Dr.

Ripal Shah Medical Director Indian Red Cross Society, Ahmedabad

Various Hospital Support Services

Support services Auxiliary services Dietary services Engineering maintenance services Hospital security

Hospital
A hospital is a place for the diagnosis & treatment of

human ills & restoration of health & well beings of those temporarily deprived of these. A large no. of professionally and technically skilled people apply their knowledge and skill with the help of complicated equipment and appliance to produce quality care for the patient.

Hospital support services

Laboratory facility CSSD Diet department

Pharmacy
Laundry Radiology

Nursing services

Auxiliary services
Registration & indoor case record (patient file,

medical record, statistics) Stores (Pharmacy store, chemical store, linen store, surgical store, glassware store, narcotic store etc) Transport services (trolley, stretchers, wheel chairs etc.) Mortuary

Dietary services
Important for the nutrition of the patients Different menu available for patients (salt free, sugar

free, fat free, gluten free, protein less, liquid diet, semi solid diet) Different menu for patient attendants (five start menu to suit the palate) Well trained dietician. Must be hygienic

Engineering and maintenance services

Calibration of equipment

Validation of equipment
In house maintenance of equipment Negotiation for purchase

General maintenance (building, plumbing, carpentry,

mason, air conditioning) Vehicular maintenance Boiler maintenance

Water, Medical Gas & Sanitary System

Hospital needs lots of water supply but should rely

on public water supply. Water supply line is concealed and repairing is a complex job; requires expertise. Two components # Water supply network system # Sewage distribution system

Water supply
Sources of water supply

# Bore well # tanker supply # Recycled water While supplying water: # Continuous reliable water supply #Quality of water # Cost & proper distribution

Medical gas system

Gases administered to patients; comprises of O2,

nitrous oxide, vacuum, compressed air. Available in OT, ICU, special room, patient room Clean reliable supply of gases on line Easy purchase of gases in bulk quantities. No nuisances of gas cylinders, breakage Sterile areas protection, point to point conectn Rationalized ordering, storing & transport Minimum damage to building

Safe handling of gases

Experienced & trained person handle gases Observe all regulation & statutory instructions

Do not remove, deface labels of manufacturer

Ascertain gases before putting into services Know properties/ hazards associated of gases

Establish & familiar with emergency situations

Never lift a cylinder with cap or guard

Layout of pharmacy

Lay out of typical laundry

Layout of central sterilization & supply department

Security & loss prevention program (1)

Types of frauds & thefts (embezzlement, pilferage,

kickback & collusion, equipment thefts, personal property theft, payroll fraud, cash theft, fraudulent practices in purchasing, receiving and storing, Fraud in registers records & billing, computer theft) Methods of internal controls Establish procedural security

Security & loss prevention program (2)

Security task of a bomb threat

Alarm system (fire, medical gas, blood bank,

narcotic, cols room & walk-in cooler, voltage fluctuation, elevator, security, patients emergency, code blue alarm) Code blue= cardiac arrest; Code red= fire alarm; Code black= bomb threat; Code white= security emergency; Code green= all clear)

Laboratory Services
Blood bank (Transfusion Medicine) Pathology Microbiology Biochemistry

Stat lab

Blood Bank services

Regulated services Service may be of own or out sourced Goal: To supply safe blood and blood components to

all needy patients in right time and in adequate quantity.

# It is under Drugs & Cosmetics Act (1945) # Administrative control of NACO.

Policy of government:

Organizations & management

Legal identity Types of blood banks

Responsibilities
Ethics in blood bank Management system Policies, processes & procedures

Accommodation & premises

Space allocation Environmental control Biological, chemical & radiation safety Internal communication system

Accommodation
Registration & Medical examination
Blood collection (A/C) Blood component preparation (A/C) Lab for blood group serology (A/C) Lab for TTI testing (A/C) Sterilization cum washing Refreshment cum rest room (A/C) Store cum records

Personnel
Personal Requirement
Qualification Job Description/Responsibilities

Responsibilities of Medical Director/In-charge/Medical

Officer, Technical Manager & Quality Manager Training Personal Health Confidentiality of Information

Equipment
Equipment requirement

Selection & Validation of Information

Equipment detail record, Unique Identification Program for calibration & maintenance of

equipments. Equipment for storage of blood & component Computer system.

External Services & Supplies

Policies & procedures for suppliers selection Inventory control Evaluation of suppliers

Blood Bank Operation

Donor laboratory
Phlebotomy procedure

Post donation care

Adverse donor reaction management Blood donation camps/drives Autologous transfusion procedure

Handling of samples & blood units

Blood Bank Operation

Component laboratory
Preparation of components

Quarantine & storage & Labeling

Refrigerators & freezers Quarantine Blood/component labelling Instructions for transfusion

Special requirments

Testing of Donated Blood

Determination of ABO group

Determination of Rh(D) type

Determination of unexpected antibodies Test for transfusion transmitted infection

Compatibility Testing
Request for blood & its component

Sample receiving, acceptance & preservation

Pre-transfusion testing Issue of blood & its component

Transfusion Reaction & evaluation

Error prevention Immediate complication Delayed complication

Detection, reporting & evaluation of transfusion

reaction

Quality control

ABO & anti D reagents Reagent red blood cells Red cell panel Anti-human globulin reagent Bovine serum albumin Enzyme reagents Hepatitis B antigen, anti-HCV & anti-HIV 1 & 2 tests Tests for syphilis Normal saline & buffered solution Blood component

Bio-Medical waste disposal & laboratory safety in blood bank/blood centre

Protection of blood bank personnel against

laboratory infection

Safety in the laboratory

Disposal of blood & laboratory material

Identification of Deviations & Adverse Events

Policies & procedures when non-conformity is

detected

Procedures for release of non-conforming blood

components

Preservating recurrence of non-conformity

Performance Improvement
Addressing complaints

Corrective action Root cause analysis Documentation of corrective action

Preventive action

Document control
Procedure for document control & review of

documents

Document required Maintenance of document in computer software

Record
Record identification Quality & technical records Record training period

Internal Audit & Management Review

Policy for internal audit & management review Procedure for internal audit Procedure for management review Documentation of internal audit & management review

Other Lab services

A well equipped Lab services is essential as it

supports the function of the hospital

It could be high income generating source for the

hospital.

An efficient Lab services reduces hosp stay Good Lab services attracts doctors & patients

Basic function of Lab services

To assist doctor in arriving or confirming diagnosis in

treatment of patients

It generates prompt/ reliable reports & also keep

archived reports

To provide services any part of the day

Assist in teaching programs for doctors, nurses and

lab technologists

Workloads
Admitted patient undergoes average of 8-20 tests during

admission

Pt. admitted in medical ward in average 10 days stay,

about 20 tests (2/ day) are done/ pt. (excluding radiographic & other tests)

A 100 bedded hosp with 10 days ALS treat 37 patients

(365%10)/ year. The hosp admits 37 x 100= 3700 pt./yr & generates about a max. of 37,00 x 20= 74,000 test/ yr

Functional divisions
Hosp lab is a conglomerate of many technologies

and methods & they are under five divisions: # Hematology # Microbiology # Clinical chemistry # Histopathology # Urine & stool analysis

Functional planning
It is involved in floor plan, areas, spaces, equipment,

organization & staffing Increasing demand, over-crowding, lack of manpower may lead to poor result Program development depends upon projected no. of tests and hosp beds Organization: Centralized Lab is better with batching of samples for economy

Location (1)
Preferable in the ground floor of hosp
In smaller hosp, between out patient & wards In large hosp, patient entry can be prevented by

sample collection window OPD sample collection: # Suitable room at OPD # Waiting room patients # Vene-pucture room # Specimen toilet (male/ female)

Area/ Space
Should be planned with future workload & expansion Adequate working areas for all activities

Primary space is required for these for those

professional activities including waiting. Secondary space is utilized for all supportive activities e.g. admin, office, toilet, staff room Circulatory space is for personnel/ material movement, store, auxiliary areas etc.

Laboratory space unit (LSU)

Basic unit planning for Hosp lab is LSU It is a module for space and all lab planning based

on LSU Primary LSU: 10x20 =a module of 200 sq mt. Rectangular module is better than square module because of it gives deep bays (more economical & circular space)

Internal designs & fittings (1)

Height of working bench should be 75-90 cm. Width of bench should be 60 cm; good for

equipment & comfort of technicians Optimum size of bench length is 2 mtr; continuous length of 6 mtr gives flexibility. Lab requires sink for staining slides etc. High level natural ighting is desirable All benches should have good flourecent lighting and sufficient electrical points.

Internal designs & fittings (2 )

Lab surfaces should be washable, heat/ stain

chemical/ proof & easy for decontamination Staff locker room & toilets Utility services: Water, Gas, Compressed air Colored piping system for easy recognition Partitions for easy working & dust prevention A/C: Formalin in Histopath. A/c is must here; if possible in all Lab

Lab staffing (1)

Under direction of a qualified doctor: MD/PhD Authorized signatory/ full or part time No. of MLTs depends on:

# No. of samples/ day # Range of tests to be performed (Cl Chem/ Hemat/ Micro/ Histopath/ other specialized) #Emergency service # Leave reserve

Lab staffing (2)

MLT responsible for most technical work under

technical supervisor (then doctor) No. of personnel (30 tests/day/ tech.) Large hosp study with 8 technicians: 2804 tests / tech/ month (requirement14 tech) Very high utilization of tech shows low quality Non productive activities (Doc/ Admin work) Scheduling: Multi-tasking & various shifts Sufficient leave entitlements

Tests performed annually/ MLT

Laboratory units Hematology urinalysis Serology Tests 13,400 390,120 11,520

Biochemistry
Bacteriology

9,600
7,680

Histology
parasitology

3,840
9,600

Lab staffing (3)

Avoid monotony ( it is long cycle, repeat task job

leads to early fatigue, psychological stain, poor time keeping, low productivity & Quality) # In service CME, instrumentation, QC adds commitments to staff Equipment: Reduces dependence of MLT; No. of samples/ day; No. & range to be performed

Equipment
Equipment = instruments, reference materials, consumables, reagents, analytical systems. Equipment availability with respect to work. Equipment shall be shown (upon installation and in routine use) to be capable of achieving the performance required. Program for calibration and monitoring of functioning. The equipment shall be calibrated from NPL, India or calibration laboratory accredited by NABL or its MRA partner having accreditation for the specific scope.

General list of equipment

Robot cell counter Centrifuge Microhenematocirt Flame photometer Spectrophotometer Hot air oven Incubator Calorimeter Analytical balance Blood gas analyzer Auto analyzer

centrifuge Refrigerators Blood bank refrigerators Water still Pressure sterilizer Pipette washer

Automation
Ensures speed, accuracy, less manpower Autoanalyser can take large tests at rapid rate

Decision to buy: Cost per test/ equip cost/ no. of

tests/ reagent cost/ semi- fully automated Calibration & breakdown support Interfacing with software AMC/ CMC & uptake time

Policies & procedures (1)

Lab samples: collected by ward staff or lab staff

collects personally. All request must be in writing Sample receiving: (blood, faces, urine, pus, body fluids, swabs etc) sufficient racks, ID, instruction to Pt, hand washing facility FANC requires separate cubicle

Policies & procedures (2)

Request forms should have all important info

(demographic & clinical details, last tests) Time of accepting samples; Priority of tests: routine & emergency samples Sample container: as specified Identification of samples: Most Important Reports double checked & signed Records to be kept for monthly/ yrly review

Record
request forms,
test results and reports, instrument printouts, procedures, worksheets, complaints and action taken, instrument maintenance and calibration records, quality control records, package inserts, supplier records, staff training and competency records .

Miscellaneous
Lab safety & TTI

Liaison with clinicians: difference between diagnosis

& report: discussion needed Technicians motivation: discuss various issues, periodical meeting & try to solve problems Cross training Lab waste disposal