Hospital Organization and Management PDF

CH# 2: HOSPITAL AND ITS ORGANIZATION Hospital  A hospital is an organization utilizing combinations of specialized scientific equipment and functioning through qualified and trained personnel for restoration and maintenance of good health.  Hospital also serves as medium through which medi...

CH# 2: HOSPITAL AND ITS ORGANIZATION Hospital  A hospital is an organization utilizing combinations of specialized scientific equipment and functioning through qualified and trained personnel for restoration and maintenance of good health.  Hospital also serves as medium through which medical professional staff pools their efforts for the betterment of public health.  In this institution medical services are provided to patients for regaining health  Provision of medical services that are facilitated by medical and associated technical staff of nurses and dietitians Patient  Patient is the focal person around which all the activities of a hospital revolve  This patient may be an in-patient (cloistered in the hospital and occupy a bed for some period) and an out-patient (utilizing hospital facility by not occupying its bed)  The extent of medical services largely depend upon nature of institution  More usually primary emphasis is placed on in-patients  CLASSIFICATION OF HOSPITALS  Hospitals may be classified in number of ways. However., it is worthy to note that a single institution may fall into more than one grouping. The following is a general classification of hospitals.  Based on Services:  General hospitals  Specialty 1. Medicine 2. Surgery 1.1 Internal Medicine 2.1 Orthopedic 1.2 Psychiatric and nervous diseases 2.2 Gynecologic 1.3 Tuberculosis 2.3 Cardiology 1.4 Communicable disease 2.4 Otolaryngologic 1.5 Pediatrics 3. Maternity  CLASSIFICATION OF HOSPITALS  Based on ownership and control  Governmental  Armed forces (Naval, Combined Military Hospitals etc)  Federal Governmental Hospitals  Provincial Hospitals (Head Quarter Hospitals, Social Security Hospitals, Civil Dispensary, Rural dispensary. Basic health units, etc.) Teaching hospitals  Non-governmental  Private for profit  Private charity  A teaching hospital provides clinical instruction to medical college students. In these hospitals, a medical graduate undergoes one year of compulsory hospital training as house job.  Some non-governmental hospitals also maintain intern and residency pro­grams for the training of the medical graduates in various specialties. After graduation , most of physicians look for position in teaching hospitals because these teaching institutions offer further educational opportunities and broad experiences in clinical care of patients.  Ideally a teaching hospital should support educational and research program but the national teaching hospitals have no or very little research program yet in real sense.  Organizational Pattern of Hospitals  The organizational. pattern of a hospital resembles with that of pharmaceutical industries.  The only difference is of positions and titles assigned in hospitals.  The smaller the hospital the fewer the administrative positions.  The large hospitals may subdivide the general areas of clinical units. Organogram for teaching hospital Organogram for private hospital  Organizational Pattern of Hospitals  Management:  The government, military and private hospitals have different management systems.  A medical superintendent, who is appointed by ministry- of health manages the former, military hospital is managed by Commanding officer.  While a private hospital usually has an organized governing body which is responsible for the conduct of the hospital in a manner consistent with its objective of making available high quality patient care.  The total number of members in governing body will vary from hospital to hospital.  The partner ship of some hospitals may consist of large number of people from widely scattered areas, a representative group from within the membership is elected for board of trusties.  This group is known as board of directors, governing board , board of governors or board of managers.  Generally the representatives are selected for their ability to contribute to its effective management.  As part of organizational setup the governing body elects its officers one of which acts as chief executive and causes to appoint a wide variety of committees necessary for the discharge of its duties. These may include an executive committee, building committee, investment and finance committee and a joint conference committee  The governing committee is responsible for defining role of the; 1. Powers and duties of the governing body officers , committees and chief executive officer 2. Qualification for governing body membership 3. Method of selection for membership 4. Tenure 5. Evaluation of performance of employees.  Organizational Pattern of Hospitals Administration:  The board of trustee of a hospital delegates' hospital's active management to an administrator and his staff of associates, assistants, supervisors and departmental heads.  The administrator of a hospital is responsible for operation of the entire institution, assuring institutional staffs and patients of highest possible standards of services and economy by planning, directing and coordination of activities. Thus the future of an institution depends on the capabilities of its administrator.  The administrator of hospital is described as specialist in administration and must specially be qualified and trained for this position. Usually an administrator holds the degree of master of hospital administration However qualified persons holding other degree can also be appointed as administrator.  The main functions of administrator are; 1. Enforce trustee policy in the daily management. 2. Establish organizational structure to carry out programs of the hospital and to meet needs of the patients 3. Implementing the governing body policy on the financial management of hospital 4. Develop and implement a comprehensive management reporting system throughout the hospital 5. Provide maintain and safeguard appropriate physical recourses in the institution 6. Look at the weakness influencing any aspect of institution.  Organizational Pattern of Hospitals  Medical staff: is the group of individuals who are fully licensed to practice medicine.  The medical staff is the backbone of any healthcare institution, thus it must be very well organized and controlled so as can perform at an optimal level of professional performance  The organized medical staff is accountable to hospital governing body and has overall responsibility for quality of medical care , professional services provided and the ethical conduct in the hospital.  The structure of medical staff will vary from hospital to hospital due to varying size and activities of the hospital and its staff. However, typically, this staff may be divided into various categories.  The active medical staff is at the forefront of health provision and delivers dominantly the medical service.  The associate medical staff functions for the advancement to the active medical staff.  Most of the members of this staff are involved in organizational and administrative duties pertaining to medical staff.  The courtesy medical staff consists of practitioners given rights to admit an occasional patient to a hospital.  The consulting medical staff comprised of medical practitioners of recognized professional abilities but are not members of the preceding categories.  The honorary medical staff consists of former staff members, retired or whom the medical staff chooses to honor.  Departmentalization  Departmentalization is the grouping of various sections and divisions according to the same nature of services provided. The degree of departmentalization of the hospital depends entirely upon the extent of specialization of the staff.  In small hospitals, only two departments medicine and surgery will provide all the clinical services. Other significant services may either offered on a -limited basis or sought externally from the outside facility.  Supportive services such as radiology and pathology are usually acquired externally. In a large hospital. hospital staff' is highly specialized and therefore there are greater subdivisions within a clinical department. Clinical department is broadly divided into medicine and surgery.  Clinical Departments  The department of medicine includes the following subdivisions: Internal Medicine Allergy Infectious Diseases Cardiology Endocrinology Dermatology Immunology Geriatrics Nephrology Pediatrics Psychiatry Neurology Rheumatology Pulmonary Diseases Gastroenterology  The Department of surgery is generally divided into the following: General Surgery Orthopedic Surgery Neurologic Surgery Obstetrics & Gynecology Ophthalmology Dental & Oral Surgery otolaryngology Thoracic surgery Urology proctology Plastic surgery  Such subdivisions can be observed in a teaching hospital.  Each of these subdivisions have chief of services who in return is responsible to the departmental chief.  In addition the medical staff is organized in such a manner as to provide fair representation of each individual in the staff through administration and governing body. Support services The functioning of clinical departments is facilitated by supportive or non clinical services The supportive services include  pharmacy department ,  medical records department ,  blood bank , central sterile supply  social services department ,  biomedical department ( for clinical instrumentation ),  maintenance and engineering division.  Pharmacy department  The pharmacy department is 'staffed with pharmacists and is supervised by director of pharmacy or pharmacist-in-chief. This department offers the following services:  Drug distribution, including floor-stock and unit dose distribution  Dispensing of drugs to out-patients  The intravenous admixture program  The clinical services provided from the hospital pharmacy may include therapeutic consultation, drug information, for physicians, nurses, and other allied health personnel and for patients  Pharmacy department Clinical pharmacy practice also encompasses preparation of  patient drug profiles,  recording patient drug history,  advising physicians of possible drug-drug interactions  and drug effects on clinical laboratory test results. It also involves preparation of patient  drug use review,  therapeutic monitoring,  and monitoring of specific adverse drug reactions to decrease their incidences, and management of chronic care patients.  Pharmacy department  Purchasing and inventory control of drugs and allied items.  Conduct and support of pharmaceutical and clinical research, respectively.  Education service for pharmacy personnel, medical profession, nursing staff and for patients.  Serving function for vital committees such as pharmacy and therapeutics committee, infection control, research review, antibiotics, ambulatory and standardization committees.  Special services may include the provision of radiopharmaceutical services, total parenteral preparation, and poison control center. Pharmacy role in hospital  Pharmacy department is one of the many departments of a hospital that exerts a great deal of influence on professional position of the institution as well as upon its economics of the total operational costs.  It is all due to its inter relation with and the inter dependency of other services upon it.  In a hospital setting, doctor diagnosis and prescribes , the pharmacist dispenses the medicines and the nurse administer the drugs to the patients ( unless patient is on self medication regimen)  Clearly then , pharmacist who practices his profession in an institutional environment must be aware of forces operating around him and he must learn not only to understand them but to assist marshalling them towards the ultimate goal of better patient care.  In a teaching hospital , hospital pharmacist has innumerable opportunities to participate in and to develop educational programs for pharmacy medical nursing staff and for patients  Nursing service  Nurse is an individual who attends, helps, teaches, counsels and takes care of the patients, particularly who acquire beds in hospital. Nursing care is an integral part of total health care system and necessary for regaining and maintaining health.  A nursing team is made up of workers with varying degrees of nursing skill and directed by a professional nurse. Helping the patients to help themselves is a new element of nursing practice.  Another element is diversification and specialization of nursing individuals. Now a nurse may be specialized in oncology, blood bank, night nursing care, floor nursing care etc.  Nursing is a noble job and a nurse must respect individuality, dignity, and rights of every patient, regardless of race, color, national origin, and social or economic status.  The nursing service is organized similarly to other service in the hospital and is headed by Director of Nursing with administrative authority. The director of nursing must be an experienced nurse with administrative talent.  As an administrative staff, the director nursing participates in formulating policies and devising procedures required for achievement of objectives, and in developing and appraisal of the quality of nursing services.  In some institutions , director of nursing service is responsible for administration and operation of school of nursing  Dietetic services  Dietetic service is one of the essential services in an institution. It is staffed by adequate numbers of dietitians, technical and clerical personnel and is directed by a person with professional qualifications in nutrition. This is responsible for preparation of palatable and appropriate food by applying effectively the principles of nutrition science.  In Pakistan only the establishment of large private hospitals have instituted this service  The dietetic service, if existed is responsible for: 1. Purchasing, planning and preparation of menus for both patients and employees. 2. Recording of dietary histories of patients such as those unable to accept a limited diet regimen. 3. Interviewing patients regarding their food habits. 4. Counselling patients and their families concerning normal or modified food regimens. Encouraging patients to participate in planning their own normal or modified regimens. 5. Encouraging patients to participate in planning their own normal or modified regimens 6. Participate in appropriate ward rounds , research activities and conferences. Medical records department  Patient record keeping is responsibility of medical records department of hospital  This department is staffed by technically skilled personnel and is headed by suitable qualified individuals  Every hospital is required by law to maintain adequate medical records of their patients  The purpose of medical record keeping are to: 1. Serves as basis for planning and for continuity of patient care. 2. Provide a means for communication among the physicians and professionals contributing to patients care. 3. Furnish documentary evidence for course of patients illness and treatment during each hospital stay 4. Serves as a basis for review, study and evaluation of the care rendered to the patient 5. Assist in protecting the legal interest of the patient , hospital and responsible practitioner 6. Provide data for use in retrospective research, education and for legal issues.  Sufficiently detailed medical record includes 1. Identification of patient 2. Patients sociological data 3. Personal family history 4. History of present illness 5. Physical examination 6. Special examination such as consultations , clinical lab data, x-rays etc 7. Provision of working diagnosis 8. Medical or surgical treatment 9. Gross and microscope pathological findings 10.Progress notes 11.Final diagnosis 12.Conditions on discharge 13.Follow up 14.Autopsy findings in case of death of patient Parts of medical records  Admission sheet  Admission history sheet  Physical examination sheets  Lab sheets  Medical record sheets  Discharge summary sheet  Autopsy sheet Admission sheet  Used for placing patient identification data Unit record number Admission Patient name, address, sex, sheet age, marital status, telephone number, Physician name, number, adress Admission date, time, diagnosis  Admission sheet also attaches consent form for authorization for medical and surgical treatment  Release of information to other physician and reimbursing authority if any. Admission history sheet  It include  Informants name  Name of individual taking history  Patient chief complaints  Description of patient illness present past illness + operation/surgery immunization + transfusion history +reactions and complications  Admitting diagnosis, current medication, diet, height, weight, occupational history, health of spouse, pregnancy, family history Lab sheet  It is entered into patient medical record after each lab test during hospitalization.  This includes reports on preprinted forms obtained from microbiology, chemistry, hematology, serology, radiology, pathology.  Some reports, instead of recording are directly pasted as original on medical record. Medical record sheet  It provide space for recording of all treatment procedures performed upon patient  It includes: operative notes(description of findings, detailed account of techniques used, tissues removed)  Progress notes are made in medical record for purpose of providing the physician with chronological picture and analysis of clinical course of patient.  Final diagnosis is also entered in same sheet of patient medical record after completion of all diagnostic procedures. Discharge summary sheet  Upon discharge from hospital, Discharge summary sheet is entered into patient medical record as an outline of patient hospitalization.  Discharge summary sheet include: 1. Brief history 2. Results of physician examination 3. Lab data 4. Description of patient hospital course 5. Diagnosis 6. Operation performed 7. Complication 8. Disposition 9. Present condition 10. Medication prescribed during and after hospitalization 11. Estimated length of disability if any Autopsy sheet  It is included if patient dies during hospitalization.  This contain complete protocol of findings resulted from autopsy Ideal features of medical record 1. Accurately documented so as an effective patient care can be provided at another time 2. Readily accessible as this will facilitate the easy consultation with other physician and enable an emergency treatment 3. Easily used for retrieving and compiling information. This help in retrospective data analysis. 4. Containing all significant and detailed clinical information to enable an effective continuing care to patient in same institution at another time, another practitioner can assume the care of patient at any time and consultant can give opinion after the examination of medical record of patient.  Pathology service  The department of pathology services has personnel who are adequately trained and experienced in laboratory work.  This department is supervised by a qualified physician with training in pathology and is able to assume professional, organizational and administrative responsibility for the services rendered.  The clinical lab, clinical chemistry, microbiology, clinical microscopy. hematology, serology and the section for drug analysis in blood samples may be the subdivisions of a pathology department.  In some institutions, blood bank is also included under the pathology services.  Blood bank  Most hospitals operate their own blood bank because of the essential nature of blood as a therapeutic agent and to get ensured quality.  In some hospitals, this service is operated independently while in other, it function as a subsection of pathology department because of its laboratory-like operation.  If operating independently, this department is staffed by hematology technicians and supervised by a licensed physician having basic interest in hematology.  Radiology  The department of radiology is a vital department for the diagnostic application of radiant energy particularly in the form of x-rays.  This department is under the supervision of a qualified physician who has also obtained an adequate training and experience in general radiology.  An adequate number of radiology technologists are staffed to provide services from this department.  This service is provided only after a written direction from an entitled physician.  Nuclear medicine  Nuclear medicine department is an integral part of an institution which provides oncology service.  The services of this department include the use of radiopharmaceuticals for the diagnosis, palliation and treatment.  This department is staffed with physician with specialization of nuclear medicine, health/medical physicist, nuclear pharmacist, technologists, and oncology nurse.  Radiotherapy department  Consist of physicians which are trained as radiotherapist, medical physicists, radiation technologists, radio pharmacist, nurses and secretarial personnel  Physician adequately trained and experienced in general radiation principle supervise this department.  Services provided from Radiotherapy department are performed only on the written order of medical staff member who has entitled to direct for such services.  Radiation department provides therapeutic services of radioactive radiant energy for treatment of tumors and carcinomas.  Appropriate dose is calculated for irradiation of patient with isotopes.  Example cobalt-60(used for cancer treatment)  Recently Brachytherapy introduced in which radioactive source is inserted with incision in tumor for calculated period of time to treat them.  For this purpose cessium-137 and 1192 is used  Diagnostic services  Radiology (x-ray), computerized tomography, (CT), ultrasound, nuclear magnetic resonance and radio isotpic imaging are the diagnostic services offered in major institution.  Due to their different basic principles, techniques and obviously skilled, all these grouped under one department.  A pharmacist would be interested to know something about these services  CT scanning defines the precise location and limits of a clot, tumor, and other ailments in body by imaging techniques with the help of computerized slicing of acquired image.  X-rays and ultrasound are the diagnostic modalities based on use of x-rays and ultrasound respectively  NMR provides 3D image data sets providing precise anatomical displays based on proton density Medical social service department  It is an important relationship between hospital and patient and his community  This department has a professional focus on the social aspects of patient and patients family.  Social service personnel generally provide information related to medical social study of appropriate patients , social therapy and rehabilitation of patients, home environmental investigations for attending physicians, cooperative activities with community agencies , monitory helping patient, social service summaries and follow up reports of discharged patients, confirming disposition when obtained.  Anesthesia service  Trained physician who is medical staff member directs anesthesia service of hospital  Director of anesthesia service is responsible for quality of anesthetic care in surgical and obstetrical areas and availability of equipment necessary for administrating anesthesia and for related resuscitative effects.  Other duties of head of anesthesia services are development of regulations concerning anesthetic safety and retrospective evaluation of all anesthetic care.  Anesthesia care provided by anesthesiologists, qualified physician anesthetic, qualified nurse anesthetic, appropriately supervised trainees in an approved educational program.  Nurse anesthetists can employ general anesthesia under supervision of departmental director or his designee.  Material management department  A department having operational responsibility over purchase, receiving, inventories, print shop, central sterile supply, laundry, distribution, messenger service, traffic and disposal activities. An individual with training and abilities supervise this department. The other duties of this department are:  Issuance of purchase orders.  Maintenance of purchase records.  Follows-up on delayed orders.  Initiates competitive bidding procedures.  Obtains quotations from specified sources. Biomedical engineering department  It is under the control of qualified biomedical, electrical or electronic engineer.  For functioning in this department adequate number of engineers in the field of biomedical electrical, electronics, mechanical and well trained technicians are required.  Responsibility of Biomedical engineering department is to keep all clinical and lab instrument working.  Central sterile service department  The central sterile service department provides professional supplies and equipment, sterile and non-sterile, to all specialized departments. The special departments that are served through this division are nursing stations, clinic: and the operating rooms. This department practices total decontamination and gives processional support and service for improved patient care by maintaining high processing standards.  The sterile supply may include the re-usable and disposable materials. In addition to dispensing these materials, central sterile supply room may also be involved in the cleaning, storage and dispensing of specialized equipment's such as suction pumps, car­diac catheters, monitoring equipment. surgical dressing carts, resuscitation carts, and a myriad of special kits and trays.  In some institutions, procurement, storage and distribution of supplies as well as the. preparation of various sterile solutions are under pharmacist's management. In others, nurses are for the operation of central sterile supply room. In a third option, the central sterile supply room is under dual control of pharmacist and nurse.  The function of cleaning, packaging, and distribution of medical equipment's and supplies as well as manufacture of sterile fluids are under pharmacist. Nurse is responsible for former and pharmacist is responsible for later operations.  Central sterile supply room in many hospital, considered as sub- department and operated under control of operating room supervisor or nursing service. In this case director, supervisor or manager of unit does not report to the administrator or his assistant but to department head.  in some hospitals, Central sterile service is included along with operating room, recovery rooms, and intensive surgical care units, under the division of surgical care.  surgical care division is section of general nursing service.  In still other hospitals, manufacture of sterile injectable or irrigating solutions is from central sterile supply room and this solution room is placed within administrative scope of pharmacist.  Under this arrangement, pharmacist report directly to administrator or to one of his assistant.  Finance/account department  Though a pharmacist may believe that finance is a subject which does not concern him or his department.  In reality, the finances of the hospital affect every patient, employee, staff member, trustee and the community at large.  The finance department is staffed by accountants and financial personnel and a well trained and qualified individual supervisors.  This department is responsible for the financing of all operations of a hospital and delivery of salaries to the institutional employees.  The following is a brief resume of the sources from which income may be derived to meet operating expenses.  The primary source of revenue is derived from the billing of patients for services rendered.  A patient receiving such a statement usually pays it in full by himself.  Another mode of payment is reimbursement from third party coverage system whereby employer of the patient pays patient's bill in full-or pay a specified portion and remaining from patient. Shared services  Sharing of services offers a viable option to any organization in providing high quality technical services in very cost effective manner  Such services include both administrative and clinical activities.  Shared services of administrative nature are support services not involving the delivery of direct patient care and are nor normally revenue producing.  These services are easier to develop than clinical shared services program because they do-not directly involve the medical staff, and often can be implemented easily  Clinical shared services involve delivery of direct patient care or research on clinical aspects of drugs.  Shared services enable an institute to protect present and future assets, develop and safeguard wide variety of new sources of revenue, attract additional funds through charity.