Hosital Supportive Services

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Q. No. 1 What are Public Relations? Discuss its importance in a

hospital and methods to promote good public relations.

Public relations :-

Public relations are the management function which evaluates public

attitudes, identifies attitudes and procedures of an Individual and

organization with the public interest, and executes programmes of action to

carry public understanding and acceptance. In other words, public relations

is simply finding out what people like and doing more of it, finding out what

they do not like about and doing less about it. Public relations is essentially

an effort in understanding and letting understand. It is both an art and

science. Art in the sense that one has to conceive and use creative ideas in

building the bridges of understanding and science to design technologies

which help people to continue understand each other.

"Public Relations is the planned and sustained effort to establish and

maintain goodwill and mutual understanding between an organisation and its

publics" (Institute of Public Relations). The term publics refers to all the

different stakeholders involved (directly or indirectly) with the organisation's

activities.

Thepublic relations department forms the back bone ofcommercial activity

today. Basically it revolves around promotion with the motive of developinggoodwill for an individual or an organization. An organization is related to

internal and external members of the public in various ways. Through Public

Relations, an organization seeks to maintain a mutually beneficial relation

with the concerned parties. The Public Relations department monitors and

evaluates the attitudes of the internal as well as the external public. Just to

make it clear the internal public is the workforce whereas the external public

includes the stakeholders, consumers, suppliers, the government and the

media.

The Public Relations department is a branch of marketing which is ofimmense importance in todays times of intense competition. Timely

communications made by the public relations officer are the key to getting

an organization out of internal crisis. The developing of house journals

which are used in order to maintain contact with the public is also prepared

by the public relations department. The job of the public relations officer is

to ensure that a smooth two way flow of communication is maintained

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amongst the employer organization and its employees. Public relations

officer handle organizational functions such as media, community,

consumer, industry, and governmental relations; political campaigns;

interest-group representation; conflict mediation; and employee and investor

relations. They do more than tell the organizations story. They must

understand the attitudes and concerns of community, consumer, employee,

and public interest groups and establish and maintain cooperative

relationships with them and with representatives from print and broadcast

journalism. The ideal man for the department needs to have excellent

communication skills and an analytical mind. These qualities should be

coupled with patience, resilience, courage and of course excellent

organizational skills as well. The Public Relations courses gear up the

individual with all the requirements for this field.

Importance in Hospital :-

Public relations is an important function to build up corporate image of the

hospitals in the minds of the public and the patients. Therefore proper

attention must be paid to this aspect for greater appreciation of the services

by the community at large.

Almost all the major advances in medical and hospital procedures have

been in the area of physical technique. Till recently, the medical profession

in general and hospitals in particular have given relatively little thought to

the deeper psychological demands of the average adult patient, his relatives

and those who are directly or indirectly concerned with medical care.

Patients, relatives and community usually form a rather permanent

impression of the entire hospital either from their initial contacts which may

be with the Outpatient Department, Accident and Emergency (i.e. Casualty)

or even Enquiry Office. A hospital is often judged by the standard of

efficiency or courtesy offered by these departments. The inpatient area is no

less important but as this is not a first contact point, it gets comparativelyless attention from public relations point of view.

Hospital clientele, today, is aware of its rights and the expectations are

rising. As consumers, the society has absolute and inalienable right to

demand better services. A feeling is growing among the masses that

hospitals are not functioning properly as evident from an increasing number

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of patient complaints. The press and public opinion appears to be largely

against hospitals. Scanning of these reports reveal that the complaints are

mainly:

1. rough behavior of lower category of staff;

2. neglect in patient care by the staff;

3. undue delay in rendering service; and

4. Influence, poor information and guidance system.

Hospital public relations is therefore a deliberate, planned and sustained

effort to establish and maintain mutual understanding and relationship

between the hospital and the community which uses it with the sole

objective of promoting goodwill between these parties.

Good public relations is no substitute for good performance or services.False image cannot be sustained for a long time but at the same time right

policy and good performance do not get automatically appreciated or even

known without effective public relations. Good public relations would

provide , The recognition that in administering a public services an

obligation exists for the service to account not only for what is done but also

for what is not done.

The staff and Public relations:-

Good public relation also depends upon the way the hospital looks after

its employees who are providing the services. Every member of the hospital

staff is a member of the public relations department of the hospital. Either

as an individual or as a body they are responsible for projecting the image of

the hospital. The contribution which can be made by all members of hospital

staff towards sound public relations is often overlooked. A good relationship

among the staff would raise morale, improves efficiency and increase

turnover.

It is also of positive assistance in improving and establishing a hospital's

relations with the public, as they get mixed and communicate with them and

their opinion of the hospital for which they work necessarily bears the stamp

of authority.

Every hospital employee has a responsibility towards gaining the

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confidence of public by discharging his duties efficiently. Every action by

each employee is an art of 'operating trustee' and an irrevocable ingredient of

public relations. However, the major responsibility for carrying forward a

sound public relations programme rests with the highest governing body of

the organization. Public relations responsibilities can be identified as

primary and secondary. Primary responsibility is a combined affair between

the trustee, the administration and the public relations staff concerned

whereas secondary responsibility rests with all other hospital functionaries.

Many authorities over the world feel that the clinicians should also be

involved more actively in total hospital public relations efforts because

they are the viable and visible links with the patients, families and visitors

and hence with the rest of the community.

Press Relations :-

Newspapers require information about patients either as individuals,

patients, events or items of human interest occurring within the hospital or

concerning hospital staff or about developments in medicine or surgery or

any other discipline. Information on these points may be conveyed to the

press by answering direct enquiries made by reporters, holding a press

conference and the handout or press releases.

However Information concerning patients ( except as required by law), as

well as pictures of patients, shall not be released without consent of the

patient, his parent or legal guardian, from whom a signature should be

required on the hospitals publicity consent form.

Methods of Improving Public Relations in Hospitals :-

In attempting to implement a sound public relations programme it must be

appreciated that the process is based upon two way communication. It is

important for the hospital to know what the public is thinking /expecting as

it is for the public to know what it is that the hospital wishes tocommunicate. Thus, it is a continuous process.

While organising public relation programmes it should be remembered that

the patient's needs are of paramount importance in the hospital. A patient has

the right to have the best treatment a hospital is able to give him. He has the

right to be treated as quickly as possible whether in the ward or in outpatient

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department. He has the right to have adequate information about his

condition and his progress. He has the right to expect that details of the

treatment are given to him on his discharge so that his care can be continued

by his local doctor. He has the right to be properly fed, supplied with drugs

and surgical appliances to enable him to be effectively treated for the illness

or injury from which he is suffering.

Surgery and unusual procedures and tests can be especially frightening to

people who have no idea of what the processes entail. Therefore it is

necessary to prepare pamphlets that explain hospital routine. Handbooks that

summarize admitting and discharge procedures and tell about events in

between are often given to relatives of the patient. These Handbooks covers

following points,

1) Admission Information which includes instructions regardingadmission procedure i.e. what patients information is necessary how

much advance to be deposited for admission in respective wards,

room rent per day ect. and presentation of insurance facility they

have.

2) Instructions to patient regarding articles to be brought, and to take

care of jewellary and valuables.

3) Procedure to employ special nurses.

4) Allocated visiting hours, procedure to obtain visitors and attendant

pass.

5) Message to visitors regarding reasons why hour and maximum visitor

limitations are set etc.

6) Hospital policy on tipping and gifts

7) Conditions under which children may visit and the explanations of

reasons for the age restrictions

8) Cafeteria where, when open, available to whom

9) How patient may obtain barber and beauty shop service

and so on..

In addition hospital environment should be such that sympathy andcompassion can be extended to the patients. Twenty four hrs working help

desk must be available to solve patients queries, PRO must take one round

in a day to enquire that the services provided to patient are satisfactory or

not.

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Good Public relations develop and promote understanding and appreciation

of the hospital in the community. Largely, good publicity is an end result of

good public relations, and no amount of newspaper space, radio or television

time in themselves produce sustained community support without adequate,

understanding and sympathetic sevices on the part of the hospital and its

personnel. The quality nursing care, the food service, the efficiency of the

housekeeping service, the general attitude of doctors, the general attitude of

the employees, all play a role in image formation.

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Q. No. 2 Purchase and Management of stores require effective

planning and implementation. Discuss how will you organize this

function in a 300 bedded hospital.

Healthcare is an intensive and a taxing industry wherein a lot of materials

are consumed continuously 24/7. Stores department is the central blood line

of a healthcare setting," Stores management is a significant aspect as it is

required to plan and control the flow of material in the hospital. This would

in turn lead to an efficient system wherein the flow of materials can be

optimised. Moreover non availability of any material can be very critical and

can lead to irreversible damage, delay in treatment with catastrophic results

and also drive costs higher on account of unplanned emergency purchases.

"Poor quality of material in any other industry can lead to rejection of the

product but in a hospital it is very difficult as human lives are involved,"

Store Management is the process of management which co-ordinates,

supervises and executes the tasks associated with the flow of materials to,

through and out of an organisation in an integrated fashion. In a hospital it

helps in procurement of materials at low prices, controls the high rate of

inventory turnover, ensures continuity of supply, maintains the consistence

of quality, minimises the acquisition and storing cost of goods, helps in

lowering the administrative cost and maintaining the supplier relationship. It

also helps in development of new materials and new sources as well as

efficient record keeping and prompt recording of goods and finally in

development of personnel.

The primary role and obligation of the hospital to the community is to

provide efficient patient care at an optimum cost. It is estimated that in any

hospital, about 40% of the total budget is allocated for the purchase and

management of medical and other hospital stores. There is an increase in

demand for health care services both in public as well as private sector in

India, which has caused many managerial problems in existing health care

institutions, and one of the most important is cost reduction and cost control.

Systematic and scientific management of stores are common to all types of

organizations. Hospitals, which are basically service organizations, require a

vide variety of materials ranging from cotton/gauge pieces to life saving

oxygen gas and from low cost needles to high cost sophisticated state of art

medical equipment, which are essential in providing good patient care

leading to greater patient satisfaction. Store is in direct touch with the user

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department in its day-to-day activities. The most important purpose served

by stores is to provide an uninterrupted service to the various user

departments. In the case of a Hospital we can say the Operation Theatre,

Wards, Specialty Clinics, Units, Refraction Departments, Registration,

Admission Departments etc. are the user departments. The successful and

efficient functioning of a department depends mainly upon how best the

materials are supplied by stores department to them. Further stores often

equated directly with money, as materials have money value.

The goal of an efficient hospital supply management is to ensure right

quality is purchased at right time in right quantity at right price and

delivered at right place. HIS, centralised purchasing, better vendor

management and sub stores analysis are helping the hospitals in effective

and planned organization of purchase and store management

1) HIS :-

Installation of HIS is most important for effective stores planning. It really

helps Hospital a lot through its different modules like inventory

management, asset management, financial management and billing

management. The information is directly seen by the concerned departments,

making the system transparent and accessible just-in-time, thereby reducing

delays and the discrepancies and redundancies, which used to exist in the

previous system. "Data reaches within no time and thus providing better and

quick services to patients

The HIS provides continuous monitoring, trend analysis, planning and

inventory control. Online pharmacy module can carry out pharmacy orders,

order scheduling and fulfill prescriptions online from the wards to the

pharmacy stores. HIS are thus necessary precursors for developing an

efficient material management system. Hospital's Stores departments focus

on cost containment, HIS software allows to automate the workflow that

can clog a hospital's materials management department. "It gives hospitals

and the ability to automate materials management workflow resulting in netsavings, improved accuracy and ultimately allows the department to

contribute significant savings to the bottom line,". As Stores departments

work with different vendors via e-commerce platforms they are discovering

how automation can speed and improve communication with vendors over

the internet. It increases efficiency through decreased manpower costs,

decreased risk of pilferage, ability to monitor and thus control costs,

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decreased propensity for stock-outs. Furthermore the cost of transactions

with many vendors can be minimised by automation of these processes. It

also plays a very significant role to improve patient care and safety, drive

down costs and optimise inventory levels. It includes tailored, tactical

hospital inventory management software for operational requirements - a

significant area for cost savings. "Apart form this, HIS helps in providing a

end-to-end hospital supply chain software solution utilising scanning and a

wireless infrastructure to manage materials, costs and charges from

requisitioning to the point-of-care,".

Centralised Purchasing :-

Purchasing means to buy various materials by paying money or its

equivalent from suppliers / vendors. In this process, the materials are bought

and acquired using some standardized specification. The act of purchasing isa fundamental function in the supply cycle. Purchasing is a store

responsibility for the needed materials of the right quality, at the right price,

for the right source, at the right time and at the right place in the most

economical manner. This also includes selection of sources of supply,

finalization of terms of purchase, placement of purchase order, follow up,

maintenance of smooth relation with suppliers, approval of payments of

suppliers, evaluating and rating suppliers.

A central purchasing unit is important aspect of store management. A

centralised purchasing system minimises duplication and wastage, develops

a strong inventory management system, and minimises stock in the hospital

through a detailed consumption analysis of various items to ensure that

redundant items are not reordered. The formation of purchase committee

comprising the Project Head, Medical Director, Materials Head and Chief

Financial Officer helps in order to ensure transparency in purchase.

Similarly, a drug committee comprising a physician, medical director and

general surgeon can review the standard drug list. There can be separate

committees to co-ordinate with other departments, to review the purchase of

consumables, to take care of statutory obligations relating to licenses. "Withproper representation from each department, these committees will help in

knowing the need of each department."

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2) Vendor Management :-

Vendor is one of the most important links in the supply chain management

today as the whole process depends on the material which is supplied by this

vendor. A good understanding of the organisation's mission and vision

should be made very clear to the vendor and accordingly the material should

be evaluated. The vendor must know precisely the quality that the buyer

wants and how to meet those specifications prescribed. "It is absolutely

essential to maintain a cordial relationship with the vendors. We should

enter into a long-term partnership with them. They support us when we need

materials by supplying them in the right quantity at the right time,". Hospital

does a vendor rating analysis every month and score all its vendors on a five

point scale on - quantity, quality, delivery, service, and rating and on this

basis classify its vendors in the A, B, C category. The vendors falling under

the C category every month are given warnings and after repeated warningsif the service does not reflect any improvement then strict actions are

undertaken. "The vendor of healthcare material should be considered as an

extended business partner and not just the supplier of product and services,"

feels Contractor. Vendors should be confident of a business relationship in

which they will be able to synergise with the goal and objectives of the

hospital. Towards this requirement the selection of vendors becomes a very

critical need. "We have a list of approved suppliers and periodically we

update the list by adding new suppliers and deleting the old suppliers whose

performance does not meet with our quality requirement. The suppliers who

supply genuine medicines and surgical items in time, at the best rate are

enlisted and those who fail, their names are deleted or not entertained," As

for the parameters to select the right vendor, most hospital check vendor

registration with their credentials and their financial back up which helps

them to assess the vendors and their standards and genuineness.

3) Managing Stocks :-

Hospital is incurring an expenditure of at least 35-38 per cent of the revenueon their materials. A proper analysis of each location of the hospital is the

pre requisite for any material management. This is generally done on the

basis of tracking usage of various items and depending on the number of

beds, number of admissions and bed turns. This should also include the

forecasting component which is fundamental to the operations of any

business. "Hospital should have a review meeting every three months

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wherein they should check for the consumption of material, compare with

previous years same time period and take inputs of doctors and end users.

Accordingly, they should decide on purchasing a new equipment and

material," Overstocking of material leads to pilferage of material and also on

the cost of procuring, inventorying and storage costs. Generally, the

materials wherein the lead times are high are overstocked. Hospital should

get local suppliers so that the lead times are reduced to a larger extent. Again

it is something like nobody wants inventory but everyone wants service.

So, it should be borne in mind that the primary objective of inventory is to

provide customer service," Further, they can reduce lead times by selecting

local suppliers, informing suppliers of the expected annual demand,

contracting with suppliers for minimum annual purchase, maintaining

multiple suppliers, control access to storage areas, buying on consignment

basis, ordering economic quantities and disposing inactive stocks. Materials

contribute most to the cost of the treatment. Hence, it will be easier for theHospital to improve its bottom-line if material costs are reined in by

achieving efficiency in consumption of materials. . "As a strategy hospital

should also negotiate with vendors to take back non-moving items.

Moreover, hospital should request vendors to maintain sufficient stocks of

fast moving items to be able to supply at a very short notice. Hospital should

emphasis on maintaining optimum stocks, keeping alternative sources in bad

times, situational decisions in emergencies, maintaining buffer stocks and

continuous reviews 'Just in time purchasing' for high costly items and

consignment procurement will be an ideal way of effective store operation

in the healthcare sector.

The materials department has to maintain a fine balance between stocking

materials, so that it is neither over-stocked or vice-versa. "You have to be

extremely careful. It is a challenge for any hospital to adjust the storage of

consumables to avoid lack of material and overstocking because

overstocking leads to likelihood of expired stocks. The materials that are

generally overstocked are emergency medicines and consumables and

materials that are not always readily available. The healthcare industry is a

critical care sector and hence all medicines/ consumables need to beavailable round- the-clock for its smooth functioning. You should be able to

manage the inventory with 'magic numbers.' It should not be less and at the

same time you should not overstock."

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4) Cost Control Measures :-

Apart from all of the above areas, awareness about the cost of material and

its accountability is also very important. There is wide variation in cost ofmaterial and effective management of store is necessary to ensure optimal

use of money spent.

Hospital gives a monthly statement of usage/ consumption of material to

each department head so that they keep a check on the usage of material and

ensure that it is not being wasted. In hospitals the important challenges in

terms of managing the material revolve around rapidly changing technology

in medical equipment and drugs and pharmaceuticals. Inventory control is

concerned with minimizing the total cost of inventory. This involves physical control of materials, preservation of materials, minimization of

obsolescence and damage through timely disposal and efficient handling,

maintenance of stores records, proper location, and stocking. Store is also

responsible for the physical verification of stocks and reconciliation them

with book figures. The inventory ordering quantities, setting stock level,

lead time analysis and reporting. We should choose a best scheme that

makes the cost lowest and the efficiency highest. Cost can be controlled by

Consumption analysis to minimise stock.

Direct purchases from manufacturers. Just in time purchases to manage less stock and appropriate stock.

ABC analysis for proper categorisation and stress on differential

purchase based on volume and value of goods purchased (A=fast

moving goods; B=Medium moving goods; C=slow moving goods);

movement is analysed from the materials in and out status from the

stores department.

More use of generic drugs are entertained for reducing extra cost on

premium drugs. (In concern with the consultants prescribing

medications)

Life cycle costing for equipment and parts.

Quarterly reviews on utilisation of equipment are common features in

hospitals now-a-days.

Direct purchase of equipment from Original Equipment

Manufacturers (OEMs).

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In the internal system, the biggest development is introduction of

Radio frequency Identification (RFID) technology and Bar codes;

which has helped in substantially decreasing the duplications and

wastages.

Converting consumables to reusable commodities as far as possible

(eg, stainless steel trays, laparoscopic instruments).

FSN Analysis- division of hospitals materials into three categories for

better accounting ie F=Fast moving goods; S=slow moving goods and

N=Non moving goods.

VED Analysis-division of hospital goods by their criticality ie V=

Vital Goods; E=Essential goods; D=Desirable goods.

HML Analysis- based on unit cost of items and rate of consumption

and market forces ie H=High cost; M=Medium cost and L=Low cost

items.

SDE Analysis- based on availability of goods in market ie S=Scarcein market; D=Difficult to procure and E=Easy to procure items.

Preference to limited period enquiries over the rate contracts which

normally goes for two years and these give a chance for greater

negotiations and also helps to manage the fluctuating demand. On an

average Limited Period Enquiries saves 20 to 30 per cent on annual

expenditure.

5) Sub Stores Analysis :-

Sub store analysis in each and every area of hospital functioning can workwonders in streamlining the flow of materials by the hub and spoke model

where main store is the major branch head. "Every year you cannot come to

the main stores and collect the material and go to the patient. Therefore, the

utilization of concept of sub store analysis in each and every area of the

hospital wherever it would be convenient to the patient. Here, the sub stores

will work as a branch to the main store," The hospital has around 10 sub

stores in the hospital. There are major sub stores like Cathlab, operation

theatre, ICU and other wards and floors. "This is one innovative strategy

applied which has helped us in process improvement and in materialconsumption control by maintaining material costs and material accounting.

Inventory control is concerned with minimizing the total cost of inventory.

This involves physical control of materials, preservation of materials,

minimization of obsolescence and damage through timely disposal and

efficient handling, maintenance of stores records, proper location, and

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stocking. Store is also responsible for the physical verification of stocks and

reconciliation them with book figures. The inventory ordering quantities,

setting stock level, lead time analysis and reporting. Employee must be

educated as to the proper use of supplies.

In view of the complex nature of the materials management function and its

important contributions to the over all organizational objectives, it is

desirable to compile a policy manual covering all aspects of materials

management. The manual is generally prepared with a note from the

Chairman of the organization emphasing its importance. Such a policy

manual will be circulated to all divisions up to the middle management level

so as to ensure that policies and procedures are consistently followed leading

to the achievement of the corporate objectives. The policy manual

familiarizes the materials management department with the procedure and

guide lines to be observed. Periodical revision of the manual needs to beundertaken to keep it realistic and responsive.

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Q. No. 3 Discuss the importance of house keeping services in a hospital

and their role in improving patient satisfaction.

Housekeeping :-

Every house, whether private or commercial like offices, shops, hotels,

hospitals, clubs, etc., needs to be kept clean and tidy, so that it looks inviting

to all. This is where housekeeping comes in. Cleaning and maintenance

services can be spotted very easily anywhere.

The basic concept of housekeeping has started from keeping a domestic

house clean and has gradually come to maintaining high standards of

cleanliness and maintenance at commercial levels. Besides this,housekeeping should also contribute to the saving in costs of labour,

cleaning material and equipment, furnishings and the like in every type of

establishment.

Housekeeping in simple words means maintaining a house on a daily or long

term basis or looking after its cleanliness, tidiness, upkeep and smooth

running. When you keep your house clean and well maintained, you would

also like to make it as beautiful as possible. How do you make sure that

everything in the house is in usable condition? None of the objects are

broken or chipped and fabrics are not torn. All the fixtures like taps, geysers,

electric wiring, bulbs, tubes, fans, plug points, are in good working

condition, geysers are not leaking, electric wiring is proper and there is no

danger of fire due to short circuiting, and so on. Thus, the different

procedures followed to keep and maintain everything in the house in a good

and presentable order, are collectively known as good housekeeping. In

other words, we may also say that housekeeping is a process of keeping a

place clean, beautiful and well maintained so that it looks and feels pleasant

and inviting to all, either living, visiting or working there. Housekeeper is a

person responsible for keeping the premises clean and well maintained.

Importance in Hospital :-

Bad Housekeeping services is one of the most frequently heard complaints

in a hospital. Attention to patients' personal needs and comforts are as

important as the physician's medication and therefore maintaining a clean

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environment, clean linen is a vital element in providing high-quality medical

care. Also, pleasant employees in a fresh and neat uniform go a long way in

creating a positive image of the hospital.

Control and prevention of hospital infection is one of the most vital

functions of hospital housekeeping, The hospital housekeeping services

comprise of activities related to cleanliness, maintenance of hospital

environment and good sanitation services for keeping the premises free from

pollution. Inadequate cleaning and disinfection will result in health care

institutions becoming reservoirs of large number of microorganisms.

Cleaning must not only be effective in removing dirt but also in maintaining

low levels of microorganisms. Cleaning materials and disinfectants are

essential components in ensuring Quality Assurance in housekeeping

services. Materials of the right quality, quantity and used in the appropriate

specified frequency will not only augment the quality of housekeepingservices but also ensure optimum utilisation of resources. It will also

enhance patient satisfaction.

Good House keeping is an asset, of hospital and Housekeepers, the unsung

heroes of a hospital's wards, are today praised for their role in delivering an

excellent service that helps provide patients with quality care. They have

stepped beyond their cleaning role and are engaging the patients with

professionalism and welcoming hospitality.

"Housekeeping management plays a great role in patient satisfaction,reduces infection rate and operation costs and plays an important role in

physician satisfaction," Housekeeping as "the provision of a clean,

comfortable and safe environment." These things are not just the

responsibility of the housekeeping department, all members of staff should

provide these facilities for there own department.

They play important role in improving patients satisfaction by conducting

their Duties and responsibilities as follows.

The primary activities of the housekeeping department include the routine

cleaning, dusting, mopping, waxing, removal of trash, window and wall

washing and related domestic duties involved in maintaining a high standard

of cleanliness in the hospital. General sanitation, including vemin and rodent

control are among the most important duties.

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Managers in hospital housekeeping may be responsible for scheduling

routine maintenance to the facility's heating, cooling, water and sewage

systems. Skilled workers like plumbers, electricians, carpenters, painters

are needed to do minor repairs. There may be a separate department for

maintenance and engineering work and the housekeeping can coordinate

with it to do these jobs. The housekeeper acts as an inspector for and reports

to engineer about any repairs needed.

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Q. No. 4 Discuss the management of the maternity sevices in a 500

bedded hospital.

Maternity services are essential aspects of health care and should be fully

funded, staffed, supplied, and freely available to every woman regardless of

citizenship or social status. Typically the work consists of providing nursing

care to mothers and babies during their stay.

The mother and baby constitute an integral unit during pregnancy, birth, and

infancy (referred to herein as the MotherBaby) and should be treated as

such, as the care of one significantly impacts the care of the other.

Consideration and respect for every woman should be the foundation of all

maternity care. Care includes antenatal, birthing, and postnatal care forwomen with low-risk pregnancies.

Maternity ward Should be verywell planned and staffed 24 hours a day and

provides specialist care for both ante and post-natal women who have

specific more complex needs, as well as immediate post-operative care.

Labour room is related physically to its own nursing unit/ward, so that the

same staff of midwives should look after the patient through the whole

course of labour, delivery and lying in.

Each pair of delivery room needs a wash up room to soiled articles arranged

in such a way that they can be removed without again entering the delivery

room. All instruments, drapes and dressings should come to the department

in sterilized packs of the central sterile supplies department, a sterilizing

rooms are needed in which the obstetricians and mid-wives can wash and

put on their gowns, caps, masks, and gloves. The labour room should be

homely and furnished to provide well equipped facilities giving a range of

options for labour and normal birth. Rooms must be spacious and including

birthing aids to support active labour and birth. Wall bars to supportsquatting positions, birth mats, birth balls and beanbags are available in each

room. A plumbed in birth pool facility is available for women who wish to

use water for labour and birth. There is a family room which offers facilities

for partners to stay in some circumstances, or where there are sensitive

situations. All birth rooms have ensuite facilities. Epidural services should

be provided for pain relief in labour on both sites, with a designated

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Anaesthetic service, able to provide an Epidural service 24 hours a day,

seven days a week.

A certain number of deliveries call for operative surgery, such as caesarean

section and an operating room must be available for this purpose.

A special unit is needed for the care of premature infants. A separate glass-

walled cubicle is desirable for each infant. Each cubicle should be equipped

with devices for controlling temperature and humidity and each should be

connected to an oxgen supply.

The staff working in maternity units are committed to helping all women to

have a happy and healthy pregnancy and a safe birth of their baby. They

provide care for women and families to help achieve a positive transition to

parenthood. We must aim to support all women to make decisions about

what they want and need from their maternity care. This is done with up todate information about the service and enables an informed choice to be

made about the care that is best for a mother and her baby. The range of

maternity care professionals involved in care includes obstetricians,

midwives, general practitioners, anaesthetists, paediatricians, neonatal

nurses, pathologists, ultrasonographers, social workers, psychologists and

physiotherapists.

Midwives are specially trained to care for women during pregnancy and

birth and they care for women and their babies after birth. They have the

skill to provide this care or to recognise when additional care from a

specialist is needed. Midvives handle uncomplicated deliveries ; Skilled

Obstretrician doctors are always available for additional care also provided

by obstetrician doctors. The role of the general practitioner in the maternity

services is a very important one. He supervise much of the antenatal care of

the expectant mother.

Establishing a caring atmosphere, listening to the mother, encouraging her

self-expression, and respecting her privacy are essential aspects of optimal

maternity care. The care of the newborn babies should be the responsibility

of the paediatrician.

It is necessary to follow the following steps in management of maternity

services,

Optimal MotherBaby maternity services have written policies, implemented

in education and practice, requiring that its health care providers:

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Step 1 Treat every woman with respect and dignity, fully informing and

involving her in decision making about care for herself and her baby in

language that she understands, and providing her the right to informed

consent and refusal.

Step 2 Possess and routinely apply midwifery knowledge and skills that

enhance and optimize the normal physiology of pregnancy, labour, birth,

breastfeeding, and the postpartum period.

Step 3 Inform the mother of the benefits of continuous support during labour

and birth, and affirm her right to receive such support from companions of

her choice, such as fathers, partners, family members, or others. Continuous

support has been shown to reduce the need for intrapartum analgesia,

decrease the rate of operative births and increase mothers satisfaction withtheir birthing experience.

Step 4 Provide drug-free comfort and pain-relief methods during labour,

explaining their benefits for facilitating normal birth and avoiding

unnecessary harm, and showing women (and their companions) how to use

these methods, including touch, holding, massage, labouring in water, and

coping/relaxation techniques. Respect womens preferences and choices.

Step 5Provide specific evidence-based practices proven to be beneficial in

supporting the normal physiology of labour, birth, and the postpartum

period, including:

Allowing labour to unfold at its own pace, while refraining from

interventions based on fixed time limits and utilizing the partogram to keep

track of labour progress;

Offering the mother unrestricted access to food and drink as she wishes

during labour;

Supporting her to walk and move about freely and assisting her to assume

the positions of her choice, including squatting, sitting, and hands-and-

knees, and providing tools supportive of upright positions; Techniques for turning the baby in utero and for vaginal breech delivery;

Facilitating immediate and sustained skin-to-skin MotherBaby contact for

warmth, attachment, breastfeeding initiation, and developmental stimulation,

and ensuring that MotherBaby stay together;

Allowing adequate time for the cord blood to transfer to the baby for the

blood volume, oxygen, and nutrients it provides;

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Ensuring the mothers full access to her ill or premature infant, including

kangaroo care, and supporting the mother to provide her own milk (or other

human milk) to her baby when breastfeeding is not possible.

Step 6 Avoid potentially harmful procedures and practices that have no

scientific support for routine or frequent use in normal labour and birth.

When considered for a specific situation, their use should be supported by

best available evidence that the benefits are likely to outweigh the potential

harms and should be fully discussed with the mother to ensure her informed

consent. These include: Shaving, enema, sweeping of the membranes,

artificial rupture of the membranes, medical induction/ augmentation of

labour, repetitive vaginal exams etc.

Step 7 Implement measures that enhance wellness and prevent emergencies,

illness, and death of MotherBaby: Provide education about and foster access to good nutrition, clean

water, and a clean and safe environment;

Provide education in and access to methods of disease prevention,

including malaria and HIV/AIDS prevention and treatment, and

tetanus toxoid immunization;

Provide education in responsible sexuality, family planning, and

womens reproductive rights, and provide access to family planning

options;

Provide supportive prenatal, intrapartum, postpartum, and newborn

care that addresses the physical and emotional health of

the MotherBaby within the context of family relationships

and community environment.

Step 8 Provide access to evidence-based skilled emergency treatment for

life-threatening complications. Ensure that all maternal and newborn

healthcare providers have adequate and ongoing training in emergency skills

for appropriate and timely treatment of mothers and their newborns.

Step 9 Provide a continuum of collaborative maternal and newborn carewith all relevant health care providers, institutions and organizations.

Include traditional birth attendants and others who attend births out of

hospital in this continuum of care. Specifically, individuals within

institutions, agencies and organizations offering maternity-related services

should:

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Collaborate across disciplinary, cultural, and institutional boundaries to

provide the MotherBaby with the best possible care, recognizing each

others particular competencies and respecting each others points of view;

Foster continuity of care during labour and birth for the MotherBaby from

a small number of caregivers;

Provide consultations and transfers of care in a timely manner to

appropriate institutions and specialists;

Ensure that the mother is aware of and can access available community

services specific to her needs and those of her newborn.

Step 10 Strive to achieve the 10 Steps to Successful Breastfeeding as

described in the WHO/UNICEF Baby-friendly Hospital Initiative:

1. Have a written breastfeeding policy that is routinely communicated to all

health care staff.

2. Train all health care staff in skills necessary to implement the policy.3. Inform all pregnant women about the benefits and management of

breastfeeding.

4. Help mothers initiate breastfeeding within a half-hour of birth. Place

babies in skin-to-skin contact with their mothers immediately following

birth for at least an hour and encourage mothers to recognize when their

babies are ready to breastfeed, offering help if needed.

5. Show mothers how to breastfeed and how to maintain lactation, even if

they should be separated from their infants.

6. Give newborn infants no food or drink other than breastmilk, unless

medically indicated.

7. Practice rooming in-- allow mothers and infants to remain together 24

hours a day.

8. Encourage breastfeeding on demand.

9. Give no artificial teats or pacifiers (also called dummies or soothers) to

breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer

mothers to them on discharge from the hospital or clinic.

The International Mother Baby Childbirth Organization, in collaborationwith other organizations, is developing a companion document detailing the

extensive scientific evidence supporting the 10 Steps of the IMBCI, and will

update both documents over time as needed to reflect the best available

research.

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Q. No. 5 Discuss the importance of medical records. How will you

organize a medical records department? What standard operative

procedures are required for its effective functioning ?

Medical Record :-

A medical record is the chronological documentation of health care and

medical treatment given to a patient by professional members of the health

care team. It is an accurate, prompt recording of their observations including

relevant information about the patient, the patients progress, and the results

of the treatment.

The term 'Medical record' is used both for the physical folder for each

individual patient and for the body of information which comprises the total

of each patient's health history. Medical records are intensely personaldocuments and there are many ethical and legal issues surrounding them

such as the degree of third-party access and appropriate storage and disposal.

Although medical records are traditionally compiled and stored by health

care providers, personal health records maintained by individual patients

have become more popular in recent years. Hospital record is the property of

the hospital or the doctor. It is a confidential information and could not be

released without doctors permission. Any information from the patients

medical records should be released on written request from the patient e.g. to

employer or to insurance company.

Medical record documentation is required to record pertinent facts, findings,

and observations about an individuals health history including the past and

present illnesses, examinations, tests, treatments, and outcome. The medical

record chronologically documents the care of the patient and is an important

element contributing to high quality care. The medical record should be

complete and legible.

Proper documentation facilitates:

The ability of the physician and other health care professionals toevaluate and plan the patients immediate treatment, and to monitor

his/her health care over time.

Communication and continuity of care among the physicians and

other health care professionals involved in the patient care.

Accurate and timely claims review and payment.

Appropriate utilization review and quality of care evaluations.

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Collection of data that may be used for research and education.

An appropriately documented medical record can reduce many of the

hassles associated with claims processing and may serve as a legal

document to verify the care provided, if necessary.

Documentation of each patient encounter should include or provide

reference to:

Chief complaint and/or reason for the encounter.

Relevant history, examination findings and prior diagnostic test

results.

The medical record should be complete and legible.

Each patient encounter should include:

the date ,the reason for the encounter

appropriate history and physical exam

review of lab, x-ray data and other ancillary services

assessment and a plan of care, including discharge plan (if

appropriate)

Past and present diagnoses should be accessible to the treating and/or

consulting physician

Reasons for and results of x-rays, lab tests and other ancillary services

should be documented or included in the medical record

Relevant health risk factors should be identified.

Patients progress, including response to treatment, change intreatment, change in diagnosis, and patient non-compliance should be

documented.

The written plan of care should include, when appropriate:

Treatments and medications, specifying frequency and dosage

Any referrals and consultations

Patient/family education

Specific instructions for follow up

The documentation should support the intensity of the patient

evaluation and/or treatment, including thought processes and thecomplexity of medical decision-making

All entries to the medical record should be dated and authenticated by

the physician/provider signature.

Assessment, clinical impression or diagnosis and plan of care.

Date and legible identity of health care professional.

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The CPT and ICD-9-CM codes reported on the health insurance claim

form or billing statement must be supported by the documentation in

the medical record.

The confidentiality of the medical record should be fully maintained

consistent with the requirements of medical ethics and of law.

Importance of the Medical Records :-

Medical Records is an important document meant basically for recording the

treatment procedure for a patient.Medical record keeping is not only a legal

requirement but also helps in analyzing the medical care ,research base , a

source of back reference in case the patient seeks the care in the same

hospital or the need for review of the disease suffered or medication given is

there in case the patient is taking services in some other healthcare setup

thus forming a continuity of care. It is also covered in the scope of thedepartment to provide appropriate information to external data banks, which

includes the notifiable diseases .The department works closely with all of the

clinical departments admitting patients to the hospital. It is important both

for the patient, as well as, for the doctor. In 1995, after the Honourable

Supreme Court gave the decision that Doctors also come under the purview

of the Consumer Protection Act, 1986 the medical records have become an

important aspect of the written evidence.

It is important for doctors to realize that Medical Records have become thesingle, crucial and effective weapon in their hands to counter the false claims

of the consumers, when they file a case for compensation.

Outpatient treatment and inpatient management should be documented

completely by the consultant. All preoperative instructions, prescriptions and

consent for invasive procedures and surgery should be recorded carefully.

The medical record is necessary for

1. For the consultant himself :

a. Daily notes: Medical Records are the daily orders, which the consultant

has to refer time and again during the course of the treatment until the

patient is completely cured of the disease. Even afterwards it serves as an

important document for further treatment and follow-up.

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b. Operative notes: To consult the operative events and treat the patient

accordingly. To plan for the next operation. To know any anesthesia

problems met with. To plan for the operation of the next eye.

c. Follow up: Even after the treatment part is completed for the follow up of

the patient as and when the patient comes for the treatment. Even more

relevant when the patient is examined by another doctor.

d. Data: The Medical Records are, of course, the most important of all the

documents a patient is having, despite in this age of computerization where

the data is stored in the computers itself the need of the hard copy can not be

ignored.

2. For those consultants who get referrals or who have been attending the

patient at the request of the family or general physicians. :

According to the medical ethics if a patient is to be referred to otherconsultant, the original one (consultant) should

Write down the original history in detail.

His whole of the medication.

What were his findings?

To help the next doctor in reaching to a conclusive diagnosis and further to

treat the patient accordingly.

3. For the nursing staff to carryout the daily instructions regarding the

administration of Medicines.

The staff members get their instructions from them and the frequency of

each of them. They are directed by the orders from the Medical Records.

4. For the Law (For the legal purpose, making the health personnel in charge

responsible for the negligence if anything goes wrong.)

Law requires proper maintenance of case sheets. These are the single most

important document that can be used in medico legal cases. In few cases

these documents may serve as effective alibi for the patients. Law is veryclear regarding the Medical Records and the value of it. But let us first see

the guidelines of the ethics of our medical council.

1. Medical Records are the single most important document to prove the

innocence of the doctor concerned and that the consultant under the medical

ethics are supposed to give the case report to the patient on demand. All the

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details regarding the management of the patient should be documented

correctly in the Medical Records.

2. Accusation of malpractice and unethical code of conduct can be made

against the concerned consultant if he fails to provide the patient with all the

details and the case sheets of his admission, operation and the postoperative

medication along with the dosage. All the prescriptions should have the date

and signature of the physician. Also according to the Consumer Protection

Act, 1986 and its amendment in 1993 which brought the doctors also under

its purview following the landmark decision of the Honourable Supreme

Court, the Medical Records have become very important. Because every

time the patient goes to the consumer forum asking for compensation on the

ground of medical negligence, Medical Records are the crucial documents to

refute the allegations.

Organisation of Medical Records Department :-

One of the most important phases of a hospital's administrative operation is

its medical records department. Carelessness in the operation of this

department may result in medical and financial liability. The mission of the

Medical Record Department is to develop, implement and continually

improve the safe, confidential, systematic & effective method of receiving,

filing, storing, retrieving & discarding the medical record of the patients

admitted for the treatment in accordance to the legal requirements.

Generally for 500 bedded hospital Medical record department should be

centrally situated and must have adequate area for Racks, Shalves and

Cupboards for storage of medical records approximately 1000 to 1200 sq.ft.

Along with chairs tables, registration counter department should be

facilitated with Computers, telephone and intercom for communication.

The Hospital should utilize a single, unified registration system for all

patients, including both in-patients and out-patients. and Master Patient

Index with a single, unique Medical Record Number for each patient. The

utilization of a paper-based and computer-based medical record tracking

system, to facilitate the generation, completion, and filing of medical

records. This system is the central tool for the patient registration process.

The Hospital utilizes a uniform set of forms that comprise a complete

medical record for the duration of a patients care. The documents include at

least the following: front sheet, observation sheets (vital signs record),

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physicians orders, medication administration record, inpatient admission

form, progress notes with lab results and daily progress of care, and

discharge summary.

The proper handling and confidentiality of medical records is ensured.

Implementation of software to ensure folder confidentiality, and the concept

of folder ownership relative to medical departments as well as independence

from hospital organizational changes.

Medical department consists of Medical Record Officer, Medical record

technicians and Assistants. General requirement for 500 bedded hospital is

One Medical Record officer , Four M.R. Technicians and Eight Assistants.

Roles and Responsibilities:

1 .Medical Record Officer

Develop a well organized & streamlined MRD

The organization and development is done by performing the following

duties but not limited to:

Planning, organizing and coordinating Inter and Intradepartmental

tasks.

Supervision of day to day activities of MRD.

Management of court cases relating to medical records.

Complying with statutory compliance.

Develop and implement Electronic Medical Record

Scan all the IP files and store the data in the server.

Maintain zero error in MLC documentation and statutory compliance.

The MLC documents are checked thoroughly from MLC making todischarge / death.

IC 10 coding is done for every patient record.

Quality

To follow SOPs that have been laid down by Healthcare organization.

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Actively participate in meetings, and all academic and research

activities.

Participate in quality improvement activities including audits,

development and implementation of protocols, accreditation

requirements etc. To take part in all department activities meetings.

2 .Medical Record Technician

To maintain medical records both manual & computerized.

To map ICD with Diagnosis.

To generate MIS as an ongoing activity and as & when required for

medico legal requirements.

To maintain privacy & confidentiality of the patient records.

To keep the medical records in the safe custody & complete all thetime.

To make the records available as and when required.

To interact & ensure with other locations for procuring necessary

records.

To check the records for accuracy & completion within defined time-

scales.

To file records systematically with the standard indexing practice.

To follow up with the physicians/ nurses for MR completion on

priority. To initiate & monitor documentation as required by the statute.

To communicate with the government departments/ officials for

medico legal requirement on an ongoing need basis.

3. Medical record Assistants

All the functions carried out by the technician will be under directsupervision of either the medical record officer or senior medical record

technician.

To maintain medical records both manual & computerized.

To map ICD with Diagnosis.

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To generate MIS as an ongoing activity and as & when required for

medico legal requirements.

To maintain privacy & confidentiality of the patient records.

To keep the medical records in the safe custody & complete all the

time. To make the records available as and when required.

To interact & ensure with other locations for procuring necessary

records.

To check the records for accuracy & completion within defined time-

scales.

To file records systematically with the standard indexing practice.

To follow up with the physicians/ nurses for MR completion on

priority.

To initiate & monitor documentation as required by the statute.

To communicate with the government departments/ officials formedico legal requirement on an ongoing need basis.

Standard operative procedures for effective MRD functioning :-

The management of medical records is a challenging task for any healthcare

environment. It helps to have effective and enforced polices, processes and

guidelines on how to handle, write, file and manage a medical record.

Medical records administration personnel conduct quality assurance reviews,evaluate documents in the record, and identify unrecorded diagnoses,

inadequate coding, over or under use of services or resources, inadequate

documentation, and other procedural problems. For the risk management

component of quality assurance, employees identify patient complaints,

other patient incidents, equipment failures, deficiencies in informed consent

agreements, inappropriate record alteration, or other problems which may

increase liability.

Technical and Administrative Functions Performed :- Personnel must have

the medical records management and administrative knowledge and skillsnecessary to perform the following duties:

-- Plan and manage the development and maintenance of a medical records

program.

-- Develop and implement policies and procedures to process medico-legal

documents and insurance and correspondence requests, and to document,

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store, and retrieve medical records information conforming with Federal,

State, and local statutes.

-- Determine the need for and direct the set up of special indices (for

example, treatment, diseases, operations, patients, etc.).

-- Advise management and staff on medical records procedures and

problems and provide solutions to the problems.

-- Advise staff members or research investigators on methods of recording

and retrieving health care data for special studies and perform retrieval of

data for studies.

-- Coordinate with appropriate personnel to manage, supervise, and perform

administrative work to meet procedural, legal, and administrative

requirements concerned with the admission, treatment, transfer, and

discharge of patients.

-- Design, conduct, and test an in-service education program for medical

records employees, medical staff members, students, and other health carepersonnel.

-- Plan, organize, implement, and test a hospital's medical records utilization

review, quality assurance, and risk management programs.

-- Advise in the design, development, and evaluation of automated systems

to meet the changing technological needs for information required to

manage resources.

-- Plan for, justify, test, and advise on the use of computer technology for

collecting health care information, statistical data, and management of a

medical records program.

Medical records administrators have responsibility for making and

implementing administrative decisions directly affecting the care of medical

records programs. Medical records administration specialists must have

considerable knowledge of the specialized principles and practices related to

medical records management to test and make recommendations for

improving the medical records programs. They do not, however, have the

final line decision-making authority; the medical records administrator has

this authority.

Positions with this level of knowledge require skill in applying established

principles, concepts, and techniques of medical records administration to

perform recurring medical records administration assignments of a

procedural and factual nature for which there are standard methods and

practices. This level requires a knowledge of anatomy and physiology and a

practical knowledge of medical procedures and diagnosis. The employee

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uses knowledge of the basic functions, responsibilities, and relationships of

the various areas within the medical records department to assess and co-

relate data and verify information. He or she has a knowledge of statistics to

assess patient workload and establish quality controls.

Hosital Supportive Services

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