SMU MBAHCS ASSIGNMENT

SEMESTER III

MB0052

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING

ASSIGNMENT SET: I

SUBMITTED BY:

J.JERALD JEYAPRAKASH
MBAHCS

ROLL NO :- 531010671

SMU- MBA Semester III

Reg. No: 531010671

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INDEX
Q.No QUESTION Page No

Q.1

A. EXPLAIN THE DIFFERENCES BETWEEN FORMAL AND INFORMAL ORGANIZATIONS. B. WHAT ARE THE CHARACTERISTICS OF A HOSPITAL ORGANIZATION?

3 4 5

Q.2 Q.3

EXPLAIN HOSPITAL ADMINISTRATION HANNAH HEALTHCARE IS PLANNING TO OPEN A HOSPITAL IN NORTH BANGALORE REGION. FOR THIS PURPOSE THEY HAVE BROUGHT TOGETHER A TEAM OF EXPERTS. A. WHO ARE THE TEAM OF EXPERTS WHO CONSTITUTE THE HOSPITAL PLANNING? B. WHAT ARE THE PRINCIPLES OF HOSPITAL PLANNING?

10 12 13

Q.4

EXPLAIN THE VARIOUS WARD DESIGNS. EXPLAIN THEM WITH DIAGRAMS.

Q.5

WRITE SHORT NOTES ON: I. II. OPD ACCIDENT AND EMERGENCY SERVICES

20 25 29

Q.6

IF YOU ARE CALLED BE THE INFRASTRUCTURAL CONSULTANT FOR SETTING UP A NICU IN A 5 YEAR OLD MULTISPECIALTY HOSPITAL, WHAT ARE THE PLANNING CONSIDERATIONS OF NICU THAT YOU WOULD PRESENT TO THE MANAGING BOARD?

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Q.1.A) EXPLAIN THE DIFFERENCES BETWEEN FORMAL AND INFORMAL ORGANIZATIONS. Answer Formal organization: A formal organization is one which consists of a group of people working together cooperatively, under authority, towards goals that mutually benefit the participants and the organization. In this system, well defined jobs bearing a clear measure of authority,responsibility and accountability are found. Formal organizations have an intentional structure of roles in a formally organized enterprise. The structure must be flexible; there should be room for discretion, for advantageous utilization of creative talents, and for recognition of individual likes and capacities. The Structure should be organized in such a manner that the people involved and the resources are able to accomplish the purpose for which the organization was set up. That is why it is very important for a healthcare organization to set its organization structure based on its objectives. Hospitals however may share some of their objectives, but, there may be objectives that are unique to a particular organization only. The spectrum of objectives determines the organization structure, its scope and volume of activities, the required departments and their sizes, staff requirement, etc. Informal Organizations: Chester Barnard, author of The functions of executive, described informal organization as any joint personal activity without conscious joint purpose, even though contributing to joint results. Keith Davis of Arizona State University described the informal organization as a network of personal and social relations not established or required by the formal organization but

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arising spontaneously as people associate with one another. Thus in informal organizations, relationship that does not appear on an organizational chart, might include the machineshop group; the sixthfloor crowd; the Friday evening bowling gang; the morning coffee or tea club members etc. Both formal and informal types are found in organizations. Table 1.1: Formal Organization Vs Informal Organization Characteristics
Origin Goal Structure Integrating mechanisms Communication channels

Formal Organization
Deliberately created Reflects organizational goals Has definite hierarchy Held together by rules, regulations and procedures Formal official channels of communication

Informal Organization
Formed spontaneously Individual and group goals Structure less No rules, held together by feelings of friendship, mutual help and trust No defined communication channels

Q.1.B) WHAT ARE THE CHARACTERISTICS OF A HOSPITAL ORGANIZATION? Answer Characteristics of Hospital Organization Every organization has a head. In every organization there should be a clear line of authority for every individual. In a hospital, there are dual lines of authority. The Administrators are responsible for solving management problems while Doctors are involved in patient care. Hospitals are characterized by having wide diversity of objectives and goals for different personnel, professional groups and subsystems. For example: The house keeping department works towards maintaining cleanliness and sanitation, the clinical team focus on patient care, the Administration team works on problem solving and hospital betterment, the marketing team works towards brand building and better marketing of services.

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The hospital is in continuous operation which requires high operating costs and substantial personnel and scheduling problems. The diversity of personnel ranges from highly skilled and educated administrators and doctors to unskilled and uneducated employees like the staff involved in sanitary functions.

The hospital organization is characterized by interdependence. Every person involved in patient care is dependent on other departments or individuals in order to accomplish their tasks or fulfill their responsibilities. For example: An orthopedic surgeon cannot perform an orthopedic surgery without the findings from the radiology department and the assistance of the nurses and technicians. Hospitals deal with problems of life and death. This has psychological and physical stress on personnel at all levels in the hierarchy. Measuring the quality of product (healthy and satisfied patient) is a problem because patient care delivered has no precise measurement. Hospitals provide services. Unlike the production industry where productivity and quality may be easily defined, hospitals productivity and quality cannot be quantified easily. Hospitals should always comply by the medical ethics. (eg: patient confidentiality). Q2. EXPLAIN HOSPITAL ADMINISTRATION Answer Hospital Administration What is hospital administration? Hospital administration is the management of the hospital business. Hospital administration is made up of many healthcare managers and executives who take care of individual departments.

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They are in charge of all the administrative or management functions of their respective departments. These various managers or assistant administrators will report to the Hospital Administrator. Need for hospital administration: A hospital like any other business entity may function for purposes of profits too. With the burgeoning numbers of private / corporate hospitals, private nursing homes, the need for specialized managers for hospitals become evident. The stiff competition necessitates specialists to handle difficult situations. Well informed decision makers have become a necessity. Gone are the days when a highly skilled physician would also take care of the administrative functions. With the enormous challenges pressing the healthcare industry people with special and specific education are required. Hence, the presence of hospital Administrators is the need of the hour. The primary function of a hospital administrator would be to manage the resources of the hospital. The resources of a hospital are: people, methods, measurements, materials, machinery and equipment, money, time and information. Some of these resources may be scarce, like the availability of specialist doctors, or nurses, availability of diagnostic equipment, etc. A hospital organization may seem a lot like any other organization. It has many business features common to that of other businesses; however, there are certain qualities in a hospital that make it unique. These unique characteristics were already discussed in unit 1. You may read that again. Besides being an interdependent entity, a hospital is an organization of high accountability. The community looks up to the hospital for all of its healthcare needs. Hospitals deal with life and death, making it all the more a sensitive place. Hospitals mostly intervene at the time of greatest mental agony. Its clients are a lot sensitive, therefore every service provided must ensure the utmost care. Hospital Administrators are people who have understood this situation very well.

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They should bear this in mind while taking decisions. Who is a Hospital Administrator? A hospital Administrator is the overall head of the business operation and managerial functions in the hospital. The Hospital Administrator is vested with the responsibility of running the hospital operations. He / she acts as a liaison between the Governing Board, medical staff and other management staff. They play a major role along with the Governing Board in making the hospital policies. They take up human resources function also such as, recruiting, staffing, evaluation, etc. They have an active participation in the hospitals public relations. He / she is also responsible for contributions during budgeting and allocation of resources. They are involved constantly in training programs that would enhance their managerial skills and helps them to know new management trends and techniques enabling them to be on the edge. The Administrators role is very crucial in the effective and efficient running of a hospital. Roles and functions of a Hospital Administrator: Hospital Administrator is the chief executive in the hospital. A hospital may have a number of executives in various departments to handle the administrative or managerial functions. All these executives are accountable to the Hospital Administrator. Figure 2.3 represents the various major duties of the Hospital Administrator. The major functions of the Hospital Administrator are enlisted below: Functions of the Hospital Administrator: 1. Acts as a legal representative of the Hospital. The Hospital Administrator is responsible to ensure whether the hospital is complying with the government rules and whether all the statutory requirements are met. 2. Is a part of the Governing Board. He / she has the responsibility of supervising all the activities in the hospital

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3. Should ensure that all staff is aware of the hospitals mission, vision and objectives. He /she is instrumental in getting information on mission, vision and objectives down to all the staff. 4. Implements all the management decisions in the hospital 5. Formulates major rules, regulations and procedures and ensures their implementation 6. Ensures that the rules formulated are in line with the hospitals policies 7. Coordinates and participates in devising short term and long term plans for the hospital 8. Submits annual reports to the Governing Body 9. Ensures financial viability of the hospital 10. Acts as a link in between the management and the employees. Therefore participates in deciding the salary structure, benefits, etc. 11. Is responsible for a good employer employee relations 12. Works closely with other important executives in the hospital such as the Medical Superintendent, nursing Superintendent, etc. 13. Ensures that all the departments function smoothly and efficiently. 14. Is responsible for outsourcing services, contracts, hiring, etc. 15. Acts as an official representative of the hospital 16. Maintains contacts with the government, community and media.

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Fig. 2.3: Duties of a Hospital Administrator

Needs Assessment of the organisation / Clients Contributes to devising annual budgets Duties of Hospital Administrator Ensure complience with law,rules,regul ations,ethics Formulation of policies and implementati on Human Resources Function Hospital operations,Pu blic Relations functions

Characteristics of an effective Hospital Administrator: An effective Hospital Administrator should possess all the managerial skills. Besides, he or she should also be outstanding in the following qualities: 1. Should show competence at work 2. Should be sensitive to organizations and staffs problems and needs 3. Should possess the ability to analyze, synthesize and integrate various information

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4. Has the ability to foresee and plan 5. Has the ability to bring forth new and creative ideas 6. Has the ability to coordinate, organize, control and allocate resources 7. Should be able to delegate work and make efficient use of his or her own time 8. Ability to motivate and develop people 9. Should be able to introspect and evaluate 10. Should be an able communicator

Q3. HANNAH HEALTHCARE IS PLANNING TO OPEN A HOSPITAL IN NORTH BANGALORE REGION. FOR THIS PURPOSE THEY HAVE BROUGHT TOGETHER A TEAM OF EXPERTS. A. WHO ARE THE TEAM OF EXPERTS WHO CONSTITUTE THE HOSPITAL PLANNING? B. WHAT ARE THE PRINCIPLES OF HOSPITAL PLANNING? Answer The Hospital Planning Team The hospital planning team should ideally consist of the following members: 1. Hospital Administrator The Administrator is the chairman of the planning team. He is mainly involved in putting up hospital requirements to his team in terms of, facilities for the hospital, design consideration, orientation of interrelated departments and service facilities. He also oversees and coordinates the various activities involved in planning.

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2. Hospital Engineer The engineer appointed to prepare the plan of the hospital should have previous experience in constructing hospitals. He works in close coordination with the administrator and the architect. 3. Hospital Architect The hospital architect should have knowledge of the work flow involved in a hospital setup so as to suggest the design considerations of the hospital. The experience and expertise of the architect and the hospital engineer helps in planning a good hospital. 4. Financial Expert The financial expert helps the administrator to study the feasibility of the project. He can advice on the funds required for the project and the sources available for the same. The estimates given by the finance expert helps in drawing up a smooth plan. 5. Health Statistician The health statistician also contributes to the study of the feasibility of the project. He helps the team by providing vital information on the demographic picture of the region, disease related statistics, socio-economic condition of the people, all of which helps the administrator in deciding the type of facilities required and charges to be levied. 6. Representatives of government or local bodies The representatives of the government or local bodies help in the coordination of the project. They form a link between the community and the hospital 7. Nursing Director/Superintendent The nursing director can give valuable inputs to the project team, especially in ward planning.

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8. Social scientist The social scientist helps in identifying the felt needs and real need of the community. His suggestions during the planning process helps in fulfilling the communitys expectations of the project. 9. Consultant representative from user department The success of everything planned in the hospital depends on whether it is user friendly. It is therefore necessary for the planning team to take into consideration the suggestions of the consultant representative from the user department. The design and functioning should be user friendly. Principles of Hospital Planning High Quality Patient Care: The hospital must be designed, staffed and equipped to meet the stated objectives in addition to providing high quality medical care. There must be a good organizational structure. The quality of patient care delivered should be strictly monitored through continuous review of existing facilities, services offered etc. The hospital should have adequate number of competent staff who would ensure a high quality patient care. The medical staff should be provided continuous medical education that keeps them informed about the latest trends and technology. Community Orientation: The needs of the population should be borne in mind while planning the hospital. The hospital should be located at a convenient and easily accessible location. While outlining the charges for the healthcare facilities, the following factors should be taken into consideration i.e. the population mix, social status, education and earning capacity of the target population. The hospitals Governing Board may have people representatives from the community. The hospital should also involve itself in community outreach programs that might not only promote the hospital services, but will also help in developing goodwill and helps in understanding the needs of the community.

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Economic Viability: The hospital may not be profit making at all times. Hence there should be a sound financial management system in place. The healthcare facility should be able to identify and adopt means to be self sustaining. Any renovation and expansions planned should be done rationally, taking the views of the community into consideration. Sound Architecture: The design adopted in putting up a hospital should consider efficient use of the facility and personnel. Flexibility should be adopted during designing, ensuring proper circulation space for movement of staff, patients, relatives and friends. The space should also accommodate movement of goods and materials used for patient care. Identifying areas prone to infection and adopting infection control measures at preliminary stage of planning contribute to a sound architecture. In short Design should follow function and not vice versa. Design should accommodate and consider future expansion. Disaster planning should be done simultaneously with the planning and design of the hospital structure.

Q.4. EXPLAIN THE VARIOUS WARD DESIGNS. EXPLAIN THEM WITH DIAGRAMS. Answer Design and Layout Size: The size of the wards depends on several factors. It can vary from as low as 10 beds to as high as 90 beds in a single ward. Some of the parameters influencing the design and layout of the wards are: 1. Severity of the patient condition The more the severity, smaller the ward. E.g.: ICU, CCU, T.B Sanatorium etc. 2. Category of the ward General wards has more number of beds than special room or deluxe wards.

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Location: The location of the wards depends on the activities taking place, services rendered, movement of patients, relatives of patients, doctors, nurses, paramedical staff, visitors etc. Example: It is desirable to have the surgical wards close to operation theater and post op; antenatal wards close to labour theater; ICU close to the Accident & Emergency centre etc. Ward Areas: the various areas that need to be included while designing the wards are: Patient space: it includes: Multibed bays, patient rooms Day space: serves as a space for reading, writing, watching TV, etc. Patient relatives area Visitors waiting area Corridor space that would allow movement of man, machines and trolleys, stretchers, etc. Ward Design Nightingale Ward: The nightingale ward is named after Florence Nightingale. This pattern came into existence after the Crimean war during the 19th century. Each ward has a total of 40 beds. Schematic picture of this plan is given below. This arrangement has the following advantages; 1) excellent crossventilation, 2) good lighting, 3) clear and unimpeded view of all patients.

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Fig. 4.1: Nightingale Ward The disadvantages are: 1) No privacy for the patients, 2) Lot of traffic (food cart, patient trolley,ward stock etc) moving through the patient care areas causing inconvenience and disturbance to patients admitted, 3) Nurses/ other staff fatigue factor, due to the distance to be covered for rendering services located in separate areas. Variant Nightingale: To overcome some of the disadvantages faced in the Nightingale pattern, a variant of the same was created. Even in this pattern there are 40 beds. The Variant Nightingale pattern is also called Cruciform Shape. The length of the ward is 26 meters. This concept gave rise to the evolution of having single bed room/double bed room wards. A sketch of this type of layout is illustrated below.

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Fig. 4.2: Variant Nightingale Pattern

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

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

Fig. 4.3: Rigs Design Some of the special features incorporated in this design are as follows: 1. There was a major shift in the earlier concept of spacing of beds. 2. Privacy in general wards was enhanced due to wall partition of 5 ft height. 3. The distance walked by the nurses for rendering service was reduced 4. Patient beds are arranged parallel to the main corridor, in order to reduce traffic disturbances in the ward Some of the other patterns worth mentioning are: Nuffields ward: A lot of research was done on hospital design during 1950s. Nuffields study (1949-1955) deserves special mention. Based on the findings, an experimental ward was constructed. The design is represented below.

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Fig. 4.4: Nuffields Ward

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

Fig. 4.5: Rack Track Design

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

Fig. 4.6: Harness type Ward Other ward types: Courtyard ward: This type of wards makes provisions for natural light and ventilation. This also helps in saving costs and hence contributes towards the hospitals economy.

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Q5. WRITE SHORT NOTES ON: I. OPD II. ACCIDENT AND EMERGENCY SERVICES Answer Out-Patient Department Introduction The outpatient services of the hospital are significant. It is the first point of contact with the hospital. The reputation of the hospital thus, depends on how good the out-patient service is. It is also considered as the window of the hospital. It helps in reducing inpatient admissions and facilitates day care services. This helps the hospital management in reducing managing costs and as for as the patient is concerned, it benefits in terms of convenience and also reduced healthcare expenditure. Objectives: After reading this section you will be able to: Define outpatient facility Explain the importance of outpatient services Illustrate the work flow in the department List the minimum facilities required in the outpatient department. Definition: The outpatient department is a part of the hospital with allotted physical facilities; medical and paramedical staff in sufficient numbers, with regular scheduled hours of work to provide care for patients who are not registered as in-patients.

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Functions: Provides wide range of treatment, diagnostic tests and minor procedures. Eliminates the need for hospital stay/reduction in hospitalization rates. Reduces the cost burden on both hospital and patients. Imparting education to professional staff and patients. Benefits medical students, physicians and other healthcare professionals in terms of diversified clinical experience. Importance of Outpatient department: The outpatient department is the first point of contact with the hospital. Forms an entry point into the healthcare delivery system. Inseparable link in the hierarchical chain of healthcare facilities. Stepping stone for health promotion and disease prevention. Contributes to the reduction in mortality and morbidity rates. Reduces the number of admissions (IP), conserving hospital bed Filters the inpatient admissions, ensuring admission to patients who necessarily require it. Outpatients: Outpatients are those persons who are given diagnostic, therapeutic or preventive services through the hospitals facilities, who have not registered themselves as inpatients the hospital. Categories of outpatients: 1. Emergency outpatient: Emergency care is given in case of sudden severe illness or accident

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Emergency can be from the patient point of view or from the physicians point of view 2. Referred outpatient: Generally referred from outside hospitals or general physician For specific investigations or minor procedures 3. General outpatient: Usually form the bulk of the outpatient attendance For follow-up care rendered by the consultants in the hospital. Source of origin of OP cases: The various sources of outpatient case can be listed as Direct walk in patients to the hospital Referred case from outside hospitals, local doctors etc. Attendance in casualty on an emergency basis Follow-up cases or repeat visits

Flow pattern of work: Reception and enquiry i.e. first point of contact in the hospital Registration Moves to sub-waiting area Visits the doctor at OPD Subjected to number of clinical investigations Patient sent home based on clinical findings Patient is admitted (if required) for further evaluation and treatment.

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

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preventive and promotive care should be provided along with curative care. In short, better services attract more patients. The demand for outpatient services depends on number of factors like, expenses to the patient; distance to reach the OPD; transportation facilities available; socioeconomic status of the target population; degree of urbanization in the population and quality of care provided at the hospital. Planning considerations: At the time of planning the outpatient department, the following points are worthy of consideration 1. Range of outpatient services to be provided; defining the functions. 2. Number of staff required by rank and the tasks to be performed by them. 3. Possible service time per patient, depending on daily and hourly capacity. 4. Flow of patients 5. Requirement of furniture and equipment 6. Layout of the department. Facilities available at OPD: 1. Public areas and administration o o o o o o o o Trolley bay Reception and Help desk Registration counter Lobby and waiting lounge Toilet and drinking water facilities Public telephone Coffee shop, gift/flower shop Bank extension counter

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o Security out post and fire alarms

2. Clinical facilities o o o o o o o o o o o o o o General examination rooms Special examination rooms i.e. for ENT, EYE, etc. Treatment/procedure rooms Nursing station Injection room Laboratory and sample collection area Pharmacy outlet Radiology services Common problems encountered by patients at the OPD: Long waiting time to consult the doctor Non availability of lab investigation reports on time Interruptions during patient consultations because of telephone calls to doctors Poor designing of facilities Breaking the queue in the appointment system

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Q5. WRITE SHORT NOTES ON: II. ACCIDENT AND EMERGENCY SERVICES

Answer

Accident and Emergency Services

Introduction: The emergency department has become a key point in patient care in the healthcare delivery system, serving the market that demands modern, efficient facilities, trained staff and state-of-art healthcare. The volume of patients seeking routine care in emergency departments has grown considerably, since there is a large pool of mobile citizens who have no family physicians. Furthermore, the emergency department remains one of the few places where provision of healthcare unequivocally takes precedence over financial and legal considerations. Round the clock availability of services is another aspect that is characteristic of emergency departments. The emergency department is required to render a comprehensive range of services right from the elementary first-aid and general outpatient services to sophisticated management of surgical and medical emergencies and full-scale trauma care. This service, like OPD has a lot of public impact and as a result helps strengthen the image of the hospital. Maintaining a 24-hour service with its high fixed costs and periods of low utilization can be costly. A well designed and efficiently managed emergency department is an important source of revenue to the hospital. It can be noted that patients in emergency use diagnostic and supportive services of the hospital to a considerable extent and this brings in a lot of revenue.

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Objectives: At the end of this section you will be able to: Define accident and emergency service Describe the phases of emergency medical care Explain the importance of accident and emergency services Identify the planning considerations of an emergency unit Factors contributing to increased demand: Rapid urbanization and industrialization Increased diagnostic facilities in the hospital Team approach to medical care Medico-legal cases not attended by general practioner Increased recognition of the hospital as a place of healing

Definition: A patient who requires immediate treatment, which if not given would mean loss of life/limb or result in any other disability. An emergency as understood by the patient and his relatives is any illness/injury for which patient requires/desires immediate attention of the physician. Phases of emergency medical care: There are 3 phases of emergency medical care, they are1. Pre-hospital care: Prevention i.e. by public education Detection Establishing communication network Notification i.e. trained technical manpower

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Rescue operation Initial stabilization: The trauma team should reach out to the accident scene quickly as the treatment initiated during the first one hour also called Golden Hour is of importance in clinical outcome in such cases. Transportation to hospitals Continuous advance life support measures enroute the hospital. 2. Emergency department care: The hospital accident and emergency unit is activated from the time the mobile unit arrives at the site of accident till the patient is transferred either to the in-patient area or to another hospital where facilities are available. 3. Hospital care: This refers to general or specialized care received at the hospital in ICU/CCU/Burns/Trauma centre etc. This phase extends up to the rehabilitation stage of the patient. Importance of A & E services: The accident and emergency unit is a very sensitive area in public relations. Its services form the mirror image of the hospital and for some patients, the first point of contact with hospital care. The promptness exhibited in attending to the patients by the healthcare personnel reflects the hospital services. It is often an area for criticism Trauma and cardiovascular diseases are the two leading causes of sudden death. India accounts for nearly 6-8% of total road traffic accidents in the world. Location: The ideal location for the accident and emergency unit would be the ground floor, with direct and easy access for patients and ambulance from the main road. There should be a

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separate entrance to this unit and there should be clearly visible sign boards directing towards the entrance, with proper lighting (during night).Parking area should be spacious with a drive in for vehicles and transferring of patients from the ambulance comfortably. Other services to be located near the accident and emergency unit is, the admission counter; medical records department; laboratory services; radiology services; blood bank; intensive care unit; operation theater etc. Physical facilities 1. Administrative and public areas: o o o o o o Reception Entrance should be wide enough to move stretcher, trolley Public waiting area with toilet; drinking water; public phone facilities Room for security; police out post; ambulance driver; patient bystanders Office for the night supervisor Coffee shop and snack bar in the vicinity

2. Clinical facilities: o o o o o o o o o Trauma room Examination/treatment room Scrub room Space for triage/observation room Storage space for equipments Room for duty doctors/nurses Patients toilet Soiled linen room; janitors closet Locker room

Categories of staff: The various categories of staff working in the accident and emergency unit include, casualty

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medical officer; consultants on call; nursing staff; attenders and orderlies; receptionist; medicosocial workers; security staff; radiographers; laboratory and ECG technicians on call. The hospital management should ensure that adequate security is provided to the various categories of staff from manhandling, as casualty is a highly sensitive and emotional area. Adequate measures to be taken in providing the staff with personal protective equipment to protect staff against infection. Q6. IF YOU ARE CALLED BE THE INFRASTRUCTURAL CONSULTANT FOR SETTING UP A NICU IN A 5 YEAR OLD MULTISPECIALTY HOSPITAL, WHAT ARE THE PLANNING CONSIDERATIONS OF NICU THAT YOU WOULD PRESENT TO THE MANAGING BOARD? Answer

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

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The idea of having a special intensive care unit for newborns represented a developmentalmilestone in the field of neonatology. The establishment of the first premature infant center at Sara Morris Hospital in Chicago in 1920s marked a new era of concern for the sick newborn. Dr.Louis Gluck established the first newborn center at Grace New Haven Hospital at New Haven,Connecticut in 1960. At the turn of the 20th century, a French physician named Pierre Constant Budin discovered that incubator care was associated with improved survival of premature infants. Martin Couney is credited with advances in incubator design as well as premature feeding techniques. The use of ventilators in infants with respiratory distress began in 1961. Much of what is now known as intensive care, the use of intravascular catheters; blood gas monitoring; arterial pressures; heart rate; temperature monitoring and a myriad of other facets of care were developed as a result of research, after the success of assisted ventilation. Objectives: After going through this section you will be able to: o o o o Define a neo-natal intensive care unit Classify the NICU Explain the design considerations of NICU List the policies and procedures followed in NICU

Definition Newborn intensive care is defined as care for medically unstable or critically ill newborns requiring constant nursing, complicated surgical procedures, continual respiratory support, or other intensive interventions. Neonatal Intensive Care Unit (NICU) is a special unit of the hospital set up to provide extraordinary surveillance and support of vital functions and definitive therapy for infants having acute or potentially reversible life threatening impairment of a vital system.

SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

Classification of Neo-natal Intensive Care Unit There is a lack of consistent definition of levels of care in neonatal care units. The advantages of having uniform definition would include the ability to compare outcomes, utilization, and costs among institutions; develop NICU standards; inform the public of NICU capabilities; minimize the perceived need for businesses to develop NICU standards. The proposed levels of care are: Level 1. Newborn Nursery - Can perform neonatal resuscitation at every delivery - Care for healthy term newborns and for infants 35-37 weeks gestation who remain physiologically stable. - Other newborns would be stabilized and transported to a unit with the appropriate higher level of care. Level 2a. Special Care Nursery - Can provide Level 1 care plus can care for infants > 32 weeks gestation and > 1500 grams birth weight. - Have physiologic immaturity (apnea, poor feeding, temperature instability), but not requiring mechanical ventilation or Continuous Positive Airway Pressure (CPAP) - Have medical problems that are anticipated to resolve rapidly and not require urgent subspecialty care - Are convalescing after intensive care. Level 2b. Special Care Nursery - Can provide Level 2a care, and - Can provide mechanical ventilation for brief duration (<24 hours) or CPAP.

SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

Level 3a. Neonatal Intensive Care Unit. Can care for infants > 28 weeks gestation and > 1000 grams birth weight. Can provide sustained life support with conventional mechanical ventilation. May perform minor surgical procedures, such as placement of central venous catheters or repair of inguinal hernias. Level 3b. Neonatal Intensive Care Unit Can provide comprehensive care for infants < 28 weeks gestation and < 1000 grams birth weight. Can provide advanced respiratory support such as high-frequency ventilation or inhaled nitric oxide. Can perform major surgical procedures on neonates (excluding ECMO and repair of complex congenital heart defects requiring cardiopulmonary bypass). Requires prompt and on-site access to a full range of paediatric sub-specialty consultants, as well as paediatric surgeons and anesthetist. Requires availability of advanced imaging support on an urgent basis, including CT, MRI, and echocardiography. Level 3c. Neonatal Intensive Care Unit. Has the capabilities of a level 3b NICU Can provide ECMO and surgical repair of complex congenital heart defects requiring cardiopulmonary bypass. The rationale for this three-tier approach is: A reasonable geographic coverage is ensured. A high throughput for the level III units enables the maintenance of clinical skills.

SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

High levels of bed occupancy in level III units permits efficient use of expensive resources. In our country, 80-85% of all babies need only primary or level I care,15-20% needs level II care and only 5% need level III care. Level II and level III care are woefully inadequate, in both the government and non-government sectors and level I care, though available, is of very poor quality. If newborn care has to improve, all three levels of care have to be well developed and a good referral system should be in place. Neonatal Intensive Care Unit Environment: The environment within the NICU is completely new to the preterm infant, who until the time of birth, has been protected within an intra-uterine environment. Increasing amount of research shows a relationship between the NICU environment and the physiological and neurological development of the infants. An environmentally sensitive unit can enhance growth, shorten the duration of mechanical ventilation, lead to early oral feeding, reduce incidence of complications, shorten hospital stay and reduce hospital costs. Giving birth to a premature or sick infant is not usually the familys expectation, and the intimidating environment of the NICU can provide reassurance to the shock and sense of loss that families feel. Therefore in planning and designing a neonatal unit, the goal should be to provide an environment which is conducive to family-centered developmental care of sick newborns, decreasing stress for the family and the healthcare providers, improving short and long-term outcomes. Physical Facilities and Space Requirements: Core physical requirements include, continuous supply of running water, uninterrupted power supply, central supply of medical gases and suction facilities. Geographic access: Level III neonatal intensive care services should be available within 2 hours by road, under normal traffic conditions for 90 % population in a district.

SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

Location within the hospital: The NICU should be in a distinct area within the health care facility, with controlled access. Movement to other services should not pass through this unit. It should be located close to the labour room and operation theatre, to facilitate prompt transfer of sick and high-risk infants. It is suggested that units receiving babies from other hospitals should have ready access to the hospitals transport receiving area or hospitals ambulance entrance. NICU should be easily accessible from emergency room, laboratories and radiology suite. NICU Unit configuration: Hospitals proposing a level III NICU should propose a unit of at least 15 beds and should have 15 or more level II NICU beds. According to Putsep concept, a 28 bassinet unit might have 3 intensive care spaces (10.7%), 20 intermediate care spaces (71.4 %) and 5 transitional care spaces (17.9 %) for short-term observation. The unit should be in a square area so that open, unencumbered space is available. A split-unit, on either side of the hospital corridor should be avoided for ease of mobility and prevention of infections. The NICU design may range from an open ward to an individual cubicle or room configuration. Open unit configuration offers maximum flexibility for patients, staff, equipment movement and better patient view; individual cubicles design gives less noise and patient movement and reduced cross-infection rate. Size of the unit The size of the unit planned, depends on the number of deliveries in the hospital per year; whether it is a referral maternity center or babies born in other hospitals are admitted. At present the recommendation is that 1.5-2 intensive care beds and 2 special care beds should be provided for every 1000 births (can be modified according to the workload of the unit). Extra provision has to be made for babies in other hospitals.

SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

Infant care space Each infant care space should contain a minimum of 11.2 square meters, excluding sinks and aisles. Intensive care beds may require 14 square meters per infant. An estimated 50 square feet of floor space is needed per patient bed, for intermediate care. There may be an aisle adjacent to each infant care space with a minimum width of 1.2 meters in multiple bedrooms and 2.4 meters in case of single patient rooms or fixed cubicle partitions. This is to facilitate easy movement of all equipment, which may be brought to the babys bedside. In multiple bedrooms, there should be a minimum of 2.4 meters between infant care beds. This is because the provision of less than 8 feet between beds limits the ability of a family to stay at a babys bedside without interfering with staff activities. Each room should have a minimum of one door of width 48 inches, for X-ray equipment. Electrical, Gas supply and Mechanical Needs: Mechanical requirements at each infant care bed, such as electrical and gas outlets, must be organized to ensure safety, easy access and maintenance. There should be a minimum of 20 simultaneously accessible electrical outlets for intensive care infants positioned to maximize access and flexibility. Standard duplex electrical outlets are not suitable, as each outlet may not be simultaneously accessible for oversized equipment plugs. The outlets must be installed at a height of three feet. There should be a mix of AC power supply and UPS for all electrical outlets. At least fifty percent of the outlets should be connected to an uninterrupted power supply. All life support and monitoring equipment should be connected to UPS. In addition, the area needs a special outlet to power portable X-ray machines. The use of adaptors and extension boards should be discouraged. The electrical equipment must be checked, at least once a month for leakage of power supply and grounding adequacy. Voltage supply to the NICU must be stabilized with a voltage stabilizer. Minimum number of accessible gas outlets recommended is: Air; Oxygen; Vacuum; 3 out lets per infant bed. In case of intermediate care infants, two oxygen outlets, two

SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

compressed air outlets and two suction outlets should be provided for each bed. A flow rate of 20 liters per minute, at a pressure of 3.5 to 4.0 bars is satisfactory for oxygen supply. Each vacuum pointshould allow free airflow of 40 liters per minute at vacuum pressure of 500 mm of mercury. The suction outlets should be equipped with a unit alarm to signal loss of vacuum. Installations should be at a height of 3 feet. Airborne Infection Isolation Room(s) It is desirable to have an isolation room for every 6-10 beds. In most of the cases, this is ideally situated within the NICU; but, in some circumstances, utilization of a similar isolation room elsewhere in the hospital (example, in a pediatric ICU) would be suitable. Infants with open sepsis should be cared for by different nursing and resident staff. A work-area for hand washing, gowning and storage of clean and soiled materials, may be provided near the entrance to the room. The room must have a minimum of 150 square feet of clean space, excluding the entry work area. Single and multiple bed configurations are appropriate based on use. Ventilation systems for isolation room(s) should be engineered to have negative air pressure with 100 % air exhaust. There should be a minimum ventilation of 12 air-changes per hour in the isolation room and 10 air-changes per hour in the work-area. The walls, ceiling, floor must be sealed tightly so that air does not infiltrate the environment from outside or from other air spaces. An emergency communication system should be provided within the room and remote monitoring of an isolated infant should be considered. When not used for isolation, these rooms may be utilized for care of noninfectious infants and other clinical purposes. Procedure room A procedure room may be incorporated into the NICU but is preferably sectioned off to reduce patient traffic and to allow better control of techniques such as exchange transfusion, umbilical vessel catheterization. This room should be a minimum of 120 square feet in size, equipped with a hand washing section, oxygen outlet and vacuum outlet and about 4 electrical switches. The ventilation of the room should provide a minimum of 6 airchanges per hour.

SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

Entrance The entrance to the neonatal unit should be planned as a lobby with double doors; an airlock, which allows some control of the airflow within the unit. Corridors in NICU should be at least 1.8 meter wide. Scrub area At least 150 square feet of space at the main entrance, must be assigned as a scrub area with provision for hand-washing, hanging coats, stethoscopes and for leaving footwear. It should have hands-free sinks large enough to contain splashing. Blade handles at the sink should be minimum six inches long. Space must be provided, for donning of protective clothing and a bench to facilitate wearing of over-boots. About ten air-changes per hour are recommended for this area. General support space Storage areas A three level storage system is desirable. The first storage area should be the central supply department of the hospital. The second storage zone is the clean utility area for the storage of supplies frequently used in the care of newborns. It should be adjacent to or within the infant care area. There should be at least 0.22 cubic meters of space for each infant, for secondary storage of syringes, needles, intravenous infusion sets and sterile trays. A medical equipment store should be provided; 1.7 square meters of floor space for equipment storage per infant in intermediate care and 2.8 square meters per infant in intensive care. Easily accessible electrical outlets are desirable in this area for recharging equipment. All supply and medical equipment rooms should have convenient access to at least one sink. A minimum of 4 air-changes per hour are recommended for the clean utility and equipment storage rooms. The third storage zone is for items frequently used at the newborns bedside. There should be shelf space available for placing respirators, monitors, infusion pumps and feeding pumps.

SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

Bedside cabinet storage should be 0.45 cubic meters per infant in intermediate care area and 0.67 cubic meters per infant in intensive care area. Family entry and reception area The NICU should have a clearly identified entrance and reception area for families. Families shall have immediate and direct contact with staff when they arrive at this entrance and reception area. The design of this area should be impressive. Facilitating contacts with staff will also enhance security for infants in the NICU. This area should have storage facilities with a lock for families personal belongings. Floor surfaces Floor surfaces should be such that they can be easily cleaned, should minimize growth of microorganisms and should be highly durable to withstand frequent cleaning and heavy traffic. Floors should be slip resistant. Consideration should also be given to the density of materials used and acoustical properties. Materials suitable to these criteria are resilient sheet flooring (medical grade) and carpeting with an impermeable backing, chemically welded seams with antimicrobial and antistatic properties. Walls and surfaces As with floors, the ease of cleaning, durability and acoustical properties of wall surfaces must be considered. Acceptable materials include scrub paint, vinyl wall covering, vinyl covered sound absorbing panels and sheet materials that have fused joint systems. Walls may also be made of washable glazed tiles. There should be protection at points where contact with movable equipment is likely to occur. Walls must be painted white or slightly off-white to permit prompt detection of jaundice and cyanosis. Glossy finish create glare that is harmful to newborn eyes; matt finish in dark colors absorb too much light, increasing the need for artificial light sources. Doors should be provided with automatic door closers.

SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

Ceiling Ceiling should be cleaned easily and should prohibit the passage of particles from the cavity above the ceiling into the clinical environment. It should either be a monolithic ceiling or have ceiling tiles that are clipped down and washable. It should have a noise reduction coefficient (NRC) of at least 0.903. Standard hospital tiles have a NRC of 0.6519. Ambient temperature and ventilation: The NICU should be designed to provide an air temperature of 22-26oC and a relative humidity of 30-60 %. This is best achieved by air-conditioning with small package units rather than centralized air-conditioning. Portable radiant heater and infrared lamp can be used to provide additional heat to an individual infant. Effective ventilation is essential to reduce nosocomial infections. The most satisfactory ventilation is achieved with laminar airflow. In a vertical type system, the air flows from above downwards and it is recommended for use in NICU. A constant positive air pressure should be maintained, to prevent contaminated air entry from the corridors into the NICU; the vertical flow of filtered air maintains positive pressure of 15 mmHg. Millipore filters (0.5m) or high efficiency particulate aggregate (HEPA) filter may be used (to filter out bacteria). Air delivered to the NICU should be filtered with at least 90 % efficiency. A minimum of 6 air changes per hour is required, with a minimum of 2 air changes from outside air. The ventilation pattern should prevent particulate matter from moving freely in the space; intake and exhaust outlets should be situated as to minimize drafts near infant beds. Fresh air intake should be located at least 25 feet (7.6 meters) from the exhaust outlets of ventilating systems, combustion equipment stacks, plumbing vents, or areas that may collect vehicular exhaust or other noxious fumes.

SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

Noise abatement The noise level in a NICU affects the infants, staff and families. Excessive noise may lead to hearing loss, physiological and behavioral disturbances like sleep disturbances, crying, hypoxia, tachycardia and increased intracranial pressure. Equipment should be selected with a noise criterion (NC) rating of 40 or less. However, once the unit is in operation, much of the transient sound in a nursery is under the control of personnel. Hence, the personnel should devise simple strategies to reduce noise in the nursery (no tapping / writing on incubator hoods, careful closing of incubator doors, soft shoes, etc.). Communication system The NICU should be provided with an intercom system. A direct external telephone is mandatory for parents to inquire about their infants. Infant security The NICU should be designed to minimize the risk of infant abduction. Care should be taken to limit the number of exits and entrances to the unit. Control station / clerical area should be located in close proximity and direct view of the entrance to the newborn area, so that all visitors will have to pass in front of the nursing station to enter the unit. In addition, for security reasons, parent-infant room(s) should be situated within an area of controlled public access. Ancillary services Distinct support space should be provided for respiratory therapy, laboratory, pharmacy, radiology and other ancillary services when these activities are routinely performed in the unit. Satellite facilities may be required to provide these services. Hospitals providing Level III neonatal intensive care services should provide at the site, X-ray and clinical laboratory services capable of performing micro studies. This requirement is essential in order to carry out investigations on blood samples in small quantity from preterm babies in whom,

SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

frequent biochemical investigations are needed, collecting venous blood is difficult and hazardous. Anesthetist should be available. There should also be access to ECG, EEG and blood bank services. Equipment requirements During the last decade, a large number of devices for diagnostic and therapeutic application for the high-risk newborn infants have evolved. The fundamental needs of the unit are availability of adequate space, presence of sufficient number of trained nurses and continuous in-service training. It should be ensured that company supplying the equipment undertakes to train all staff in the unit. Maintenance of existing equipments in proper working condition is more important than acquiring new ones. After expiry of warranty period, yearly maintenance contract must be made for preventive maintenance and emergency repairs. Essential spares must be purchased and kept in stock. Photocopies of working and service manuals should be available in the NICU. Equipments must be charged when not in use. The in-charge nurse should maintain a register with equipment name, company address and contact number, date of installation, warranty period, problems and repairs pertaining to all the equipments, along with record keeping of equipment quality assurance. There should be a budget for purchasing, maintaining, replacing and upgrading of equipments for neonatal care. Equipments needed may be classified into following groups: Supportive systems: incubator, open care systems, transport incubator, infusion pump, phototherapy unit, ventilator, nebulizer. Monitors: The monitors with facility to display, heart rate, respiratory rate, blood pressure, oxygen saturation, Laboratory and imaging equipment

SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

The various equipments in the neonatal unit are listed below Emergency tray( containing Ambu bag and mask, infant laryngoscope, oral airways and tracheal tubes of different sizes, connectors for tracheal tubes, sterile suction catheters, oral mucus suction, emergency drugs like epinephrine 1:10,000, naloxone hydrochloride, sodium bicarbonate, IV fluids and pediatric stethoscope); Bag and mask resuscitator; Suction equipment; Catheters, syringes and needles; Weighing machine; Bassinets; Incubators; Perspex heat shield; Oxygen head box / Oxygen hood; Oxygen analyzer/ambient oxygen monitor; Heart rate monitor; Respiratory rate and apnea monitor; Thermometers; Blood pressure monitor; Invasive blood gas monitoring; Non-invasive blood gas monitoring; Pulse-oximeter; Transcutaneous blood gas monitor; Capnography or End Tidal CO2 (EtCO2) monitor; Multi-channel vital sign monitor; Ventilator; CPAP (Continuous Positive Airway Pressure) apparatus; Infusion pump; Phototherapy unit; Transcutaneous bilirubinometer; Portable X-ray and ultrasound machine; Laboratory equipment; Feeding equipment; extra corporeal membrane oxygenator (ECMO) Discharge policy in a neonatal unit The discharge policy statement is put forward by the first formal statement of the American Academy of Pediatrics on the issue of hospital discharge of the high-risk neonate. It has been developed, on the basis of scientifically derived information. Four categories of high risk neonate are identified: Preterm infant Infant who requires technological support Infant primarily at risk because of family issues

SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

Infant whose irreversible condition will result in an early death. The unique home care issues for each are reviewed within a common framework. Recommendations are given for four areas of readiness for hospital discharge: infant, home care planning, family and home environment, community and health care system. The need for individualized planning and physician judgment is emphasized..