12- Managing a Modern Hospital

8/13/2019 12- Managing a Modern Hospital

1/419

Edited by

A. V.Srinivasan


2/419

Managing a Modern Hospital


3/419


4/419

H

Managing a Modern HospitalSecond Edition

Edited by

A.V. Srinivasan

ResponseBusiness books from SAGE

Los Angeles London e! "el#i Singa$ore!!!.sage$ublications.com
http://www.sagepublications.com/http://www.sagepublications.com/


5/419

Copyright A.V. Srinivasan, 2008

All rights reserved. No part of this book ay be reprod!"ed or !tilised in any for or byany eans, ele"troni" or e"hani"al, in"l!ding photo"opying, re"ording or by anyinforation storage or retrieval syste, #itho!t perission in #riting fro the p!blisher.

$irst p!blished in 2008 by

Response %ooks%!siness books fro SA&' % ( )*+( ohan

Cooperative *nd!strial Area ath!ra Road,Ne# -elhi ((0 0, *ndia ###.sagep!b.in

SA&' /!bli"ations *n"2 1eller Road

1ho!sand aks, California 3(420, 5SA

SA&' /!bli"ations 6td( liver7s ard, City Road 6ondon 'C((S/, 5nited 9ingdo

SA&' /!bli"ations Asia+/a"ifi" /te 6td 44/ekin Street :02+0( $ar 'ast S;!areSingapore 08standards> *ndia.4. edi"al A!dit>organiation D adinistration>*ndia. EF (0 2==4 2008G

RA330.*4d"22 2008 2008008340

*S%NB 3


6/419

%ontents

anaging a odern @ospital............................................................................Response.............................................4

Contents...........................................................................................................6

List of Tables....................................................................................................7

List of Figures.................................................................................................12

Foreword........................................................................................................15

Acknowledgeents........................................................................................16

!ntroduction....................................................................................................17

@S/*1A6S AN- A-*N*S1RA1RS @ospital Adinistrators+A Ne# Class of

/rofessionals....................................................................................................(

/art 2 1@' /R$*6'..........................................................................................4

@'A61@ CAR' S'C1R+$*NANC*A6S.................................................................Aarketing *nitiative7. She has gone a step farther fro iage #ith andretention of "!stoers of CR to learning and adoption of their e?perien"e.


30/419

@ospitals in private se"tor in"reasingly fa"e "opetition and the "!stoersHpatients and refereesI are getting ore inforation fro internet and aredeanding. She has sho#n ho# to s!rvive in s!"h an environent byb!ilding "opetitive strength. She has s!pported the rationality #ithobservation and a str!"t!re. 1his and the ne?t "hapter are val!ableadditions of latest kno#ledge to this edition.

A edi"al re"ord is a "opilation of pertinent fa"ts abo!t a patient7s lifeand health history, in"l!ding past and present illnesses and treatent givenby health professionals "ontrib!ting to the patient7s "are. *t is the personal

property of the patient and ens!res "ontin!ity of treatent. 1he "hapter,Qedi"al Re"ords7, by s ata 'd#ards, "overs the p!rpose, !ses andval!e of edi"al re"ords. 1he a!thor indi"ates #ho is responsible for the"onstr!"tion, aintenan"e, adinistration of edi"al re"ords and relatedlegal iss!es. 1he forats in #hi"h the re"ords are to be aintained, thetypes of data, and the retention prin"iple are also "overed. 1his "hapter"on"l!des #ith f!t!re developents and "op!terisation of re"ords.

perations Resear"h is a !ltidis"iplinary approa"h for proble+solvingand iproving effi"ien"y. *t !ses soe of the proven atheati"al odelsto a sit!ation, #hether it is siple or "ople?. 1his has been !sed very


31/419

2%MANAGINGAMODERNHOSPITAL

#idely in ind!stries and in ohns @opkins @ospital, as early as the fifties. *tsappli"ation has be"oe easier no# #ith the availability of po#erf!l /Cs andrelevant soft#are. *ts !tility is so high that it is a "ore s!bJe"t in everyanageent "!rri"!l!. -r 9.N. &a!r, in the "hapter, Qperations Resear"hin @ospitals7, tra"es the history of this approa"h to provide rationality, akesa listing of the aJor te"hni;!es in"l!ded !nder this head, and des"ribesho# to b!ild a odel. *n the se"ond part of his paper, he sho#s ho# to applysele"ted perations Resear"h te"hni;!es to hospital sit!ations. 1hese areAllo"ation ethods, P!e!eing odels, Repla"eent odels and Net#ork

1e"hni;!es.-r eet /at#ari has applied the "on"epts of e?pert syste of de"ision

s"ien"e and developed a prototype for diagnosis. @e has sho#n theintri"a"ies of this po#erf!l tool, #hi"h is diffi"!lt to apply. @e has given aneasy introd!"tion to the "on"ept, sho#n the steps of diagnosis by taking ane?aple of a spe"ifi" disease and takes the reader thro!gh a se;!en"e of"op!ter o!tp!ts of the pro"ed!re. 1his "hapter, QCop!ter Aided -iagnosis>'?pert Systes7, #ill sho# not only a ethod to develop "op!terieddiagnosis !sing a database and "op!ter b!t also "reate an interest andeagerness to b!ild e?pert syste odels in health "are. 1his "hapter #ill be


32/419

of spe"ial interest to *1 developers and "lini"ians #ith resear"h orientation.A hospital prod!"es a large ao!nt of #aste, soe of the are poll!tants

and haardo!s to health. *n *ndia, a large proportion of hospitals and bedsare lo"ated in !rban areas, #here the "ivi" "onditions ay not be atdesirable level of effi"ien"y. *n the "hapter titled Q@ospital Easteanageent7, -r @oi ehta presents readily ipleentable systes. @egro!ps the #astes into different types, in ters of their end effe"t, and givesa "lassifi"atory s"hee to segregate the, and event!ally anage the ina anner so as to prevent !n#anted after+effe"ts. 1his "hapter deals #ith

the "olle"tion, disposal and treatent of #aste. ne aspe"t of #asteanageent is prevention>ho# to iniise #aste "reation. 1his also forsa part of the "hapter. anaging hospital #astes has not been getting theattention it re;!ires fro the "ivi" a!thorities, and also fro hospitals in the"o!ntry. -r ehta presents a "ase st!dy to ill!strate the appli"ation of hiss"hee at the end of this "hapter.

-r 5.V.N. -as looks at the need and advantage of keeping the patient"ofortable, happy and "ontented. Q/atient Relations in @ospitals7 isaddressed to all hospital staff, irrespe"tive of their rank and lo"ation. @edeals #ith ea"h f!n"tion in a hospital, and sho#s ho# a patient "an be kept


33/419

28MANAGINGAMODERNHOSPITAL

happy. 1his, and the follo#ing "hapters are relevant and apt in today7s #orldof "ons!eris.

Ehile -r -as to!"hes !pon "reating a Qdelighted "!stoer Hpatient)attendantI7, -r N. RaJara and s S#ati /andey, in their #ell+resear"hedpaper on another aspe"t of "ons!eris, insist on the need and iportan"efor Qedi"al A!dit and its Adinistration7. Starting fro listing thea"kno#ledged attrib!tes of edi"al a!dit, they set !p proto"ols for a!dit,identify its eleents, dis"!ss the a!dit types, ethods and onitoringte"hni;!es. 1hey dis"!ss the "onstraints in a!diting and diffi"!lties in

ipleentation. An inforative part of the paper is their opinion s!rvey ofdo"tors on edi"al a!dit. 1hey e?press the !rgen"y, need and iportan"e ofthis anageent pro"ess #ith the ;!otationB 1here is a tie to end"onteplation and a tie to begin7.

1he opening of the '!ropean Coon arket to *ndian ind!stries bro!ghtalong #ith it standardisation and third+party "ertifi"ation. 1otal P!alityanageent and Control of Variation #ere #idely propagated aong theind!stries>one ore aspe"t of "ons!eris, Qthe val!e for oney7. ne byone, any engineering ind!stries in *ndia #ent for *S "ertifi"ation. No# it isthe t!rn of the servi"e ind!stries, s!"h as banking, ed!"ation and hospitals,


34/419

to "ontrol the variations in their o!tp!t, and to attra"t "!stoers thro!ghthird+party "ertifi"ation of their ;!ality of servi"e. 1his #ill provide a"opetitive edge. A n!ber of hospitals #orked hard to obtain the *S 3002"ertifi"ation. 9. /rabakar in the "hapter Q*S 3002 Certifi"ation for a @ospital>An ill!strative Case7, des"ribes #hat this is all abo!t, e?plains standard"la!ses in !nderstandable ters to hospital adinistrators, and el!"idatesho# Apollo @ospital obtained this "ertifi"ation. 1his is s!pported #ith a "aseill!stration by -r A.V. Srinivasan in the ne?t "hapter.

Copiling a book of this nat!re is ;!ite a stren!o!s task, and is tie+

"ons!ing. %!t * enJoyed it as * realised its val!e for the readers. 1he interestand "ontin!ed s!pport provided by Sangita Reddy and -r /rathap C. Reddyenth!sed e in "reating this "olle"tion. * #ish to re"ord y appre"iation andthanks to the.

Ar"hana RaJgopal, *shrath @!airah, 9iranaye Rao, Ar!ndhati aidiand -hara 1eJ, #ho #ere st!dents of Apollo *nstit!te of @ospitalAdinistration, helped e a great deal in "oposing and editing the"hapters. 1heir "heerf!lness and #illingness to share y #ork ade the taska pleas!re. $inally, Shaik 9hasibi, #ith her !nliited patien"e, s!pportede in this vent!re #ith se"retarial assistan"e.


35/419

&0MANAGINGAMODERNHOSPITAL

A.V. Srinivasan


36/419

Healt# 'are in India( A

Proile and t)e !#t#re

A.V. Srinivasan

)ART1

H*S)(&ALS A" A"M((S&+A&*+S

Hos$ital Administrators,A e! %lass of )rofessionals

he hospitals "an be "lassified into three "ategories based on the n!berof beds. Category Chospitals are lo"ated in any pla"es for easy rea"h.

1hey have 40 or fe#er beds and provide priary "are. 1hese are "lini"s andn!rsing hoes. Category 3 hospitals have 4(+(00 beds, provide soe

spe"ialty+"are, have fe# designated departents in"l!ding soeinvestigation fa"ilities. 1hey have arrangeents to provide basi" needs topatients and attendants. Category A hospitals have ore than (00 beds, are!lti+spe"ialty, !se better te"hnology and attra"t s!perior ;!alifiedprofessionals.

1

*n all "ategories, both p!bli" and private se"tor hospitals f!n"tion. &ublicsector -os'itals in"l!de those #hi"h are governent anaged, "ityadinistered and "o!nity s!pported. 1hese typi"ally provide servi"e freeof "harge, operate on a b!dget, are "ontrolled by e?ternal agen"iesHdepartent offi"ialsI and are Qnot for profit7 earning. &rivate sector -os'italsare r!n by tr!st, "harity and religio!s organisations. 1ho!gh they ay

"harge for the servi"es, the obJe"tive is Qnot for profit7 earning. *n the privatese"tor, there is one ore "lass of hospitals that are large+sied, !lti+ orsingle+spe"ialty and provide servi"es that are relatively of higher te"hnology.1hey are Qfor profit7 earning and r!n on the lines of "orporate organisations.1he private se"tor>for profit Category A and % hospitals>are anageent+oriented, have rea"hed the "riti"al+ass level in the reso!r"es to look foroptiisation and are not "ontrolled by e?ternal agen"ies. 1hey have a felt+need for hospital adinistrators, #ho are trained in anageent prin"iples


37/419

2MANAGINGAMODERNHOSPITAL

b!t are not ne"essarily ;!alified edi"al professionals. 1his is a ne# "lass ofprofessionals "oing o!t of anageent instit!tions s!"h as Apollo *nstit!teof @ospital Adinistration, *ndian *nstit!te of @ospital anageent andResear"h, and 1ata *nstit!te of So"ial S"ien"es at an in"reasing rate. 1hea!thor estiated the potential deand in *ndia for s!"h professionals>hospital adinistrators> as bet#een ,000 and (=,000 d!ring this de"adeHSrinivasan 2000I. 1ho!gh ore and ore instit!tions are offeringprograes to e;!ip hospital adinistrators, the s!pply is falling short very!"h and the arket has not at!red eno!gh to rea"h this level of deand.

A""ording to the a!thor, vario!s instit!tions in the "o!ntry, #hi"h #holly orpartially spe"ialise in hospital adinistration, are hardly training (,000grad!ates in a year and ost of the are eployed in private se"tor.

MAR*ETDE+ELOPMENTANDPROD,'TPROMOTION

Sin"e this spe"ifi" Qanagerial skill arket7 does not yet e?ist at the "riti"al+ass level, the ind!stry sho!ld initiate a prootion prograe to developthis arket to its f!ll potential aong the health "are and edi"al "areinstit!tions. /!bli" se"tor hospitals are in"l!ded in this "onsideration, tho!ghthis "hange ay o""!r only after a poli"y revision in the governent and"ivi" bodies, in ters of "reating a position for the and a""eptan"e of theirrole. 1ho!gh the potential deand is e?pe"ted to rea"h (=,000, thea"hievable deand #ill be deterined by the sie+ "oposition of thehospitals in the f!t!re years, the prootion of this "lass of professionals inthe health "are ind!stry, their a""eptan"e by all private se"tor hospitals andtheir o#n professional "ontrib!tion to effi"ient anageent of hospitals ase"onoi" and viable b!siness organisations.

STRATEGIES!ORDE+ELOPMENT

1he ind!stry is no# in a sit!ation for the developent of this skill arket. *thas to ake a "aref!l analysis, for!late a s!itable professional approa"h

and evolve a plan based on arketing prin"iples for ne#+prod!"t+prootion.1he Category C hospitals #ill stand to gain a great deal, if they adopt thesyste of eploying trained and ;!alified adinistrators to take "are of theanageent aspe"ts. Another strategy ay be to "reate a developentprograe for the entreprene!ranager, #ho ay or ay not have edi"al;!alifi"ations, to start this sie hospital. Category C is an !ntapped arket#ith high potential, #hi"h deserves n!rt!ring and a long+ter strategy for itsdevelopent to be initiated by the ind!stry. 1he gains #ill be oreeployent for grad!ates, effi"ient r!nning of hospitals, the attendant lo#er


38/419

(&+*"-%&(*&

"ost to the patient, easy a""essibility and advantages of arket "opetition.

)art 2 THE PRO!ILE

SOMERATIOS

-!ring the period (38(+200, the n!ber of hospitals and the n!ber ofbeds in"reased at the rate of and 2.= per "ent, per year, respe"tively. 1hegro#th of hospitals, beds and their n!ber per lakh of persons arepresented in 1able (.( Hinistry of @ealth and $aily Eelfare, 200I.

&able . umber of All Hos$itals and Beds !it# +atio to *ne Lak# )ersons

1he /rivate se"tor aintained


39/419

$MANAGINGAMODERNHOSPITAL

N!ber /er "ent /op!lation N!ber /er "ent /op!lation

to 1otal Served to 1otal Served

by ne by ne

@ospitals 2,=84 4 2


40/419

(&+*"-%&(*-

presented.

%A,SEO!DEATH

1he "a!se of death aong "hildren, ad!lts and old people are presented in1able(. for sele"ted killer diseases Hinistry of @ealth and $aily Eelfare, 200B1able ((.04I. *t "an be observed that there is a predi"table pattern. ldpeople die of astha, bron"hitis and paralysis. Ad!lts die of t!ber"!losisH1%I of the l!ngs, "an"er and vehi"!lar a""idents. Children die of pne!onia,preat!re birth and gastroenteritis. Ad!lts and old people have e;!al"han"e of death "a!sed by heart atta"k. 1he n!ber of deaths d!e toanaeia, is abo!t the sae for the three age gro!ps.

"ISTRI.,TION./AGE

/ersons over the age of 3 are less prod!"tive and ore prone to diseases,seeking edi"al attention. &enerally, this segent of the pop!lation is notf!lly "apable of paying for the servi"es re"eived, !nlike ad!lts H( to 3

years of ageI #ho are likely to be engaged in prod!"tive o""!pation.Another #ay of looking at this sit!ation is that there #ill be as any as


41/419

%MANAGINGAMODERNHOSPITAL

opport!nities in the for of edi"al ins!ran"e, hospital "ooperatives, andhospitals and "orporates Joining hands for !t!al benefit ne"essitatingp!bli" poli"y in this area. 1he "oing de"ade #ill bring into *ndia a variety ofinnovations and initiatives in edi"al "are.

EMERGINGPRO!ILE

1here is an !neven distrib!tion of hospitals and beds bet#een !rban andr!ral areas. /rivate hospitals ay "onsider effe"tive and innovative o!trea"hprograes to serve the r!ral areas, at least in the hinterland. 1his "o!ld

give rise to a novel ripple effe"t, !ltitier operation and feeder systes.ne+third of the total n!ber of hospitals and beds in the r!ral areas are inone state, 9erala. aharashtra and &!Jarat a""o!nt for over half thehospitals and one+fo!rth of the beds in !rban areas. An intensive st!dy ofthese three states #ill provide soe lessons in e?panding into thehinterland.

Saller states have a better pop!lation+to+bed ratio. 1his ay be be"a!seof adinistrative "onvenien"e or the e"onoy of s"ale ay be favo!rable intheir "ase. An e?tension of this finding "an be applied to large states, ea"h of#hi"h has several regions. *ntensive health "are developent in ea"h regionsho!ld res!lt in favo!rable pop!lation+to+bed ratio. States ay "onsider

in"entive pa"kages to attra"t private se"tor hospitals in these regions.Considering *ndia as a developing "o!ntry, the n!ber of do"tors per lakh

of pop!lation is satisfa"tory. @o#ever, "onsidering the rate of absorption ofedi"al te"hnology in this "o!ntry, this ratio>8>is ;!ite lo#, "opared to2( in developed "o!ntries. 1he sit!ation #ith regard to n!rses is still #orse.1here is not even one n!rse for every do"tor. 1he n!ber of n!rses per lakhof pop!lation> >is no #here near the average for a developing "o!ntry. *tis a #ell+kno#n fa"t that n!rses play a very iportant role>professional andeotional>in the re"overy of patients. 1hey "an be ;!i"kly trained and thee?penses in"!rred are "ost+effe"tive. $ro the so"ial angle, this is a #ay toprovide dignified eployent for ed!"ated #oen, parti"!larly belonging to

lo#er e"onoi" "lass. A state poli"y, s!pported by so"ial and health "areorganisations, is needed to "reate the right balan"e bet#een n!rses anddo"tors.

1he disease pattern aong different age gro!ps s!ggests the feasibility ofspe"ialised servi"es and an organisational strategy to "reate a ni"he arket.1he in"reasing n!ber of old age patients indi"ates the need for a statepoli"y and a ne# viable prod!"t>hoe health "are. 1he health "are ind!stry"an t!rn this into an opport!nity by devising long+ter finan"ial andins!ran"e s"hees.


42/419

HEAL&H %A+E SE%&*+,'(A%(ALS

E'ONOMI'EN+IRONMENT

1he e?pendit!re by &overnent of *ndia on edi"al "are and health servi"eshas been in"reasing over the years. 1he in"rease over the years is steady,fro Rs per "apita in (38+8= to Rs 84 in (383+30 Hinistry of @ealth and$aily Eelfare 200I. 1hese fig!res #ill "oe do#n #hen they are

dis"o!nted for inflation and "op!ted to a standard base. 1he in"rease isalso larger than the ann!al pop!lation gro#th, #hi"h is (.3= per "ent.@o#ever, one sho!ld realise that a aJor part of the b!dget #ill be spent onsalaries, leaving only a sall ao!nt for health "are. An interesting feat!reis that e?pendit!re, as per"entage of the total b!dget, has been steadilyfalling. ne interpretation of this sit!ation ay be that the ann!ale?pendit!re is ore for aintenan"e of assets and in"rease in salaries, thanfor e?pansion and ne# te"hnologies. 1his indi"ates a state of stagnan"y inthe p!bli" se"tor. @en"e, this is an opport!nity for non+governentalagen"ies and the private se"tor to intervene to their o#n advantage.

1he ho!sehold se"tor &ross -oesti" Saving as a per "ent of &ross

-oesti" /rod!"t steadily in"reased fro =.2 per "ent in (3( to 24. per"ent in 200 HhttpB))indiab!dget.ni".inB 1able (I. 1his is an indi"ator of theopport!nity for private se"tor initiative in health "are a"tivities. A "ond!"ivee"onoi" environent e?ists for this ind!stry to gro# for the benefit of boths!pplier and b!yer in the arket, provided organised efforts are ade,planned and "hannelled by the ind!stry.

%ased on the /areto distrib!tion of ho!sehold "ons!ption e?pendit!re,the a!thor has estiated the sie of the affl!ent "lass of people in 200 tobe (,(00 lakh persons. 1his is the floor val!e for the sie of the potentialarket for private se"tor initiative in the health "are se"tor. A part of thene?t (0 per "ent of the ho!seholds #ill add to this arket HSrinivasan 2000I.

%ON'L,SIONS!ROMHEALTHEPENDIT,RE

ver the years, the e?pendit!re on edi"al "are, at "!rrent pri"es, has beenin"reasing. @o#ever, it reained a "onstant proportion of the b!dget. 1hisgives an ipression that the in"rease has been ore for the aintenan"ee?pense of the syste and only a arginal ao!nt has been spent fordevelopent and innovation. *t also sho#s that it never re"eived any
http://indiabudget.nic.in/http://indiabudget.nic.in/


43/419

8A.V. SRINI+ASAN

additional thr!st in poli"ies and spending. 1he in"reased savings in absol!teval!e, again at "!rrent pri"es, perhaps provided the thr!st for the privatese"tor initiative in the health "are se"tor. %ased on these analyses, astrategy for arket developent by private se"tor is stip!lated in the ne?tparagraph.

STRATEG/!ORMAR*ETDE+ELOPMENTINPRI+ATESE'TOR

*f the per "apita "ons!ption e?pendit!re is an indi"ator of Q#illingness to

spend and affordable7, the potential arket for private se"tor operations inthe health "are arket #o!ld be in the states ofB @ia"hal /radesh,aharashtra, /!nJab, 9erala, &!Jarat, Assa and @aryana HSrinivasan 2000B40I. A rational arket developent strategy #o!ld be to set !p health "areentities in the fo!r etros, the ne?t si? largest arket+to#ns and the affl!ent"ities of the states entioned. 1he data regarding "oparative pi"t!re ofhealth "are e?pendit!re aong the Asian "o!ntries sho#s that HaI there is#illingness aong *ndians to spend on health "are, and HbI thro!gh aninnovative arketing strategy of ba"k#ard flo#, this servi"e "an be e?portedto other "o!ntries in Asia.

)ART$

&+E"S A" )+E"(%&(*S

HEALTH'AREEPENDIT,RE

%eran H(33=B Chapter (I, in Q@ealth Care '?pendit!re in *ndia7, statesB QAtthe ost aggregate level all analysts agree that non+governent so!r"es ofhealth e?pendit!re far e?"eed the spending levels of governent so!r"esand that by far the largest part of non+governent spending is the o!t ofpo"ket e?pendit!re of individ!als and ho!seholds.7 1he relative sie of the

different so!r"es of f!nds for national health e?pendit!re, as estiated by%eran, is presented in 1able (.=.


44/419

Healt)'areinIndia(A Proileandt)e!#t#re

@e s!pports this stateent by referring to the sall+s"ale ho!sehold

s!rveys report, #here even poor ho!seholds #ere fo!nd to be spendingbet#een per "ent and (0 per "ent of their in"oes on health. /rivatehealth e?pendit!re is fo!nd to be relatively high as a proportion of in"oe.%eran H(33=B Chapter (I interprets this phenoenon th!sB

Eithin these high levels of spending, ab!latory illness "are probablya""o!nts for the largest part of the total, and e?pendit!re on hospitalservi"es a saller part. 1his aspe"t of the "oposition of ho!seholdhealth spending refle"ts the str!"t!re of servi"e provision in *ndia,#here appro?iately t#o+thirds of the hospital beds are in p!bli" se"torfa"ilities. *n "ontrast, ore than t#o+thirds of the ;!alified allopathi"ab!latory "are providers pra"tise privately, along #ith an !nkno#n,

b!t probably even a larger n!ber of other ab!latory "areproviders of other systes of edi"ine of lo#er levels of ;!alifi"ation*t is also likely that this so!r"e of health e?pendit!re has been gro#ingore rapidly than governent spending.

1his finding has an interesting ipli"ation for private se"tor initiative inthe field of health "are in *ndia, parti"!larly #hen read #ith anotherstateent in the sae paperB QA re"ent s!rvey of the health benefitsprovided by private firs reported the high fig!re of Rs (,443 per eployeefor the firs s!rveyed.7

)OTENTIALMAR*ET!ORHEALTH'AREININDIA

A proinent and potentially ri"h arket for health "are in *ndia is theorganised se"tor of "orporates and affl!ent individ!als. %eran e?plains thehigh level of private health e?pendit!re by "onsidering both s!pply anddeand fa"torsB

*ndiaTs private health e?pendit!re is !n!s!al in its variety and s"ope.$ro frontline providers in r!ral villages to large hospitals, severalsystes of edi"ine "oe?ist, #ith separate health "are providers,

&able .9 Source of 'unds for ational Healt# E:$enditure%ource /er cent

@o!sehold

/rivate Se"tor 2(

State &overnent 2(

Central &overnent (0

6o"al %odies 4


45/419

10A.V. SRINI+ASAN

fa"ilities, and edi"al "olleges. St!dies sho# that any of theseproviders pra"tise an Qe"le"ti"T edi"ine, "obining therapies froore than one syste, and !s!ally in"l!ding soe eleents ofallopathy. St!dies in other "o!ntries have s!ggested that, in edi"al"are, s!pply "an "reate its o#n deand. 1h!s, it sees pla!sible thatthe e?isten"e of !ltiple re"ognised systes of edi"ine #o!lds!bstantially in"rease the ao!nt of private "are provided, and"onse;!ently private health e?pendit!res. 1his sit!ation is f!rthersti!lated by the alost "oplete absen"e of enfor"ed reg!lationdeterining entry into edi"al pra"ti"e, or ;!ality "ontrol to affe"t theability of !n;!alified providers to stay in pra"ti"e....*ndiaTs poor health stat!s ight be e?pe"ted to a""o!nt at least in partfor a high level of health "are !se and spending. *n addition, i"ro+levelst!dies of health "are !tilisation and e?pendit!re s!ggest that *ndians ofall so"ial "lasses are relatively heavy !sers of health "are H%eran,(33=B Chapter (I.

1o s!pport this arg!ent, %eran "opares the data of -!ggal andAin7s st!dy of algaon distri"t, #ith a siilar st!dy in Eest ava in*ndonesiaB

1he differen"es are s!ggestive. *llness in"iden"e rates varied bet#eenthe t#o "o!ntry saples and e?pendit!re "lasses. %!t the *ndianrespondents sho#ed a higher propensity to !se treatents, and spent!"h ore per episode than the *ndonesians. 1he res!lt is signifi"antlyhigher o!t of po"ket spending in *ndia, despite, in soe "ases, lo#errates of illness reported. $ro y e?perien"e in both "o!ntries H*ndiaand *ndonesiaI * #o!ld s!ggest that these differen"es are not siply af!n"tion of greater health needs in *ndia, b!t also refle"t both thegreater availability and a""ess to private health "are in *ndia>the largen!ber of pra"titioners of Qe"le"ti"T treatent>as #ell as the greaterpropensity of *ndians to seek foral health "are.... Hibid.I

AGENDA!ORTHE!,T,RE

Soe of %eran7s other observations on Q*pli"ations and Agenda for the$!t!re7 areB

(. *ndia spends a higher proportion of its in"oe on both governent andnon+governent health "are in "oparison #ith other "o!ntries in theregion.

2. *n ters of spending better, one often hears the laents of poor


46/419

Healt)'areinIndia(A Proileandt)e!#t#re11

otivation and anageent in the p!bli" se"tor. Certainly theeffi"ien"y and ;!ality of p!bli" servi"es "o!ld be iproved by betteranageent and adinistration.

4. Ehile the national health poli"y la!dably proposes spe"ifi" targets forp!bli" servi"es to eet, it gives only "!rsory attention to thedevelopent of the private health se"tor.

. /!bli" reso!r"es have not been s!ffi"ient to eet all of governent7sstated goals in health "are, and they are not likely to in"reaseiensely in the "oing years.

1he la"k of basi" inforation on *ndia7s private health se"tor is striking.

A syste as a #hole !st be the developent of better inforation onthe private health "are se"tor, ranging fro the itinerant r!ral dr!gseller, to the Qfive starT !rban hospital. 1his inforation sho!ld in"l!de"osts and e?pendit!res, !tilisation patterns, and des"riptions of the sie,"oposition and pra"ti"es of different types of providers H%eran, (33=BChapter (I.

%AE+ S,R+E/O!HEALTH'AREEPENDIT,RE

1he National Co!n"il of Applied '"onoi" Resear"h HNCA'RI "ond!"ted the@o!sehold S!rvey of @ealth Care 5tilisation and '?pendit!re in (334. *t"overed all the states and !nion territories of *ndia. 1he saple "onsisted(8,=34 ho!seholds spread over both r!ral and !rban areas of the "o!ntry.1he follo#ing sele"tive findings are taken fro this report HRaaani(33B8=+


47/419

12A.V. SRINI+ASAN

the r!ral areas and 3.< for the !rban areas. $or nearly (2 per "ent of theillness episodes in the r!ral areas and abo!t 8 per "ent of the illnessepisodes in the !rban areas, no treatent has been so!ght. 1he higherper"entage of !ntreated illness in the r!ral areas probably refle"ts poorphysi"al and finan"ial a""ess to health "are in the r!ral parts of the "o!ntry.1he ost iportant reason for not seeking any treatent t!rns o!t to bethat the illness is not "onsidered serio!s eno!gh.

1he dependen"e on private health fa"ilities is fairly high for the b!siness"lass, the salary earners)professionals of the !rban areas and for the"!ltivators in the r!ral areas. 1he average distan"e travelled #orks o!t to .3k for the r!ral areas and 2.2 k for the !rban areas. 1he "oparative datafor !rban and r!ral areas on the !tilisation of health "are servi"es are sho#nin 1able (.


48/419

Healt)'areinIndia(A Proileandt)e!#t#re1&

this report are "ited here, follo#ed #ith a -esired $!t!re S"enario, asinterpreted by the a!thor.

. )REDI'TION./TI!A'

Aong the infe"tio!s diseases, t!ber"!losis, A*-S, ve"tor+borne diseasesand diarrhoea #ill re"eive the highest priority in health "are in the ne?t 2years. @o#ever, their in"iden"e level #ill de"line per"eptibly. Aong thenon+ "o!ni"able diseases, is"haei" heart diseases, strokes and feale"an"er #ill be the leading diseases attra"ting high priority. 1here #ill be anin"rease in a""idents, s!i"ides and hoi"ides. 'otional and psy"hiatri"probles ay "a!se an in"reased disease b!rden in the f!t!re.

"esired future scenario*

@ealth "are instit!tions #ill be geared to absorb this trend and deand. 1hey#ill #ork "losely #ith s"hools and so"ial organisations for the prevention andearly diagnosis of infe"tio!s diseases. &overnent and health "are instit!tions#ill "opleent ea"h other in #orking to#ards this goal.

0. )REDI'TION./TI!A'

*ndigeno!s systes of edi"ine #ill help in identifying and synthesising ne#

dr!gs, and #ill be !sef!l in the treatent of "hroni" diseases. Clini"al trials ofne# edi"ines and te"hnologies developed overseas #ill be !ndertaken in*ndia. /rod!"tion of iaging e;!ipent and others, hepatitis and anti+rabiesva""ines and diagnosti" kits #ill re"eive attention.


@ealth "are instit!tions #ill t!rn this into a b!siness opport!nity. A ne# kind ofrelationship #ill develop bet#een health "are instit!tions and dr!g resear"hinstit!tions, both *ndian and foreign. 1his ay t!rn into a ba"k#ard integrationopport!nity for a @ealth Care *nstit!tion.

/. )REDI'TION./TI!A'1he stat!s of the e?isting te"hnologies to 'revent* diagnoseand treatthe topten diseases "onsidered to be of high priority by the year 2000 are far frosatisfa"tory for the follo#ing diseases Hthe diseases are listed in order ofiportan"eIB

1e"hnologies to'reventA*-S, hepatitis, ve"tor+borne diseases, ne!ro+psy"hiatri" diseases, feale"an"er, "ardiovas"!lar diseases, diarrhoea, t!ber"!losis.


49/419

1$A.V. SRINI+ASAN

1e"hnologies to diagnoseA*-S, hepatitis, ne!ro+psy"hiatri" diseases.

1e"hnologies to treatA*-S, hepatitis, ne!ro+psy"hiatri" diseases, feale "an"er.


1his is an opport!nity for the health "are instit!tions to bring appropriatete"hnologies and adopt the to take "are of this sit!ation. Resear"hinstit!tions, phara"e!ti"al RD- !nits, and health "are instit!tions #ill !se

the "onsorti! approa"h #ith interested organisations o!tside the "o!ntry, toa"hieve this goal.


Alternative systes of edi"ine #ill thrive and displa"e allopathy and odernedi"ine.


@ealth "are instit!tions #ill t!rn this threat into a b!siness opport!nity, #hi"h#ill res!lt in f!rther gro#th of alternative systes of edi"ine and this ayres!lt in a logi"al strategy to anage */R reg!lations.


edi"al professionals #ill get together to start "ooperatives of "lini"s andn!rsing hoes, #ith edi"al "are re"eivers as parti"ipating ebers. 1hegro#th of n!rsing hoes #ill be !"h higher than the gro#th of large+sied,!ltispe"ialty hospitals.


6arge and #ell+established health "are instit!tions #ill !se this opport!nityand introd!"e instit!tion+based servi"esB a ne# relationship #ill be b!ilt

bet#een the, and the n!rsing hoes and "ooperatives. *nforationte"hnology appli"ations, parti"!larly net#ork "o!ni"ation, #ill be e?ploitedeffe"tively.


1#o fast+gro#ing segents #ill be health "are instit!tions set !p by gro!ps ofedi"al professional+entreprene!rs and large *ndian ind!strial ho!sesparti"ipating in the starting of hospitals as Joint vent!res. @ospitals #ill be r!nas "oer"ial organisations giving iportan"e to planning, "ost+"ontrol,


50/419

Healt)'areinIndia(A Proileandt)e!#t#re1-

;!ality ass!ran"e, anageent effi"ien"y and "!stoer satisfa"tion.K

"esired future scenario

A ne# generation of hospital adinistrators, trained in anageentte"hni;!es and prin"iples proJe"t "ons!ltants #ho "o!ld "onstr!"t hospitalson a t!rnkey basis and non+banking finan"ial instit!tions spe"ialising inhospital "reation and anageent, #ill spring !p in the "o!ntry.

;. )REDI'TION./TI!A'

*ntegrated health "are net#orks #ill f!n"tion #idely and effe"tively, and bringhealth "are at an affordable pri"e to a large n!ber of the pop!lation.


1his #ill "hange the indset of edi"al professionals and instit!tions. 1heso"ial ores of edi"al professionals and patients #ill "hange to a positiveattit!de. 1his #ill open !p ne# aven!es of eployent and se"!red in"oes.1he old adage, Qprevention is better than "!re7, #ill be the ne# slogan adoptedby health "are instit!tions. @ealth "are instit!tions and so"ial organisationsHN&sI #ill provide ed!"ation and training on a large s"ale, parti"!larly inr!ral areas and !rban sl!s, on preventive eas!res.

)art - TAS* AHEAD

HOSPITALADMINISTRATOR

1he private se"tor>"orporate, tr!st or of the religio!s kind>need to beadinistered rationally and s"ientifi"ally to be self+s!pporting, if not s!rpl!sprod!"ing. 1his "an be a"hieved only if they apply anageent prin"iples forplanning, reso!r"e allo"ation, investent analysis, pri"ing and "ost "ontrol inhospitals. 1hey sho!ld behave like "orporate bodies and be anagedeffi"iently. *n order to do this the "o!ntry needs a spe"ial "adre of

professionals trained in anageent prin"iples applied to hospitaladinistration. 1his spe"ifi" Qanagerial skill arket7 does not e?ist at a"riti"al ass level in the "o!ntry. @en"e, the health "are ind!stry sho!ldinitiate a #ell designed prootion prograe to develop this arket to its f!llpotential. &overnent hospitals ay soon follo# the, on"e poli"y revisiontakes pla"e #ithin governent and


51/419

1%A.V. SRINI+ASAN

K A!thorTs interpretation

"ivi" bodies. 1his is a totally !ntapped arket, #hi"h deserves n!rt!ring anddeveloped thro!gh a long+ter strategy. 1he gains #ill beB ore eployentfor grad!ates, effi"ient r!nning of hospitals, lo#er "ost to the patient, easya""essibility and the advantages of arket "opetition.

-R.ANORIENTATION

1he !neven distrib!tion of hospitals and beds bet#een !rban and r!ral areasneeds to be attended to. /rivate hospitals "o!ld "onsider effe"tive andinnovative prograes to serve the r!ral areas, at least in their hinterland,

#hi"h ay give rise to a novel ripple effe"t leading to !lti+tier operations andfeeder systes. An intensive st!dy of the states of aharashtra, &!Jarat andEest %engal "o!ld provide soe "l!es in e?panding into the hinterland.Saller states have a better pop!lation+to+bed ratio. Applying this prin"iple toregions in large states, health "are developent in ea"h region ay bebro!ght abo!t by attra"ting private se"tor hospitals to these regions.

"O'TORSANDN,RSES

Considering the rate of absorption of edi"al te"hnology by *ndia, this ratio ofn!ber of do"tors per lakh persons is ;!ite lo# "opared to that in developed

"o!ntries. 1he sit!ation #ith regard to n!rses is still #orse. 1here is not evenone n!rse for every do"tor. N!rses play an iportant role, both professionaland eotional, in the re"overy of a patient. 1hey "an be trained in reasonablyshort tie and the e?penses in"!rred are "ost+effe"tive. $ro the so"ial angle,this is an opport!nity to provide dignified eployent to ed!"ated #oen. Astate poli"y s!pported by so"ial and health "are organisations is needed to"reate the right balan"e bet#een n!rses and do"tors.

I'HEMAR*ETS

1he disease pattern aong different age gro!ps s!ggests a possibility to

develop several ni"he arkets and offer spe"ialised servi"es. 1he in"reasingn!ber of old+age patients indi"ates the need for a state poli"y to providehealth s!pport to the. 1he health "are ind!stry "an t!rn this into anopport!nity by devising long+ter finan"ial, so"ial and ins!ran"e s"hees.MAR*ETSIE1he potential for private se"tor operations in the health "are arket is high in


52/419



several states. A rational strategy for developent of health "are arket"o!ld be ipleented in the fo!r etros, the ne?t si? large arket to#ns andother affl!ent "ities in the "o!ntry. 1here is #illingness aong *ndians tospend for health "are. 1hro!gh an innovative arketing strategy to "reateba"k#ard flo#, this servi"e "an be e?ported to other "o!ntries in Asia.

1he "lientele for "orporate hospitals #ill generally be at the !pper end ofin"oe distrib!tion, generally referred as Q1he Very Ri"h7 and Q1he Cons!ingClass7 and a fra"tion of QClibers7. 1he a!thor estiates the potential arketfor health "are in *ndia to be aro!nd Rs (,000 "rore by 20(0. 1his #ill still bean !nderestiation, sin"e e?e"!tive privileges are be"oing ore and oregenero!s the #illingness to pay for a "!re, as an attit!de, is getting strongerany edi"al ins!ran"e prod!"ts are being introd!"ed in the arket and thegro#th of "orporate hospitals is an in"reasing trend leading to "opetition.

LAST4ORD

1he *ndian health "are se"tor has high e"onoi" potential and is at a t!rningpoint for gro#th. 1here is every possibility of it be"oing an e"onoi" gro#thengine. *n the last (0 years, a great deal of developent has taken pla"e inthe health "are ind!stry in ed!"ation, te"hnology, availability of treatent,arketing, organisational str!"t!re, private initiative and poli"y "hanges.

1o !se terinology fro physi"s, health "are ind!stry has oved o!t ofinertia and gathered oent!, developing in all spheres at an a""eleratedphase. @o#ever, fro a so"iologi"al point of vie# and on a "oparative s"ale,the e?pendit!re for treatent reains !naffordable and high for the "oonan. 1he large r!ral pop!lation "ontin!es to be deprived of the advan"es andthe lo# ;!ality of the "lini"al pro"esses are not !n;!estionable.

*n order to get a better idea on the latest developents in the health "arese"tor>poli"y initiatives by &overnent of *ndia on health "are teleedi"ineappli"ations in the "o!ntry stat!s of edi"al to!ris oint vent!res andb!siness initiatives by *ndian b!siness leaders proJe"tions on vario!s

reso!r"es !sed Spending pattern of the "lientele and sie of the health "arearket>the reader ay look into, Q@ealth"are, An 5npre"edentedpport!nity7, on the #ebsite of *ndia %rand ';!ity $o!ndation H###.ibef.orgI .
http://www.ibef.org/http://www.ibef.org/http://www.ibef.org/


53/419

18A.V. SRINI+ASAN


AE


54/419



/ark, 9. (33s Te)tbook of &reventive and %ocial "edicine.abalp!rB %anarsidas %honot.

Raaani, S. (33. Q@o!sehold S!rvey of @ealth Care 5tilisation and '?pendit!re7, "argin*!ly+

SepteberB 8=+


55/419

)lanning a Modern Hospital

9.%. %ubba 8ao

)lanning a e! Hos$ital

lanning is the ost iportant aspe"t of establishing a hospital. *f the planis good all ay go #ell. *f the plan is not tho!ght o!t "aref!lly the #ork

ay never be "opleted. /lanning a ne# hospital starts #ith setting goals forthe hospital, #itho!t #hi"h the organisation "annot have a definite dire"tionor fo"!s. 1his is follo#ed by the st!dy of the e?ternal environent of theorganisation, and the internal and e?ternal reso!r"es #ith #hi"h the goals setare to be a"hieved. 1his e?er"ise fa"ilitates sele"tion of the eans by #hi"hto a"hieve goals #ithin a reasonable "ost. *t is !"h ore than planning tob!y a pie"e of e;!ipent here or arrange for re"r!itent of a spe"ifi" do"torthere. *n *ndia, as all over the #orld, hospitals are key health "are deliveryinstit!tions. At the tie of independen"e, the "o!ntry had (,(4,000 beds. 1hebed+to+pop!lation ratio #as 0.2 beds per (,000 pop!lation, #hi"h #asgrossly inade;!ate. 1here is one bed per (,< pop!lation in *ndia no#, #hileit is one to (


56/419


operational "osts, b!t also generate s!rpl!s for e?pansion and ade;!ateret!rns for the investors.


57/419

22A.V. SRINI+ASAN

/lanning a ne# hospital, or adding fa"ilities in an e?isting one, starts #ithsetting goals for the hospital as a #hole. Eitho!t goals, the organisation"annot have dire"tion. 1he hospital planning e?er"ise "overs the st!dy of these"tion of the pop!lation it proposes to serve, the geographi"al area to be"overed, variety of servi"es to be provided, ;!ality standards to be et,e;!ipent to be provided and anpo#er to be re"r!ited and trained. Ehileplanning, these fa"tors sho!ld be taken into a""o!nt. 1he steps involved inplanning the fa"ility are "onsidered serially.

)ROMOTER5SO.6E'TI+E

1he prooter needs to deterine the obJe"tives of the proJe"t #ith "larity.1hese in"l!de the type of servi"es to be providedB

Se"ondary "are)tertiary "are. Sophisti"ation in the b!ilding plan and e;!ipents. 1he investents and ret!rns the prooter is looking for.

1o rationally deterine the above, a feasibility report based on a arkets!rvey is essential.

'easibility re$ort

1he st!dy sho!ld "learly bring o!t the follo#ingB

1he potential of the planned instit!tion. 1he edi"al fa"ilities that are la"king and need to be ade available. 1he igration pattern of patients. Copetition fro e?isting hospitals and ne# entrants.

%ased on observations and findings fro the arket s!rvey, a detailed'ro?ect re'ortsho!ld be prepared, #ith the follo#ing obJe"tivesB

1o re"oend edi"al fa"ilities in ters of departents ande;!ipents. 1o deterine anpo#er re;!ireents. 1o proJe"t finan"ial perforan"e for the first (0 years of operation. 1o arrive at an ipleentation s"hed!le for "opleting the proJe"t. 1o st!dy the s"ope for f!t!re e?pansion of fa"ilities.

1he report sho!ld realisti"ally dis"!ss Qoperational7 feasibility, finan"ial


58/419

Healt)'areinIndia(A Proileandt)e!#t#re2&

viability and the edi"al departents in heavy deand in thr!st areas. *tsho!ld alsoanalyse the lo"ation of the site, the hospital design, anpo#er planning,proJe"t "ost, finan"ial analysis, sensitivity analysis and ipleentation.

LO'ATION

1he follo#ing "hara"teristi"s sho!ld be "onsideredB

1he land sie sho!ld be ade;!ate for ho!sing the instit!tion and also

have aple provision for f!t!re e?pansion. Areas ideal for vario!s bed"apa"ities sho!ld be indi"ated. &ood infrastr!"t!ral fa"ilities, s!"h as #ater, po#er, transportation and

"o!ni"ation sho!ld be available. /ro?iity of the lo"ation to the different segents of the potential

arket is an iportant fa"tor.

MAR*ETS,R+E/

1o deterine the feasibility of the proJe"t, the first "onsideration in the s!rveyis to st!dy the "hara"ter, needs and possibilities of the "o!nity #hi"h thehospital is going to serve. 1he e?isting edi"al fa"ilities in the region sho!ldbe st!died in ters ofB

P!ality and n!ber of hospitals. 1he areas of spe"ialisation>do"tors)spe"ialists)paraedi"al staff. 6evel of te"hnology, latest edi"al e;!ipent. /atient flo#, disease pattern. Costs of investigation and treatent.

/!bli" opinion regarding the e?isting fa"ilities, the need for oredepartents, and the response fro the edi"al "o!nity are vital to thest!dy. *t is on the basis of this inforation that a de"ision "an be taken abo!t

#here a hospital sho!ld be b!ilt and its type and sie. *s the "o!nity a#ealthy one or is it ade !p of oderate #age earners are the ind!strial#orkers indigent>these are the de"iding fa"tors in deterining the kind ofhospital sho!ld be planned for. $or e?aple, if the "o!nity largely"onstit!tes #ealthy individ!als, one "an plan to b!ild a l!?!rio!s hospital,#ith del!?e roos and sophisti"ated diagnosti" and therape!ti" e;!ipent ifit is largely eant for indigent patients, a non+profit or "haritable hospital isneeded.


59/419

2$A.V. SRINI+ASAN

Apart fro levels of in"oe, "hara"teristi"s s!"h as o""!pation, agedistrib!tion, and so on !st be st!died. 1hese deterine the ao!nt andkind of hospital fa"ilities the ne# lo"ation #ill need, and the ao!nt theresidents are #illing to pay. $or e?aple, if there is a large pop!lation ofsenior "itiens, ore geriatri" servi"es #ill have to be provided. *f it is ana""ident+prone ind!strial area, then the tra!a "are departent needs to bestrengthened. 1he general attit!de of the people to the "lini"al servi"es ise;!ally iportant.

1he ne?t phase of the s!rvey is to st!dy all the e?isting hospital fa"ilities on

an area+#ise basis. 1his st!dy sho!ld be "oprehensive, "overing both short+and long+ter needs. 1he ost iportant part of the st!dy is an inventory ofthe fa"ilities, beds and servi"es of every hospital. *t sho!ld "over the follo#ingareasB

%ed "apa"ity of the instit!tion /hysi"al "ondition of fa"ilities @ospital o""!pan"y %ed ratio Vol!e and kind of hospital servi"es provided P!ality of fa"ilities and servi"es

1he st!dy sho!ld in"l!de an assessent of the re;!ired staff and servi"es> do"tors, n!rses and other professional staff re;!ired for the proposedhospital, and the hospital7s ability to initially provide the and s!bse;!entlys!pport the.

$inding and retaining "opetent spe"ialist do"tors and n!rses in ade;!aten!bers is not an easy Job at the best of ties. 1his diffi"!lty is parti"!larlya"!te in to#ns and reote areas. *t is not !n!s!al to find hospitals, #hi"hother#ise have all fa"ilities, b!t are !nable to provide good servi"e to the"o!nity d!e to la"k of staff Htho!gh soe of the ay ake teporaryarrangeentsI.

@o# any and #hat kind of spe"ialists are re;!ired for a hospital toprovide ade;!ate "are for the "o!nity7s needs has to be "aref!llyanalysed and de"ided !pon. *t is generally agreed that in addition totraditional servi"es, s!"h as internal edi"ine, general s!rgery, paediatri"s,obstetri"s and gynae"ology, spe"ialists in the dis"iplines of eye, ear+nose+throat H'N1I, deratology, radiology, pathology, and so on, ay also need tobe provided. Not all sall+ and edi!+sie hospitals "an s!pport spe"ialtyand s!perspe"ialty servi"es.


60/419

Healt)'areinIndia(A Proileandt)e!#t#re2-

1he ain e?er"ise is to a";!ire the servi"es of trained n!rses and otherprofessional staff. &etting trained n!rses is a serio!s proble in o!r "o!ntry.Eell+;!alified laboratory te"hni"ians and phara"ists are freely available.@o#ever, the sae is not tr!e of physi"al therapists and spe"ialisedte"hnologists.A+ERAGE'OSTS

1he "ost "op!ted per bed depends on vario!s fa"tors, s!"h as the "ost ofthe land in a parti"!lar pla"e, the #age and salary rate, a""essibility ofaterials, and so on. Siilarly, sophisti"ated e;!ipent and e?pensive

"onstr!"tion aterial #ill signifi"antly enhan"e the investent. @o#ever,indi"ative average "osts for a typi"al hospital e?pressed as Qper bed7, keepingthe "!rrent level of "osts, #o!ld appro?iately beB

/riary "areB Rs 8 lakh. Se"ondary "areB Rs (2 lakh. 1ertiary "areB Rs 20 lakh.

1he above are only referen"e fig!res, the a"t!al "osts #ill be s!bJe"t to ahigh variation depending on a variety of "onsiderations.

%ONSIDERATIONS@ealth "are is essentially a servi"e ind!stry. /atients #ill look for ;!alityservi"e and e?pe"t "opassion. 1hese intangible fa"tors !st be anifestedand be obvio!s at the planning stage itself.

1he physi"al setting of the hospital !st "onnote a "lean and "heerf!lenvironent.

1he "ons!ltants and staff in a hospital are its biggest assets. 1hey areresponsible for providing ;!ality servi"e to the patients.

1raining of the staff is the ost iportant "riterion and !st beephasised fro the o!tset.

'INAN'IALPLANNING

odern hospitals are "ost+intensive. $inan"ial planning is "r!"ial. 1heparaeters !sed by finan"ial instit!tions for san"tioning ter loans are #ellkno#n. %!t seeking their approval needs a lot of do"!entation, andgenerally takes three onths to one year. /roviding in"oplete inforation#ill res!lt in delay, affe"t the "ash flo# for the proJe"t, and haper the


61/419

2%A.V. SRINI+ASAN

progress. $inan"ial needs sho!ld be anti"ipated and planned for. 1his "oversboth operational needs as #ell as f!nds for a";!isition of "apital ites. nesho!ld be ready #ith ore than one proJe"tion, s!"h as, #hat happens if,

*n"oe is lo#er by, say, (0 per "ent. '?penses are higher by, say, ( per "ent. %ank san"tions loans for a saller ao!nt.

An e?er"ise providing finan"ial res!lts !nder "hanging ass!ptions andtheir eval!ation, "alled Qsensitivity analysis7, sho!ld be "arried o!t.

SO,R'ESO!!,NDS

1he re;!ireent of f!nds needs to be "onsidered as !nderB

Long,term funds

&enerally these long+ter f!nds are not taken o!t of the b!siness. n"einvested, these are traditionally !sed for a";!iring long+ter assets and forthe provision of #orking "apital. Ade;!ate provision for long+ter f!nds !stbe ade d!ring the initial years #hen a";!isition of aJor assets takes pla"e,and it takes t#o to three years to rea"h a break+even level of in"oe.

1he so!r"es of long+ter f!nds areB /rooters7 "ontrib!tion. perating profit pl!s depre"iation. 6ong+ter loans. 6easing "opanies.

S#ort,term funds

1hese f!nds are !sed to eet "!rrent e?penses s!"h as payents to staff,s!ppliers, for servi"es, and for ites of #orking "apital.

Sources for ac=uiring finance /rooters #ho provide "apital f!nds. State and lo"al governent a!thorities #ho give s!bstantial grants. %anks and finan"ial instit!tions, s!"h as *nd!strial -evelopent %ank of

*ndia H*-%*I, *C*C* %ank, for teporary and long+ter loans. -isinvestent of non+perforing assets.

Allo"ation of f!nds for "onfli"ting deands needs "aref!l planning and


62/419


ingen!ity, as opti! !tilisation a""elerates the proJe"t, and s!b+opti!!seay stall the proJe"t. Assistan"e fro a finan"ial "ons!ltant is ne"essary forproper planning, anageent and "ontrol of finan"es.

Some (m$ortant %onsiderations

A hospital is a "r!"ial organisation and stands !ni;!e and in"oparable toany other organisation. *t is !ni;!e and spe"ial be"a!se it deals #ith life and

death. /atients are not J!st attra"ted by high+te"hnology. 1he deand no# isfor devoted do"tors, propt and a""!rate diagnosti" fa"ilities, ;!ality n!rsingand a good s!pport servi"e. Soe of the "onsiderations #hile planning ahospital are dis"!ssed in this se"tion.

)RO+ISION!ORDISASTERS

*n lo"ations #here there is a history of h!rri"anes, tornadoes, floods,earth;!akes, or other nat!ral disasters, planning and design sho!ld "onsiderthe need to prote"t the life and safety of all health "are fa"ility o""!pants, andthe potential need for "ontin!ing servi"es follo#ing s!"h a disaster.

',N'TIONALRE7,IREMENTS

Ehen "onstr!"tion is "oplete, the fa"ility sho!ld satisfy the f!n"tionalre;!ireent for the appropriate "lassifi"ation, s!"h as general hospital,tertiary "are, single+spe"ialty "entre, and so on.

SITINGANDORIENTATION

Siting and orientation is an iportant part of every proJe"t, not only foraestheti"s and a""ess, b!t also to !tilise the potential to "apt!re or avoidnat!ral energy. 6ands"aping provides shade, siting provides prote"tion frod!sty #ards, !tilisation of the prevailing breee, orientation effe"ts and

#indo# arrangeent for e?pos!re to the s!n7s rays. Consideration ofalternate sites ight be appropriate #here physi"al, infrastr!"t!ral or otherrestri"tions ake effe"tive orientation ipra"ti"al.

&HEEN+ELOPE

1he envelope or e?terior en"los!re, in"l!ding "onfig!ration, fenestration, #allaterials, "olo!rs, ins!lation, sealing, roofing and #all areas of e?pos!res,overhangs, and so on, as #ell as ass, #ill affe"t energy deands. 6avish


63/419

28A.V. SRINI+ASAN

air"onditioning ay res!lt in a str!ggle to eet ele"tri"ity bills.

%ONSER+ATION O!EN+IRONMENTANDIN!E'TION'ONTROL

1his !st be #ell+planned and ade;!ate eas!res for s!""essf!lipleentation need to be addressed fro the very o!tset of the proJe"t.

EN+IRONMENTAL IMPA'TANAL/SIS

No adverse effe"t Heven a negligible oneI on the environent of the

neighbo!rhood and "o!nity !st be ens!red. $or instan"e, noise, poll!tedair, traffi" noise> in"l!ding air traffi">and lo"ation of in"inerators needattention.

SPONSOR5SO.LIGATION

1he sponsor for the proJe"t sho!ld provide a prograe for the f!n"tioning ofthe fa"ility that des"ribes spa"e re;!ireents, staffing patterns, departentalrelationships, and other basi" inforation relating to the f!lfilent of theinstit!tion7s obJe"tives. 1his ay be general or detailed, b!t sho!ld in"l!de ades"ription of ea"h f!n"tion, the appro?iate operational spa"e needed for

ea"h f!n"tion, n!ber of staff or other o""!pants of vario!s spa"es, typesand sies of beds and e;!ipent, and interrelationships of vario!s f!n"tionsand spa"es. *t sho!ld in"l!de a des"ription of those servi"es ne"essary for the"oplete operation of the fa"ility. $a"ilities #hi"h already e?ist in the"o!nity need not be d!pli"ated.

',T,REEPANSION

1he f!n"tional prograe sho!ld also address the potential for f!t!ree?pansion of essential servi"es, s!"h as F+rays, laboratories, and !pgradationby adding on agneti" Resonan"e *aging HR*I, Cop!terised 1oographyHC1I S"an, and so on.

STANDARDS1he hospital sho!ld eet all standards that have to be stat!torily "oplied#ith.SIE

-epartent sie #ill depend on the prograe re;!ireents andorganisation of servi"es #ithin the hospital. Soe f!n"tions ay be "obined


64/419


or shared, provided the layo!t does not "oproise safety standards,edi"al and n!rsing pra"ti"es.

Basic Minimum +e=uirements for a Hos$ital of /1 Beds

Setion 19 !ailities Scope1his standard "overs the ini! basi" re;!ireents for 40+beddedhospitals, in"l!ding physi"al spa"e, staff and e;!ipent.

'unctions

A 40+bedded hospital sho!ld generally have the follo#ing fa"ilitiesB

Grou$ > Medical and Allied "isci$lines

Anaesthesiology %lood bank -entistry HoptionalI 'ergen"y edi"ine &eneral edi"ine &eneral s!rgery

bstetri"s and &ynae"ology /aediatri"s

Grou$ 0> Healt# and Allied Services

$aily #elfare @ealth ed!"ation aternal and "hild health "are N!trition S"hool health "are

Grou$ /> ursing? )aramedical and Allied Services

-ental te"hnology HoptionalIB in"l!ding dental hygiene

-ieteti"s and 1herape!ti" "atering HoptionalI -r!gs and /hara"y 'le"tro"ardiography H'C&I te"hnology 6aboratory te"hnology 6a!ndry te"hnology HoptionalI edi"al re"ord te"hnology N!rsing servi"es perating theatre te"hnology HoptionalI in"l!ding anaesthesia te"hnology


65/419

&0A.V. SRINI+ASAN

Sterilisation and disinfe"tion Central Sterile Servi"es -epartent HCSS-Ite"hnology

5ltraso!nd iaging F+ray iaging

Grou$ 2> Engineering and Allied Services

'le"tri" s!pply, in"l!ding po#er generation and stabilisation @orti"!lt!re, in"l!ding lands"aping 6i;!id /etrole! &as H6/&I s!pply HoptionalI

e"hani"al transport, in"l!ding ab!lan"e servi"e edi"al gases s!pply and va"!! HoptionalI Refrigeration

Se#age treatent and disposal H#here re;!iredI, in"l!dingsanitation and drainage

Solar energy HoptionalI Solid #aste disposal, in"l!ding in"ineration 1elephone and "o!ni"ation, in"l!ding paging Eater treatent and s!pply H#here re;!iredI, in"l!ding pl!bing Eorkshop HoptionalI

Grou$ 3> Administrative and Ancillary Services

A!dio+vis!al servi"es, in"l!ding field p!bli"ity &eneral adinistration @o!sekeeping aterials anageent, in"l!ding inventory "ontrol edi"al so"ial #ork HoptionalI Se"!rity


66/419

Healt)'areinIndia(A Proileandt)e!#t#re&1

al @one

ostic @one

((12

mediate @onence @one

1-: Laundry1%: Manifold13: Sub,station18: orks#o$1: Mortuary20: incinerator

Setion 29 .ed Distri;#tion Bed

distribution

*t is s!ggested that the allo"ation of beds for obstetri"s, gynae"ology andpaediatri"s "o!ld be 20, and rest of the (0 beds "o!ld be s!itably dividedbet#een other spe"ialties, s!"h as edi"ine, S!rgery, 'ergen"y, and so on.*n "ase the need arises, beds eant for a parti"!lar departent sho!ld be

available for other departents.

Setion &9 Spae and P)ents General1his se"tion "overs spa"e, physi"al and environental re;!ireents for a 40+bedded hospital. 1he b!ilding "an be divided a""ording to the f!n"tionsdes"ribed in Se"tion (. A typi"al #ork+flo# analysis is given in $ig!re 2.(.

'igure 0. ork,flo! Analysis

Administrative @one

6 1

Ambulatory @one

(2

1: +ece$tion+egistration2: )#armacy&: E:amination%onsultation$: ursing Station-: %linical Laboratory%: (maging

3: )atient Area8: ursing Station: *$eration eatre10: Labour +oom11: GeneralAdministration

1& 1$ 1- 1%

13 18 1 20


67/419

&2A.V. SRINI+ASAN

12: General Stores1&: 4itc#en1$: %SS"


68/419

&otal area

1he total area to be provided for a hospital "ople? #ill depend on theavailability of land. @o#ever, for g!idan"e, an area of ( he"tare or ore isre"oended for a 40+bedded hospital.

Site $lanning

@ospital sites #ith a high degree of sensitivity to o!tside noise sho!ld beavoided, b!t ay be "opatible #ith other "onsiderations, s!"h as

a""essibility and availability of servi"es. 1he b!ildings sho!ld be so plannedthat sensitive areas like #ards, "ons!lting and treatent roos andoperation theatres are pla"ed a#ay fro e?ternal noise. Ehile planning thehospital b!ilding, the iportan"e of lands"ape eleents s!"h as open areasand horti"!lt!re to in"rease the "ofort "onditions inside the b!ilding and inthe s!rro!nding environent sho!ld be kept in vie#. rientation of b!ildingsho!ld "onfor to provisions and re"oendations "ontained in *SB


69/419

Lone $!n"tions Area)%ed 1otalAreaHs;!are etreI Hs;!are etreI

/!bli" 5tilities

Cir"!lation Spa"e

Abulatory @one '?aination andEork!p (0 400

!t+patient -epartent H/-I #)aination 8oos

> S!b+

#aiting

Cons!ltation

> Cons!ltation Roos

> 1oilets

> S!b+

#aiting

N!rsing

Station

> N!rses7 -esk

> Clean 5tility

> -irty 5tility

> 1reatent Roos

> *nJe"tion and -ressing

> Saple Colle"tion

> 'C&

> 5ltraso!nd

> S!b+#aiting /!bli"

5tilities

Cir"!lation

Spa"e

iagnostic @one Clini"al6aboratory = (80

> Saple Colle"tion

> %leeding Roo

&able 0. 'unctional and Area Analysis for a /1,bedded Hos$ital@one Functions Area3ed

suare etre

Total Area

suare etre

#ntrance @one Re"eption and Registration

> Re"eption Co!nter

> Re"ord Storage

/hara"y

> *ss!e Co!nter

> $or!lations

> -r!gs Storage

2 =0


70/419

> 6aboratory

> Eashing)-isinfe"tion

> Storage

> S!b+

#aiting

*aging

> /reparation

> Change

> 1oilet

> 1reatent Roo

> Control> -ark Roo

> S!b+

#aiting /!bli"

5tilities

Cir"!lation

Spa"e


71/419

Area)%edHs;!are

etreI

1otal AreaHs;!are

etreI

Lone $!n"tions

*nterediate Lone Eard 2 N!rses7 -esk

> Clean 5tility

> -irty 5tility

> /antry

> 1reatent Roo

> Store

> 1rolley %ay/atient Area

> %ed Spa"e

> 1oilets

> -ay Roo

> *solation

An"illary Roos

> -o"tor7s Rest Roo

> N!rse7s -!ty

Roo /!bli" 5tilities

Cir"!lation Spa"e

/atient Area

> /reparation> /re+anaesthesia

Staff Area

> Changing

> Restin

g 1)6R

Area

> S"r!b and &o#n

> /reparation

> peration)6abo!r Roo

> -isposal

An"illary Area

> 1rolley %ay

> ';!ipent Storage> Sterile

Storage /!bli"

5tilities

Cir"!lation

Spa"e 9it"hen

> -ry Store

> -ay Store


72/419

Lone $!n"tions Area)%ed 1otal AreaHs;!are etreI Hs;!are etreI

> /reparation

> Cooking

> -elivery

> /ot Eash

> 5tensil Eash

> 1rolley /ark

CSS-

> Re"eipt

> Eash

> Assebly

> Sterilisation

> Sterile Storage

> *ss!e

6a!ndry

> Re"eipt

> Eeight

> Sl!i"e+Eash

> @ydro+'?tra"tion

> 1!ble> Calender

> /ress

> Clean Storage

> *ss!e

anifold

> 6anding %ay

> anifold

> Copressor

> Va"!!

S!b+

station

> @.1. /anel> 1ransforer

> 61 /anel

> &enerator Set

> Stabili

ser /!p

@o!se


73/419

Eorkshop

*n"inerato

r

%onstructional re=uirements

Circulation areas

Cir"!lation areas, s!"h as "orridors, entran"e halls and stair"ases in thehospital b!ildings sho!ld not be less than 40 per "ent of the total floor areaof the b!ilding.

'loor #eig#t

1he height of all the roos in the hospital sho!ld not be less than 4.00 and not ore than 4.= , eas!red at any point fro the s!rfa"e of thefloor to the lo#est point of the "eiling. 1he ini! headroo, s!"h as!nder the botto of beas, fans and lights sho!ld be 2.0 eas!redverti"ally !nder a bea, fan or light.

1he height of the operation theatres ay be s!itably in"reased if vie#inggalleries are provided.Roos sho!ld have, for the adission of light and air, one or ore

apert!res, s!"h as #indo#s and fan lights, opening dire"tly to the e?ternalair or into an open verandah. 1he ini! aggregate areas Hif a #indo# ispartly fi?ed, the area #hi"h "an be opened sho!ld be taken into a""o!ntI ofs!"h openings, e?"l!ding doors b!t in"l!sive of fraes, sho!ld not be less

@one Functions Area3ed

suare etre

Total Area

suare etre

Adinistrative @one ort!ary

> Re"eipt)*ss!e

> %ody Store /!bli"

5tilities Cir"!lation Spa"e

&eneral Adinistration

2 =0

&eneral Stores /!bli" 5tilities

Cir"!lation Spa"e

Total =0 (800


74/419

than 20 per "ent of the floor area in "ase s!"h apert!res are lo"ated in one#all, and not less than ( per "ent of the floor area in "ase s!"h apert!resare lo"ated on t#o opposite #alls at the sae sill level.

1he ar"hite"t!ral finish in hospitals sho!ld be of high ;!ality in vie# ofaintenan"e of hygieni" "onditions, espe"ially in sanitary blo"ks. $looring insanitary blo"ks sho!ld preferably be done #ith arble or polished stone, anddado or glaed)"erai" tile finish given on #all.

1he design of the b!ilding sho!ld ens!re that noise "a!sed by #alking,oveent of trolleys, banging of doors, and so on does not penetrate intoother areas. '?pansion Joints sho!ld have a non+etalli" beading finish.

Sanitary fitments

1he re;!ireents of the sanitary fitents sho!ld be in a""ordan"e #ith"la!se(


75/419

Medical records

*t is desirable to aintain the edi"al re"ords of the o!t+patient departent,in "ontin!ation of registration area.

%linics for various medical disci$lines

1hese "lini"s in"l!de general edi"ine, general s!rgery, obstetri"s,gynae"ology and paediatri"s. 1he "!bi"les for "ons!ltation and e?ainationin all "lini"s sho!ld provide for the do"tor7s table, "hair, patient7s stool,

attendant7s seat, #ash basin, e?aination "o!"h and e;!ipent fore?aination. 1he treatent and dressing roo sho!ld be spa"io!s eno!ghto a""oodate a edi"ine shelf, sinks, dress tables #ith s"reen in bet#eenand a pedal+operated bin to hold soiled aterial. 1he edi"al "lini" sho!ldhave fa"ilities for "ardiographi" e?aination.

"ental clinic 5*$tional8

-ental "lini"s ay have fa"ilities for dental hygiene, dental #orkshop androo for patient7s re"overy. 1he "ons!ltation+"!+e?aination roo sho!ldserve as a !ltip!rpose roo for "ons!ltation, e?aination, dental s!rgeryand treatent.

*bstetric and gynaecological clinic

1he "lini" sho!ld in"l!de a separate re"eption and registration area,"ons!lting+ "!+e?aination, treatent and "lini"al laboratory. *t sho!ld beplanned "lose to in+patient #ard !nits, to enable the to ake !se of the"lini" at ties for ante+ and postnatal "are. 1he "lini" sho!ld also be at a"onvenient distan"e fro other "lini"s in the /-. Antenatal patients have to!ndergo "ertain foralities prior to e?aination by the do"tors, so a "lini"allaboratory for this p!rpose is essential. A toilet+"!+"hanging roo "lose tothe treatent roo sho!ld also be provided.

'amily !elfare clinic1he "lini" sho!ld provide ed!"ative, preventive, diagnosti" and "!rativefa"ilities for obstetri" and gynae"ologi"al treatent, paediatri" and healthed!"ation. 1he iportan"e of health ed!"ation is being in"reasinglyre"ognised as an effe"tive tool of preventive edi"ine. /eople visitinghospitals sho!ld be infored abo!t environental hygiene, "lean habits,


76/419

need for taking preventive eas!res against epidei"s, faily planning, andother s!"h iss!es. 1he treatent roo in this "lini" sho!ld a"t as theoperation roo for intra+!terine "ontra"eptive devi"e H*5C-I insertion andinvestigation, and so on.

)#armacy 5dis$ensary8

1he dispensary sho!ld be lo"ated in an area "onveniently a""essible fro all"lini"s. *ts sie sho!ld be ade;!ate to a""oodate per "ent of the total"lini"al visits to the /- in one session, at the rate of 0.8 s; per patient.1he dispensary and "opo!nding roo sho!ld have !ltiple dispensing#indo#s, "o!nters and shelves. 1he plan a""ording to #hi"h the "o!ntersand shelves are arranged #ill depend on the sie of the roo. edi"ines thatre;!ire "old storage !st be kept in refrigerators.%asualtyEmergency

'ergen"y "ases sho!ld be attended by /- d!ring /- ho!rs and in #ardsafter#ards.

%linical laboratory

1he "lini"al laboratory sho!ld be provided #ith a =0 " to 80 " high ben"h

of abo!t 2 length per te"hni"ian, and the f!ll #idth of the roo for thepathologist in "harge of the laboratory. 'a"h laboratory ben"h sho!ld have alaboratory sink #ith s#an+ne"k fittings, reagent shelving, gas and po#erpoint and !nder+"o!nter "abinet. 1he top of the laboratory ben"h sho!ld beof a"id)alkali+proof aterial.

(maging

General

1he role of the iaging departent sho!ld be radio diagnosis. Radiology is afast+developing te"hni;!e, and the departent sho!ld be designed keepingin vie# s"ope for f!t!re e?pansion. 1he departent sho!ld be lo"ated at apla"e #hi"h is easily a""essible to both /- and #ards, and also to theoperation theatre.

As the departent deals #ith high voltage, presen"e of oist!re in thearea sho!ld be avoided. Radiography is a devi"e for aking pi"torial re"ordsby eans of F+ray sensitised fil, #hereas fl!oros"opy is dire"t vis!alisationthro!gh edi! of F+ray.


77/419

+ece$tion,cum,registration !it# !aiting areas and toilet

An independent registration se"tion sho!ld be provided #here radiology is anindependent departent. 1he sie of the "o!nter sho!ld be s!ffi"ient toa""oodate a "lerk7s seat and re"ord "hests. *t ay be interposed #ith the#aiting area. 1oilet fa"ilities, separately for en and #oen patients, sho!ldbe pla"ed "lose to #aiting areas.

+adiology and fluorosco$y room

1he sie of the roo depends !pon the type of e;!ipent installed. 1heroo sho!ld have a s!b+#aiting area #ith toilet fa"ility and a "hange roofa"ility, if re;!ired. 1he fl!oros"opy roo sho!ld be "opletely devoid ofdire"t light by provision of air+lo"k. Radiography !nits sho!ld be operatedfro a separate "ontrol roo, or behind a lead obile prote"tion s"reen of(0 lead e;!ivalent, #herever ne"essary.'ilm develo$ing and $rocessing room

$il developing and dark roos sho!ld be provided in the departent forloading, !nloading, developing and pro"essing of F+ray fils. 1he roosho!ld be provided bet#een a pair of radiography roos, so that ne# ande?posed F+ray fils ay be easily passed thro!gh the "assette pan #ith 20 lead ba"king installed in the #all in bet#een. 1he roo sho!ld be"opletely "!t off fro dire"t light thro!gh provision of airlo"k. $orventilation, e?ha!st fans sho!ld be provided. 1he roo sho!ld have aloading ben"h H#ith a"id and alkali resistant topI, pro"essing tank, #ashingtank and a sink. $looring for the roo sho!ld be a"id and alkali proof.

'ilm drying

/rovision of spa"e sho!ld be ade for drying fils either by atospheri"drying, or by e"hani"al "ontrivan"es in the for of hot "habers.

Stores

1he "!pboards or b!ilt+in+"!pboards re;!ired for storing fils and "hei"alsay either be pla"ed in the radiologist7s roo, or in a separate store. 1he!ne?posed fils sho!ld be stored a#ay fro the radiography roo.@o#ever, in "ase the !ne?posed fils are to be stored in the darkrooadJa"ent to the radiography roo for a teporary period, these ay bestored in a 20 lead+lined bo?.


78/419

(n,$atient nursing units

General

1he *n+patient N!rsing 5nits Hthat is, #ardsI "on"ept is fast "hanging d!e tothe poli"y of early ab!lation, and only a fe# patients really need to be onbeds. 1he basi" "onsideration in the pla"eent of #ards is to ens!res!ffi"ient n!rsing "are, segregating patients a""ording to three "ategories,lo"ating the a""ording to the needs of treatent #ith respe"t to edi"aldis"ipline and "he"king and preventing "ross infe"tion. *n this "ase, theresho!ld be t#o #ard !nits, one for ales and one for feales.

Location

Eards sho!ld be relegated to the ba"k to ens!re silen"e and freedo fro!n#anted visitors.)lanning !ard units

1he #ard !nits sho!ld be ade at the rate of < s; per bed and sho!ld bearranged #ith a ini! distan"e of 2.2 bet#een the "entre of t#obeds, and a "learan"e of


79/419

Table 2.1 continued

)lannin"aModernHospital$$

*bstetrics and gynaecology de$artment

aternity servi"e in"l!des antenatal "are, delivery and postnatal "are.

%efore and after "hild birth, the patient sho!ld be attended at the o!t+patient"lini", and d!ring labo!r the patient is "onfined to bed in the n!rsing !nit.1he o!tpatient "lini" sho!ld also provide diagnosti" fa"ilities for gynae"ologypatients. Sin"e these servi"es are "y"li", it is re"oended that the in+patient !nit is lo"ated "lose to the o!t+patient "lini", aking it easilya""essible to the pregnant #oen.

1he in+patient !nit sho!ld "opriseB

(. a delivery s!ite !nit2. a n!rsing !nit4. a neonatal !nit

and they sho!ld be pla"ed on the sae floor. 1he neonatal !nit sho!ld be"lose to the labo!r roo, spa"io!s and isolated fro the ain #ards, toavoid infe"tions. *t sho!ld have the basi" fa"ilities of good ill!ination,elbo#+operated #ash basin, ro!nd+the+"lo"k r!nning #ater fa"ilities, bea+type #eighing a"hine, s!"tion apparat!s, o?ygen "ylinders and aphototherapy !nit.

ater su$$ly

Arrangeents sho!ld be ade to s!pply (0,000 litres of potable #ater perday to eet all re;!ireents Hin"l!ding la!ndryI e?"ept fire fighting. Storage

(. N!rsing Station, 2. 1reatent Roo, 4. Eard /antry, . Eard Store,. Sl!i"e Roo

Sanitar< re=#ire>ents

1hese are given in 1able 2.2.

Ta;le 2:2 Sanitar< Re=#ire>ents

!te ubers 8euired

Eater "losets 2 for ale #ard

4 for feale #ardAbl!tion taps ( for ea"h #ater "loset pl!s

( #ater tap #ith drainage arrangeent

in the vi"inity of #ater "losets

5rinals 2 for ale #ard

Eash basins 2 for ea"h #ard

%athroos 2 for ea"h #ard

Cleaner7s sinks and sinks)slab for "leaning a"kintoshes ( for ea"h #ard

9it"hen sinks and dish#ashers ( for ea"h #ard in #ard pantry


80/419

)lannin"aModernHospital$-

"apa"ity for t#o days7 re;!ireents sho!ld be on the basis of the abovegiven "ons!ption. Ro!nd+the+"lo"k #ater s!pply sho!ld be ade availableto all #ards and departents of the hospital. A separate reserve eergen"yoverhead tank sho!ld be provided for the operation theatre. Eater storageoverhead tanks #ith p!ping) boosting arrangeent sho!ld be installed.1he laying and distrib!tion of the #ater s!pply syste sho!ld be a""ordingto the provisions of *SB 20=+(3


81/419

$%4.B. S#;;aRao

Emergency lig#ting

'ergen"y portable light !nits sho!ld also be provided in the #ards anddepartents to serve as an alternative so!r"e of light in "ase of po#erfail!re.

%all bells

Call bell H*SB 22=8+(3==I s#it"hes sho!ld be provided for all beds in all typesof #ards, #ith indi"ator light and lo"ation indi"ator sit!ated in the n!rsesd!ty roo.

Stand,by small generatorsStand+by sall generators sho!ld be provided to generate ele"tri"ity andpo#er s!pply to operation theatre air+"onditioners and shado#less laps.1he lightning prote"tion syste of hospital b!ildings sho!ld be in a""ordan"e#ith *SB 2403+(3=3.

Ventilation

Ventilation of hospital b!ildings sho!ld be a"hieved by either nat!ral s!pplyand nat!ral e?ha!st of air, or e"hani"al s!pply and e"hani"al e?ha!st ofair.

1he follo#ing standards of general ventilation are re"oended for

vario!s areas of the hospital b!ilding, based on aintenan"e of re;!iredo?ygen, "arbon dio?ide and other air ;!ality levels and for the "ontrol ofbody odo!r #hen no prod!"ts of "ob!stion or other "ontainants arepresent in the air, or #hen anaesthesia gases #hi"h are highly e?plosive, arepresentB

1he general prin"iples of nat!ral ventilation sho!ld be in a""ordan"e #ith*SB 44=2+(3


82/419

)lannin"aModernHospital$3

a""essibility for aintenan"e and noise "ontrol. '?ha!st fans sho!ld beprovided on #alls on one side, or in the atti" !nder the roof. 1he e?pelled airsho!ld not find entry ba"k into the hospital.

Gas su$$ly

Medical gas

edi"al gases "oprise ainly o?ygen and nitro!s o?ide. Cylinders sho!ldbe ade available.%ooking gas

$or better hygiene, !se of 6/& "ylinders is re"oended. 1hese sho!ld alsobe kept in a roo fro #here a ne"essary pipeline #ith gas o!tlets, asre;!ired, ay be provided to hospital kit"hens and #ard pantries.

Laboratory gas

6/& "ylinders sho!ld be ade available for the pathologi"al lab.Alternatively, kerosene stoves sho!ld be ade available #here gas s!pply isnot available.

&ele$#one and intercom

Eiring in "ond!its sho!ld be provided to give telephone o!tlet points in

roos, #ards and departents, as desired by the a!thorities. An inter"osyste ay also be provided in addition to the telephone. 1he"o!ni"ation syste sho!ld be ade;!ately designed in hospitals to alertall persons looking after patients and all eployees of the hospital #ho areinside the b!ilding in the event of an eergen"y. 1he alar syste sho!ldbe "apable of being operated fro inter"os, telephones and theadinistrative offi"e.

'ire $rotection

Ade;!ate first+aid and fire+fighting e;!ipent sho!ld be provided andinstalled in a""ordan"e #ith *SB 2(30+(3


83/419

$84.B. S#;;aRao

"haber and "hiney.

SE'TION$9 STA!!RE7,IREMENTS

1he staffing pattern for a 40+bedded hospital is presented in this se"tion.1his re;!ireent ay be phased into three stages, as per "onvenien"e anddeand b!ild+!p Hsee 1able 2.4I.


84/419

)lannin"aModernHospital$

! %tage

!!

!!! Total

"edical %taff &eneral edi"ine ( ( 2

&eneral S!rgery ( + ( 2

bstetri"s D &ynae. ( ( + 2

/aediatri"s ( + + (

Anaesthesiology ( + + (

-entist HoptionalI ( + + (

/athologist HoptionalI + ( + (

Radiologist HoptionalI + + ( (

,ealt- %taff$eale @ealth Assistant

( (

'?tension 'd!"ator ( + + (

N!tritionist + ( + (

/!bli" @ealth N!rse + + ( (

ursing %taff atron ( (

peration 1heatre N!rse ( + ( 2

6abo!r Roo N!rse ( ( + 2

&eneral N!rse < ( ( 3

N!rsing Aides < ( ( 3

&araedical %taff /hara"ist)Asst.

/hara"ist

( ( 2

-ietitian)Asst. -ietitian HoptionalI + ( + (

1e"hnologist)1e"hni"ian 'C& ( + ( 2

1e"hnologist) 1e"h. *aging ( + ( 2

1e"hnologist)Clini"al /ath ( ( + 2

@aeatology)%lood %ank ( + + (

1e"hnologist)6a!ndry HoptionalI ( + + (

1e"hnologist)edi"al Re"ords ( + + (

1e"hnologist)CSS- ( ( e?ternalenvironent, organisational assessent, h!an reso!r"es and politi"alpro"esses.

ETERNALEN+IRONMENT1he environent presents "onstraints and opport!nities that need to beanalysed for designing organisations. Soe of the ;!estions that need to beans#ered in this "onte?t areB

(. Ehat are the e"onoi", politi"al and legal "onditions that ay have thesae or de"reased ipa"t !pon the health "are organisationsO

2. Ehat are the deographi" and "!lt!ral "onditions that ay reain thesae, or have a de"reased ipa"t !pon the design of servi"es to berendered by the hospitalsO

4. Eill the ne# organisational fors, like !lti+instit!tional arrangeentsHergers, "orporate str!"t!res, health ins!ran"e arrangeents, and soonI, infl!en"e the design of the hospitalsO

. Ehat are the latest developents in edi"al te"hnology that need tobe a";!ired by the hospitalsO

*RGANISATIONALASSESSMENT1his se"tion deals #ith assessing the ission of the hospital and re"onsiders


90/419

it in relation to its f!t!re environent. *t also deals #ith goals and spe"ifi"strategies developed by the organisation on one hand and the ;!antity,;!ality and type of servi"es to be provided on the other. *n this anner,probles related to the "!rrent str!"t!re and the internal pro"esses of thehospital ay be identified, for e?aple, the inability to anti"ipate problesand take "orre"tive a"tion ;!i"kly, "o!ni"ation barriers, diffi"!ltiesres!lting fro "onfli"ting roles, eployee t!rnover, and re"r!itent andsele"tion probles.

H,MANRESO,R'ES1his involves eval!ating the "apabilities and potential of key persons in theorganisation. 1he ;!ality of perforan"e of senior+ and iddle+anageentprofessionals is iportant not only for eeting the goals of the organisation,b!t for ipleenting proposed "hanges in the organisational str!"t!re. 1he@!an Reso!r"e -evelopent H@R-I strategy also needs to be o!tlined inthe assessent of h!an reso!r"es.

)OLITI'ALPRO'ESS

1his involves a systeati" assessent of the inforal internal dynai"s ofthe hospital. 1he inforal gro!ps and leaders #ho infl!en"e the prograesin the hospital need to be identified. 1his ay help the anageent to allo#these leaders to parti"ipate in the planning and de"ision+aking pro"ess atan early stage.

Eith the help of the inforation that is generated fro the assessent ofthese fo!r "onte?t!al fa"tors, the top anageent #ill be"oe orekno#ledgeable, and #ill be able to take the right de"ision in sele"ting anappropriate str!"t!re for the hospital.

*rganisational Structure

rganisational str!"t!re is defined in any #ays. *t is defined by @odge andAnthony H(38I asB

the hierar"hi"al pattern of a!thority, responsibility, and a""o!ntabilityrelationships designed to provide "oordination of the #ork of theorganisation the verti"al arrangeent of Jobs in the organisation.

/!gh et al. H(3=3I refer to it asB


91/419

a foral syste of intera"tion and "oordination that links the tasks ofindivid!als and gro!ps to help a"hieve organisational goals.

Child H(3


92/419

anagerial tool that aids in g!iding the organisation to#ard its goals, and"an be likened to the skeleton of the organisation+body H@odge andAnthony (38I. 6astly, the organisational str!"t!re defines and governsthe relationships aong the vario!s #ork !nits, ens!ring that all #ork isassigned and "opleted in an orderly fashion, #hi"h in t!rn, "ontrib!tes toeffe"tive overall organisational perforan"e H-!n"an (3


93/419

fe#er the areas of de"ision+aking in #hi"h they are involved, the ore"entralised is the organisation. *t #as also fo!nd that the higher theorganisation7s degree of "entralisation, the lo#er is its rate of prograe"hange H@age and Aiken (3


94/419

rganisations eploying different kinds of professionals are highly "ople?.Aong the servi"e organisations, the hospital is the ost "ople? for oforganisation. ne #ay to eas!re "ople?ity is to deterine the n!ber ofdifferent o""!pations #ithin an organisation that re;!ire spe"ialisedkno#ledge and skills. An organisation is "onsidered "ople? #hen iteploys n!ero!s kinds of kno#ledge and skills and #hen theseo""!pations re;!ire sophisti"ation in their respe"tive kno#ledge and skillareas.*n a hospital, typi"ally, eployees of different o""!pational gro!ps #ill

appear in the #ards d!ring the "o!rse of the day. ne "an find a variety ofdo"tors, adinistrators, n!rses, dietitians, F+ray te"hni"ians, laboratoryte"hni"ians, o""!pational therapists, so"ial #orkers, ho!sekeepers,engineers and others. *n organisations #here there is greater "ople?ity,the greater is the rate of prograe "hange H@age and Aiken (3


95/419

&: e Middle Line

1his "onsists of people #ho "onne"t the strategi" ape? to the operating "ore.1hese are interediate anagers #ho transit, "ontrol and help inipleenting the de"ision taken by the strategi" ape?.

$: e &ec#nostructure

1his in"l!des staff f!n"tionaries and analysts #ho design systes forreg!lating and standardising the foral planning and "ontrol of the #ork.$or instan"e, this f!n"tion is looked after by departents s!"h as finan"e,

prod!"tion planning, h!an reso!r"es, and others.

-: e Su$$ort Staff

1his in"l!des people #ho provide indire"t s!pport to the #ork pro"ess andare not involved dire"tly in it. Servi"es like the "afeteria, ailing andtransport are "onsidered to be a part of it.

intberg H(384I states that by p!tting all these eleents together, #e"an get a "oplete pi"t!re of the #hole organisation. @o#ever, allorganisations are not identi"al they differ in ters of the part #hi"he?er"ises greater "ontrol, and the anner in #hi"h the a"tivities of theoperating "ore are "oordinated, and siilarly #ith other eleents of the

organisation7s str!"t!re. intberg H(383I reported fro the st!dy of (23organisations that only abo!t half "o!ld neatly be fitted into "ertain"ategories. 1he others #ere hybrids, "onforing to t#o or ore"onfig!rations. 1his is likely sin"e organisations are "ople? entities, #ithdifferent parts fa"ing different environental deands, and thereforedeveloping into different "onfig!rations.

@ospital organisations also follo#ed soe of the "onfig!rations that aresiilar to an!fa"t!ring organisations. @o#ever, d!ring their evol!tion, theydeveloped !ni;!e feat!res. 1he ost iportant is an arrangeent "alled thetriad, the foreost e?aple of #hi"h is fo!nd in private and tea"hinghospitals. 1he triad in"l!des the governing body, the "hief e?e"!tive offi"er

and the edi"al staff H-arr and Raki"h (332I. *n theory, the triad peritssharing of po#er and a!thority aong theselves. @o#ever, it is best"hara"terised as an a""oodation rather than sharing. 1hea""oodation res!lts fro the inde'endent status of t-e '-ysicians andconsultants#ho play a aJor role in treating patients in the hospital. S!"ha""oodation #ill be !"h ore effe"tive #hen the governing bodydelegates responsibility to the Chief '?e"!tive ffi"er HC'I and senioranagers for the day+to+day operation of the hospital.


96/419

*rganisational "esigns

Coon organisation designs seen in health servi"e organisations are H6eatand $red (38IB

$!n"tional design -ivisional design Corporate design atri? design /arallel design

1hese designs are briefly e?plained in the follo#ing se"tions.

Date post:	04-Jun-2018
Category:	Documents
Upload:	joeblack555
View:	219 times
Download:	0 times

12- Managing a Modern Hospital

Documents