's needs while making decisions that arebased upon sound,ethical business principles andpractices.


56/113

Caring equally for all without regard to race, color, national origin, disability,age, religion, sex or any other basis prohibited by law.

The provision ofemergency services to the people of our community regardlessof their ability

to pay.

Working together interdependentlyto serve our clients better

Continuing Education

VIRTUAL HOSPITAL believes that continuing education for all staff is essential to

our future.

A minimum oft 0.7 Continuing Education Units (CEUs) are required (7 contact hours)

annually. One tenth of a CEU equals one hour of education. One contact hour equals

one hour of education.A maximum of ten contact hours related to formal credits are allowed.

Purpose of the Bylaws

Bylaws provide for the governance of the professional nursing staff of

VIRTUAL HOSPITAL, a framework for its operation, and are reflective of the peer

review process. These Bylaws describe the staff and the responsibility of the

professional staff within a shared governance model. The professional nursing

staff is a component of VIRTUAL HOSPITAL, and not a separate legal entity or

organization.


57/113

Description of Nursing Services :Nursing services are provided through the followingdepartments:

Birthing CenterProvides a family-centered approach to the birthing

process through labor,delivery, post-partum, and nursery care. Cardiac RehabilitationA supervised outpatient program that includesexercise, life-style

changes, education and emotional support for people who have had acardiac event. Thisprogram is medically supervised and individually designed to enhancethe patients quality oflife.

Clinic Serviceso Family Practice Clinics - Provides preventive health services,counseling, well person

check-ups and many other services .o General Surgery Clinic - Provides a variety of surgical procedures .o Women's Clinic - Provides obstetric, gynecology and urogynecologyservices.

EducationEvaluates the organization's training needs and develops andfacilitates programs

for staff training and competency assessment to support quality andpositive patient and serviceoutcomes.

Emergency DepartmentProvides Level IV trauma care in twotrauma beds and four

emergency treatment rooms. The emergency department is staffedwith specially educatedregistered nurses 24 hours a day. Emergency physicians provide 24 hourin-house coverage.

Home and Community HealthProvides quality, comprehensive in-homehealth services that

are designed to decrease the need for institutional care and help promotepatient independence,serving a 33 mile radius surrounding Waverly. Community healthservices, including flu and pneumonia clinics, blood pressurescreening, adult hepatitis B immunizations, tobacco cessation and

prevention programs. Infection Prevention/Occupational Health/Employee HealthInfectioncontrol is responsible

for establishing WHC policy and providing education on prevention ofinfections in staff,visitors, and patients.


58/113

To evaluate the Performance:

The following process as developed by the members of the Nursing Performance

Improvement Council and adopted by the staff defines the process of

performance evaluation as PEACHS.

P= Problem IdentificationE= Establish PI Steps

A= Apply the Change

C= Check the Change

H= Have the Process Revised

S= Status Check

Meeting Times:

Nursing councils shall meet monthly and function consistent with By-laws.

Minutes will be taken, duly recorded and distributed to the nursing staff. Meeting

times and length will be specifically approved by the majority of the Council

members present.

NURSING EDUCATION:

Provide both the foundation of general education and a nursing curriculum

that emphasizes the knowledge, skills and values.

Faculty and students establish a partnership wherein the faculty provides

diverse learning opportunities and the student accepts responsibility for

their own learning.

Systems comprise the structure:

Student System: accept responsibility for their own learning

Nurse System: when implementing safe, effective patient care within

various roles.

Health Care System: Safe, quality health care is attained and continuously

improved utilizing the expertise of health


59/113

PROGRAM:

Infection Control

Grievance

Medication Basic Life Support

Vital signs

Operation Theater (Patient handing over and receiving)

ROTA/ ROTATION

Orientation

Infection control:

The highest incidence HAI is observed amongst invasive procedures.CDC, 2 Millions pts in US developed HAI.

90k pts died.

4th leading cause of death in US.

Cost additional $4-5 billions/yr.

Role of Nursing Personnel in prevention of HAI:

Nursing background helps them in there job with infection control. The physician might be more in tune with the disease and its process.

The nurse is more in tune with the hospital policy development &

compliance ,would like to see.

More programs to educate nurses in epidemiology.

Risk Factors for HAI:

Low resistance of patients to infections.

Contact with infectious persons. Invasive procedures/interventions.

Inappropriate antimicrobial usage.

Drug resistance.

Contaminated environment


60/113

High Risk Areas in Hospital:

Nurseries.

ICUs.

Dialysis Units. Organ transplant.

Oncology ward.

OTs(Delivery rooms,Post Op Rooms)

Hospital Infection Control Program

Monitoring:

Microbiological surveillance.

Investigation & Control of outbreaks if any. Monitoring Of anti microbial resistance.

Providing facilities to the hospital staff to maintain good infection control

Educating/training programs for hospital staff.

Provisions for staff health activities.

Written documents outlining the various infection control policies.

Effective Control Measures:

Hospital planning (Riggs pattern wards, isolation room ICU, air lock systems,corridors cleaning, hand washing, natural ventilation)

Administrative Control:

(Rounds, training to nurses, health education, hosp inf. control committee,

people, aseptic techniques, disinfections, antibiotic policy, CSSD, laundry, ICU,

house- keeping)


61/113

Grievance:

is used to describe circumstances where an employee wishes to raise a

matter of concern in connection with his or her employment, including the

application of terms and conditions of service.Common issues which may give rise to a grievance (not intended to

constitute an exhaustive list) include; a decision taken by your manager,

terms and conditions of employment, health and safety, new working

practices, organizational change and equal opportunities.

Stage 1 - Informal - Let the Trust know the nature of your grievance .

through a informal conversation or in writing

manager will seek to resolve the grievance informally first .

Stage 2 - The Formal Grievance Process

Normally be done within 14 calendar days of it becoming clear that theissue has not be resolved Informally.

Manager must invite the employee to a meeting to discuss the grievance,

normally be confirmed within 7 working days.

Human Resources representative must be present at this meeting.

Stage 3 - The Right To Appeal

employee believes that their grievance has not been satisfactorily

writing summarizing appeal to the Deputy Director of Human Resources,

within 14 calendar days following the date of the decision letter.

Appeal meeting= not less than 7 days.

Medication:

Only RNs and Physicians are allowed.

Strict action would be taken if uncertified personnel will attempt to

administer drugs to patient.

Basic Life Support: (BLS).

Life saving technique.

Every new nurse/staff.

Every 3months for 2 days and validity for 2 years.


62/113

ROTATION:

for employees in learning the subtleties of some tasks and thus end up

increasing the physical demandsemployees to be physically able to perform the most difficult tasks

Education and training of workers for new jobs

Orientation:

orientation should include provision of adequate and appropriate informationregarding local procedures and departmental orientation.

staff should be nominated to show the new employeearound the department.Within the first two months of employment, the line manager should meet

with the new appointee to establish their performance objectives, standards

to met, and any training needs .

All new staff should have completed their local orientation checklist .Orientation of ward, policies and procedures, different system , off basic

skills .


63/113

Organogram Of Nursing Department:

Clinical Nurse Manager/ Nurse Lead responsible for an entire

directorate/department (i.e.Surgical,MedicalDiagnostic & Imaging

etc.) least

Modern Matrons is responsible for overseeing all nursing within a

department or directorate.

Healthcare Assistants

Staff Nurses Senior staff nurses

Junior/Deputy Sister; Charge Nurse; Ward Manager

Sister/Charge Nurse; Ward Manager

Senior Sister; Charge Nurse; Senior Ward Manager

CEO

COO

Chief Nurse

Asst.Chief NurseServices.

Coordinator Clinicalareas

Surg/Med/Obs/Gyn

Coordinator Specialareas.

Opd/OR/Minor

Asst.Chief NurseTraining &Research.

CMO

CFO HR
http://en.wikipedia.org/wiki/Surgicalhttp://en.wikipedia.org/wiki/Surgicalhttp://en.wikipedia.org/wiki/Surgicalhttp://en.wikipedia.org/wiki/Medicalhttp://en.wikipedia.org/wiki/Medicalhttp://en.wikipedia.org/w/index.php?title=Diagnostic_%26_Imaging&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Diagnostic_%26_Imaging&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Diagnostic_%26_Imaging&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Diagnostic_%26_Imaging&action=edit&redlink=1http://en.wikipedia.org/wiki/Medicalhttp://en.wikipedia.org/wiki/Surgical


64/113

Non Nursing Duties:

Chief

Nurse

Nurse III

Nurse II

Nurse I

Nurse III

Nurse II

Nurse I

Nurse III

Nurse II

Nurse I

Physicians'secretary

Ward clerk Porter

Billing clerk

Medico-social

worker Pharmacist

Recordkeeper.


65/113

STAFFING:

1. No UNIVERSAL FORMULA which guarantees safe and effective patient care.

2. Unpopular methods include

G.R.A.S.P ----- General responsibility assignment software pattern.P.I.N.I ------ Patient intensity for nursing index.

N.I.S.C.M ----- National info system for Crisis management.

3. Top Down Planning:

Historical Data

Bed occupancy and throughput.

4. Formulae dependant on patient dependency and work load.

Skill Mix:

CSSD:Central Sterile Supply Department

Include processing and sterilization of syringes, rubber goods [catheters,

tubing], surgical instruments, treatment trays and sets, dressings etc

SPECIAL TRAININGCICU/ICU

Ventilator care, Critical carecourses

ADDITIONAL Skills

Special Care Unit ACLS, SCU training

BASIC SKILLS FOR NURSESGeneral wards

I/V cannulation,Medication, BLS


66/113

Advantages

-Quality improvement.-Sustainable process optimization

-Reduction of administrative responsibility

-Assurance about compliance to all relevant norms

(ISO EN )

Operating Room Nurse Objectives

Candidate required for management of surgical procedures during and

after major/minor operations.Checklist to monitor the physical plan of the operating room

Communication lines, both interdepartmentally and interdepartmentally,

to provide for total needs of the patient.

Maintain a record

excellent inter-personal skills

Should have 5 years of experience in this field

Opd Nurse:

An OPD Nurse is one that works in the Out Patient Department of the hospital,

where patients receive diagnoses and/or treatment but do not stay overnight


67/113

EMERGENCY Room Objective:

Working within trauma units, emergency room/critical care units,

evaluating acute responses, providing emergency medical, preparing

patients for stress testing and echocardiography, patient referrals and

managing assessments.Levels Of Care:

Level 1= minimal care

Level 2= intermediate care.

Level 3= total care.

Level 4= specialized care.

SWOT ANALYSIS:

Strengths:Qualified Nursing staff and experienced Nursing managers

Standardized care

Improved quality of care

Improve leadership.

set of documents

Good clinical governance

Existing skills (high level) of some Departmental nursesTake pressure off General Practitioners and Specialists

Weaknesses:

Increase Turn over of staff.

Resources required to educate and supervise Nurse Practitioners

Potential for staff to leave organization after training

Lack of consistent clinical practice (in some specialty areas)

Low ability to retain the professional


68/113

Opportunities: Improve response time

Expand services

Decrease length of stay

Improve links between health professionalsDevelop infrastructure to strengthen nursing health care and increase

efficiency in hospital sector.

Societal changes

Technological development

Challenges:

Competitor Problems.

Lack of knowledge understanding of the Nurse Practitioner role

Funding / cost

Medico legal issues

Workload for candidates

Demographic change

Raising population expectations to health system.

Improvement Nursing through staffing care:

Improvement of technique in nursing care.

Time and work assignment.

Need to increase the number of staff.

Training of auxiliary workers.

Evaluation of performance on individual basis.

Optimum utilization of staff through supervision.

Analysis of task performed by different categories of workers

Shifting Of Nursing Personnel: (Vary in different Hospitals)

Morning Shift 8am 2pm.

Evening Shift 2pm -8pm.

Night Shift 8pm-8am.


69/113

Budget:

Nursing Salary & wages are 68% ofthe nursing direct expense budget.

Nursing Salary & Wages are 15% of the hospital direct expense budget

The Clinical Practice Guideline and Education and Mentoring Working Parties

will provided support for the development of nurse practitioner roles within

existing budgets.

Participation Of Chief Nurse in budget preparation leads to cost consciousness.

-Increase cost effectiveness.

-Efficient use of resources.

Budget primary concern with:

Personnel salaries

Supplies.Equipment outlay.

Capital expenditure.

Factors affecting:

Type of hospital & level of care.

Personnel policies.

Training & research programs.

Authorized bed capacity

Proportion of nursing care1. Turnover rate.

2. Standard of nursing care.

3. Physical layout of hospital

4. Methods of assignments.

Budgeting Staff

Daily FTE required-used to plan daily staffing

Total Patient Care Hours = Daily Hours of Care

365

For 8 hour shifts Daily Hours/8

For 12 hour shifts Daily Hours/12


70/113

PHARMACY DEPARTMENT

Saba Ilyas Qureshi

Roll No: 11071


71/113

What is a Hospital?

Hospital is a complex organization and an institute which provides health to

people through complicated but specialized scientific equipments and a

team of trained medical staff educated in the problems of modern medicalscience

Thus the hospital is a specialized body where the patient care is the focus

point and about which all activities of the hospital revolve

Salient Features of Hospital Pharmacy

Usually found within the premises of the hospital.

Usually stock a larger range of medications, including more specialized andinvestigational medications (medicines that are being studied, but have not

yet been approved), than would be feasible in the community setting.

Provide medications for the hospitalized patients only, and are not retail

establishments.

Does not provide prescription service to the public.

Some hospitals do have retail pharmacies within them which sell over thecounter as well as prescription medications to the public, but these are not

the actual hospital pharmacy.

What does the Pharmacy department do?

Administrative

P & T committee

Hospital Formulary

Educating staff


72/113

Clinical Services / Patient Care

Patient counseling

Poison and drug information

Information Service

Drug Distribution and Control

MM and inventory control

Automated pharmacy services

Quality & Performance Improvement

Pharmacy improvement programs

Medication Safety

Adverse drug reactions (ADR)

Objectives

To provide at all times, medications of the highest standard in appropriate

dosage forms consistent with the needs of the patients in collaboration withthe medical staff;

To rationalize drug utilization and procurement in colla