JUNIOR INTERNSHIP MANUAL

M. MARIAPPAN

Contents : Instructions Background Learning Process Study of the Departments 1. Emergency Department 2. Day Care Unit . In!patient "ards #. $ut!patient Department %. La&our room and "ard '. $peration (heatre ). *ursing Department +. La&oratory ,. Pharmacy 1-. Physiotherapy 11. .adio/ogy 12. Business office 0 front office 1 . Bi//ing 1#. 1m&u/ance 1%. Catering and Dietetics 1'. 2ousekeeping ser3ices 1). Linen ser3ice 1+. 4edica/ .ecords 5data processing6 1,. Portering department inc/uding transport 2-. Security 5fire pre3ention and car parking6 21. Steri/e Supp/y 22. (e/ephone 2 . 7inance and 81ccounts 2#. Personne/ 5inc/uding residents and consu/tants6 2%. Staff medica/ "e/fare 2'. Purchase and stores 2). Engineering departments 2+. 9enera/ office administration
Performance Analysis !eneral "#i$elines

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STU%ENT&S INTERNSHIP MANUAL

INSTRUCTIONS TO STU%ENTS 1. ;ind/y read the information "hich is gi3en &e/o" carefu//y. 2. (he Students to report to the hospita/ in time. 2e0she shou/d fo//o" the respecti3e hospita/ timings gi3en &y the hospita/ super3isor. . (he Student shou/d maintain 1--< attendance. 1ny a&sence e=ceeding t"o days /eads to supp/ementary internship "hich means the student has fai/ed and /ater passed in internship. #. (he attendance sheet shou/d &e signed &y the hospita/ super3isor and shou/d &e su&mitted a/ong "ith the internship report "ith in the specified period %. (he student shou/d report to hospita/ and facu/ty super3isors regu/ar/y "ithout fai/. '. (he Student "i// choose a fe" or a// departments to study in!depth ). (he internship "ork has to &e carried out as gi3en &e/o" a. (o prepare the materia/s "hich is a3ai/a&/e in the &ooks make as a standard one &. (o /earn and assess the particu/ar department "hich is se/ected &y you. c. (o assess the performance of the department d. (o compare the standard manua/ and rea/ department system e. (o make suita&/e recommendations "hich "ou/d &e con3enient to imp/ement and shou/d gi3e &etter resu/ts +. (he /ast date for su&mission of report "i// &e informed to you as and "hen it is fina/i>ed. (he report is to &e su&mitted &efore the /ast date. 1. (he internship report is prepared on the institute internship ?ourna/. 2. (he student shou/d &e prepared and ready for seminar and presentations. . (he information pro3ided in this manua/ is ?ust an o3er3ie" and some important key issues in hospita/ functions. (he hospita/ is a comp/e= organisation "here there is so much of information and techni@ues to /earn. So it is ad3ised that the student shou/d take more initiati3e to go through and /earn the other aspects "hich are not co3ered in this manua/. #. (ry to find out the physica/ structureA /ocation and /ayout p/anA si>e of the departmentA organi>ationa/ structure and staffing patternA human resource a3ai/a&i/ityA e@uipment p/anning and /ayout and the e@uipment and systems and procedures as a ma?or component of the internship "ork.

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Atten$ance : T(e st#$ent is e)*ecte$ to maintain +,,- atten$ance $#rin" t(e interns(i* *erio$. Ho.e/er0 a st#$ent is *ermitte$ to ta1e t.o $ays lea/e if (e 2 s(e is really #na3le to atten$ t(e interns(i*. T(is lea/e s(o#l$ 3e ta1en in a$/ance in cons#ltation .it( t(e (os*ital s#*er/isor an$ .it( t(e *rior *ermission of t(e Hea$ of %e*artment. If a st#$ent e)cee$s more t(an 4 $ays of lea/e0 (e 2 s(e .ill 3e $eclare$ faile$ in t(e interns(i*.

5AC6!ROUN% (he manua/ is designed for the purpose of students to get comp/ete e=posure of hospita/ and its functions. (he practica/ e=posure "i// &e a ma?or component of this programme. It is ad3ised that the student shou/d attempt to in3o/3e direct/y in hospita/ operations during the internship

LEARNIN! PROCESS 1 $n the first dayA the student "i// report to hospita/ super3isor. 2e0She may spend the first day &y going around the "ho/e hospita/ and fami/iari>e himse/f0herse/f "ith in the hospita/. 2. (he student "i// initia//y study the "ho/e hospita/ in terms of goa/A structure and techno/ogy &y going through historica/ documents and inter3ie"ing senior emp/oyees. . In consu/tation "ith the hospita/ and institute super3isorsA the student "i// se/ect a mi=ture of c/inica/ and non!c/inica/ department for the study. In each department the student "i// study the fo//o"ing B a. LocationA design or /ayout of the hospita/ &ui/dings and measurements of 5areas6 each department and space a//ocation for 3arious functionsA spatia/ re/ationship 5function to space6 "ithin each department. &. (o go through present operationa/ po/icyA systems and proceduresA functions of the se/ected departmentA the system of co!ordination and inter persona/ re/ationships etc. c. (o fami/iari>e "ith e@uipment a3ai/a&/e at the se/ected department and 3arious methods of maintenance. d. (o go through personne/ matters!such as ?o& descriptionA responsi&i/itiesA reporting systemsA human resource p/anning ! ade@uacy in shifts and num&erA training and de3e/opments methods. e. (o get information on financia/ mattersA fund raising methodsA procedures fo//o"ed for income and e=penditures. f. (o study in detai/ a// the systems and procedures in the department g. (o measure the performance of the department in terms of "ork/oad of a// @ua/ity of ser3ices. h. (o make rea/istic recommendations to impro3e the performance of the department. Note : T(e st#$ents are a$/ise$ to select one $e*artment in case of lar"e si7e (os*itals. All $e*artments s(o#l$ 3e co/ere$ in small (os*itals.

STU%8 O9 %EPARTMENTS : +. Emer"ency %e*artment :Cas#alty; Physica/ Structure ! Lay out p/an 0 interna/ design and tota/ areas of the department 4edica/ organisationB!organisationa/ structure *o of staff in each category are "orking in the department. 54anpo"er Status6 .eporting systemA communications etc. E@uipment detai/s 5name of the e@uipmentA year of purchaseA Company makeA num&er of e@uipmentA maintenance system6 and other faci/ities a3ai/a&/e Systems and Procedures are fo//o"ed for ma?or and other emergency cases 4edico /ega/ cases 1dmission procedures Cith in hospita/ or (ransfer to other hospita/s $&ser3ation of patients during the night Procedures of patient &rought in dead Procedures of patients shifted to $( direct/y from casua/ty .esuscitation faci/ities (reatment of minor in?ures Staff safety and securityB security for 3io/ent patientsA /iaison "ith Po/ice *on!accidenta/ in?uries to chi/dren Link &et"een other departments!D!.ayA EC9A Socia/ ser3ice La&A transport etc. Procedures to &e fo//o"ed "ith .eceptionA c/erica/ records. Safety of the patients property 7ood and refreshments Communication faci/ities to patients0attenders List of &ooks and formats maintained at casua/ty E=amp/es!4edico /ega/ .egister Dead on arri3a/ .egister Li3e Birth *ote Death .eport 7ormat of stomach "ash aspirate *otifia&/e diseases 7ormat of Death Intimation 57orm *o.2 and #6 to &e sent to corporation 7ormat of Birth Intimation 57orm *o.16 to &e sent to corporation *um&er of cases per month emergency cases non!emergency cases specia/ties!"ise accident cases etc. any other important matters Cork /oad ana/ysis staff and patient ratio doctors and patients ratio uti/i>ation of human resources and faci/ities

De/i3ery death rate Ear/y neonata/ death rates Infection rate Death rate0sur3i3a/ rate

4. %ay care #nit Definition of day care unit Physica/ StructureA Lay! out p/an and Si>e of the department Staffing pattern 5specify the no of staff in each category6 and .eporting system List of e@uipment a3ai/a&/e C/inica/ admission po/icies 1dmission and discharge arrangements Use of operation theatres Communication "ith $( Consent Bi//ing forma/ities Link "ith other departments /ike La&A =!ray etc. 4edica/ .ecords procedures Specia/ faci/ities a3ai/a&/e if any and others List Books and 7ormats etc a3ai/a&/e "ith in the department *o of patient 3isited to day care "ard during the month (ypes of patients 5Specia/ty "ise6 Cost effecti3eness *o. of minor cases treated dai/yA month/y and year/y. Income contri&ution from &y day care unit <. In=*atient .ar$s Physica/ Structure ! Lay out p/an and si>e of the I P Department $rganisationa/ structureB!Different types or categories of the Card Staffing pattern 5*o. $f staff a3ai/a&/e in each category!4anpo"er status6 and .eporting system *ursing staff and Duty 4edica/ $fficers handing o3er and taking o3er system 1dmission procedure Bed a//otment procedure Link "ith other departments /ike .eception and en@uiryA Bi//ing proceduresA /a&A =!rayA cardio/ogyA ICUA $(AL. etc. Consu/tants 3isits or Doctors 3isits E(imingsA 7ee .u/es etc Patients mea/s ser3ice systems List of ma?or and minor e@uipment a3ai/a&/e at the "ard Drug procedures Procedures to &e fo//o"ed "ith regard to patients &e/ongings and 3a/ua&/es Iso/ation po/ices and nursing procedures

In patients 9uide/ines Caste disposa/ system and management 5(o study the po/ices of State 9o3ernmentA City CorporationA and Po//ution Contro/ Board .egu/ations "ith regard to "aste disposa/ system6 Linenry issues and storage!systems 5(o study in detai/s6 .u/es a&out smoking .u/es of .e/ati3es0 attendantFs stay at night Patient E*urse ca// system Card forms! 4edica/ cerificatesA consent forms and a// others 1ccident to patients and 3isitors! reporting systems Incase of death of the patient! the arrangements 7aci/ities pro3ided /ike ( GA .adioA phoneA 1ir conditioners and other amenities for the patients!ru/esA maintenance procedures. Procedures of Gisiting 2ours E to study in detai/ En@uiry a&out the patientsF condition! "ho has to ans"er. Discharge summary and other reports handing o3er procedures (o report the Books and formats a3ai/a&/e "ithin the department. Patient and nursing staff ratio Bed occupancy rateA and other indicators

>. O#t *atients $e*artment Physica/ Structure!Lay!out p/an and si>e of the department $rganisationa/ structure and reporting system 54anpo"er status6 Direction or sign Boards to guide the patient .egistration of patients $ut patient timings $utpatient department functions 1ppointment to patients for consu/tation $ut patients consu/tation schedu/e PatientFs satisfaction a&out the ser3ices e=tended (o 3erify any system a3ai/a&/e to e3a/uate patient satisfaction. 4edica/ records procedures .eception and "aiting areas faci/ities .e/ationship "ith day!care unit. List of e@uipment a3ai/a&/e (o report the Books and formats a3ai/a&/e "ithin the department. Systems for patients referred to radio/ogyA patho/ogy and Pharmacy 1m&u/ance faci/ities Performance ana/ysis .eferra/ systems 5refer to senior consu/tant for opinion or further treatment etc6 $ut Patient "aiting timeA time spent for diagnostic procedures Cost point of 3ie" patientsF opinion

(o ana/yse the no. of $P treated per dayA "eek A month and years Cure rateA impro3ed cases rateA death rate!unit!"ise and department "ise. '. La3o#r Room an$ ?ar$ Physica/ structure! /ayout p/an and Si>e of the department $rganisationa/ structure and reporting system 54anpo"er status6 .e/ationship to paediatric department. Ser3ice from other departments /ike .adio/ogyA patho/ogyA socia/ ser3icesA etc. 4edica/ .ecords systems Gisiting arrangement for father .egistration of &irths! 2ospita/ and corporation .egistrar of Births B/ood &ank supp/y in case of &/ood re@uirement C/eaning procedure! fumigation etc.A .e/ationships "ith outsiders List of e@uipment a3ai/a&/e Performance ana/ysis (o measure the uti/isation e@uipment Usage of /a&our room *o. of cases performed dai/y0 month/y *o. Sti// &irthsA norma/ de/i3ery *o of cases &ecome comp/icated due to non a3ai/a&i/ity of personne/ *o of caesarian sections List of &ooks and formats @. O*eration T(eatre Physica/ structure!/ayout p/an and si>e of the department $rganisationa/ structure and reporting system 54anpo"er status6 7unctions of $( (ime schedu/e of surgeries!$( .egister C/ean and dirty >one!Schedu/ed of c/eaning and other procedures Liaison "ith theatre steri/e supp/yB organisation and accounta&i/ity .adio/ogy ser3icesA C!1rm etc La&oratory &ack up ser3ice fro>en sections (ransfer contro/ arrangements Safety of the patient and code of procedure to pre3ent "rong operations are carried out. .eco3ery "ard organisation and procedures .efreshments for theatre staff Linenry ser3icesA inc/uding protecti3e c/othing C/eaning proceduresA inc/uding "ashing do"n Infection contro/ procedures Caste disposa/A infected /inenA &/ood uti/i>ationA etc! ru/es 1nesthetics accounta&i/ity for ser3ice and e@uipment

Preparation of /ists systems and documentation S"a&s need/es and instrument checking procedures 1naesthetic machines checking procedures Changing room procedures List of e@uipment a3ai/a&/e and maintenance procedures List of &ooks and formats a3ai/a&/e Secretaria/ ser3ices. Performance ana/ysis *o. of surgeries performed dai/y0 "eek/y and month/y *o. of cases operated &y specia/ty "ise *o of cases done indi3idua/ doctors dai/y0month/y *o of ma?or surgery and minor surgery &y specia/ty "ise Contro/ of $( Infection .ate.

A. N#rsin" %e*artment 4anagement structure and reporting system 54anpo"er status6 $rganisation of nurse!managed departments *ursing po/icies *ursing procedures Dep/oyment of nursing staffB ratio of @ua/ified to un@ua/ified staff. !*urse education po/icy staffing courses and organisation $rganisation of inser3ice training 1//ocation of nurses to non!recurring departments such as .adio/ogy and staff hea/th 2and/ing of medico /ega/ cases. .o/e of nursing in in3entory management .o/e of nursing in housekeeping maintenance Dai/y roundsA carryout the doctorsF orders In3estigation procedures 1rrangement for cross consu/tation 4aintenance of patients hea/th records 4aintenance of pre!operati3e and postoperati3e cases. Infection contro/ management Caste disposa/ management Discharge procedures Duties of &i//ing La&our .oom procedures ICU!admissionA in3estigationA routine cares in ICUA preparation of patient to $( and hand/ing of death cases. $(A La&our room c/ean/iness and fumigation (o gi3e the /ist of &ooks and formats a3ai/a&/e at hospita/ 2and/ing of &iopsy specimen .e/ationship "ith CSSD department

4aintenance of /inen and management La&oratory re@uest procedures .e/ationship "ith La&oratory!understanding of recei3ing and documentation of in3estigation reportsB norma/A emergencyA and important matters Performance ana/ysis Performance appraisa/ system 7urther training re@uirement Cork /oad "ith respect to no. of nursing staff posted in "ard

B. La3oratory Physica/ structure /ayout p/an and si>e of department $rganisationa/ structure and reporting system 54anpo"er status6 Specimen co//ection and receptionB inpatients and outpatients Use of ph/e&otomists 5Cho is dra"ing the &/ood6 Safety procedures $n ca// ser3ices (raining to ?unior medica/ /a&oratory scientific officers! o&taining appro3a/ from the counci/ for professions supp/ementary to medicine. Hua/ity contro/ po/ices Samp/es from genera/ practiceI po/icy manageria/ accounta&i/ityA fro>en sections from theatre Data processing Separate departmenta/ po/icies and systems for each of the main /a&oratories 4ortuary proceduresB re/easing &odies to undertakers Contro/ of infection accounta&i/ityI responsi&i/ity of the micro&io/ogist 7unction and contro/ of infection committeeA iso/ation procedures disinfectant po/icyA staffing re@uirements and systems In3estigations referred to other Centres Bio chemistry functions Centra/ "orking up arrangements for g/ass"are ser3icing apparatus E accounta&i/ity and po/icy System of su&mitting reports .e/ationship "ith &i//ing and reception 9uide/ines to the patient "ith regard to paymentA co//ection of reportA other procedures. Detai/s of &ooks maintenance and formats Performance ana/ysis (est performed &y specia/ty "ise Staff accounta&i/ity in test accuracy Hua/ity contro/ check through out side agencies Staff and no. (est carried out per day (ime/y su&mission of report *o. of patient got discharged "ith recei3ing the test resu/ts .e3enue contri&ution &y /a&.

1ny other matters C. P(armacy Physica/ structure /ayout p/an and si>e of the department $rganisationa/ structure and reporting system 54anpo"er status6 Pharmacy /icensing procedures 1nti&iotic po/icy Steri/e f/uids ! purchase or manufacture Purchase systems and procedures security check 9.* 59oods recei3ed note6 Incoming materia/ register .ecei3ing @uotations Comparati3e statements 1ppro3a/ for orders P/acing an orders In3oicesA de/i3ery cha//ans Bi//s etc Inspection of materia/ Procedure purchase returns Card pharmacy ser3ice!issuesA supp/yA storage and administration Inter store transfers systems Sa/esB!cash sa/es and credit sa/es Procedures of credit sa/es!authorisation Procedures of patients &e/onging to corporate sectors Procedures for staff and dependents!discountA concession etc. $P prescription systems inc/uding payment charges Inpatient sa/es Procedures of sa/es returns Hua/ity contro/ Drug information systems Purchasing and stock contro/ systems De/i3eries and storage Contro//ed and schedu/ed drugs procedure 4anagement of *arcotic Drugs 7ormu/ary!the /ist of drugs a3ai/a&/e at pharmacy to &e supp/ied to consu/tants and prescri&ing doctors 4anagement of e=pired drugs (ake home prescriptions $ut of hours ser3ices Drug house representati3es po/icy C/inica/ drug tria/s ethica/ committee procedures Stores security and fire pre3ention

(ransport of drugs "ithin the hospita/ Prescription forms Dai/y stock 3erification 2a/f year/y and month/y stock 3erification List of &ooks maintained and formats Computer app/ications in pharmacy Correspondence "ith drug contro//er office etc. .e/ationship "ith main receptionA &i//ing and main accounts office Secretaria/ ser3ice Performance ana/ysis *o of prescriptions re?ected during the day0month 5*on!stock itemA ne" item in the marketA de/ay in orderingA de/ay from supp/ier etc.6 *o.of times "rong medicines issued &y the pharmacist Caiting time per patient per prescription Stock 3erification at regu/ar inter3a/ !discrepancy De/ay in hand/ing of e=pired drugs

+,. P(ysiot(era*y Physica/ structure!/ayout and si>e of the department $rganisationa/ structure and reporting system 54anpo"er status6 Definition and functions E@uipment a3ai/a&/e 13ai/a&i/ity of ser3ices in $PDA "ards and ICU 1ppointment systems and /ink "ith reception Patient records $n ca// arrangements 2ydrotherapy poo/ Domici/iary ser3ices Procedure for &i//ing (reatment of inpatient and outpatient 1ny other important procedure "ith regard to e@uipment hand/ing List of &ooks and formats a3ai/a&/e Performance ana/ysis *o. of cases treated per day0month *o.of cases referred from 3arious department .e3enue contri&ution &y the unit. ++. Ra$iolo"y Physica/ structure and si>e of the department $rganisationa/ structure and reporting system 54anpo"er status6 7unctions of the department 4o&i/e e@uipment

.e/ationships "ith medica/ records department Use storage and retrie3a/ of sma// fi/m formats .ecords system fi/ing and retention of =!ray fi/ms and other imaging and patients records $n ca// ser3ices 4a?or accident procedures 4anagement accounta&i/ity "ith in hospita/ Safety of staffA radiation protection proceduresA hea/th and safety Procedures isotopes storage hand/ing 4aintenance of e@uipment accounta&i/ity 7re@uencyA emergency repair procedures Image @ua/ity contro/ procedures $rganisation of fi/m processing Procedures for identifying patients .e@uest procedures 2and/ing of specia/ procedures 1ppointment systems for indi3idua/ imaging moda/ities and e=aminations Linenry ser3ices and !Domestic ser3ices Shifting of e@uipment and patients from one p/ace to anotherA faci/ities re@uired .e@uisitioning storage and de/i3ery of stores and supp/ies Caste disposa/A si/3er reco3ery Intercommunication 7i/m reporting systems and dispatch procedures C/inica/ access to departments conference Ser3ices for Casua/ty departmentA $(A "ards maternity *ursing support ser3ices to &e defined Junior medica/ staff re@uirement 7ire and security Bi//ing procedure .e/ationship "ith other departments 4aintenance of medico /ega/ cases etc Statistics procedures Performance ana/ysis *o of =!ray regu/ar and specia/ per day0month/y Caiting time De/ay in hand/ing procedure due to technica/ and human pro&/em fre@uency 5*on! a3ai/a&i/ity of technician6.

+4. 5#siness office or 9ront office Physica/ structure Lay out and si>e of the department $rganisation and staff reporting systems 54anpo"er status6 .eception

En@uiry .egistration of patients Eout patients and inpatients Consu/tants and consu/ting rooms 4anagement information system .ecord maintenance Cash co//ection system 9uide/ines to patients attendersA 3isitors etc .e/ationship "ith other departments!dra" the f/o" chart. .ecords and formats a3ai/a&/e. 1ny other important matters Performance ana/ysis (raining need assessment Cork /oad ;no"/edge /e3e/ and communication ski//s of staff

+<. 5illin" Physica/ structureA /ayout and si>e of the department $rganisation and staff reporting system 54anpo"er status6 Procedures for out patient &i//ing (he different heads of out patient &i//ing Bi//ing procedure for admission Bi//ing chart 3erification and checking Procedures of inpatient &i//ing (he different heads of inpatient &i//ing (he responsi&i/ities other departments "ith regard to &i//ing In patient deposit co//ection Bi//ing "ith regard to discharge 1uthorisation procedure for free patientsA discount and concession .ecords and formats a3ai/a&/e .e/ationship "ith accounts office and cash section 1ny other matters "ith regard to &i//ing Performance ana/ysis Dai/y co//ection statements 4onth/y co//ection statements 2and/ing of dues (reatment of &ad de&ts 1ccuracy in patient &i//s 5Bi//s cance//ed6 Caiting time in issuing &i//s +>. Am3#lance Po/icy and procedure and Parking arrangements 7aci/ities to am&u/ance staff Supp/ementary ser3ices hospita/ car ser3ice and 3o/unteer car ser3ice

1m&u/ance &reakdo"n record Performance ana/ysis *o of ca//s re?ected day0month *o of times dri3ers non a3ai/a&/e day0month

+'. Caterin" an$ %ietetics a. Caterin" Structure /ayout and si>e of the department $rganisationa/ and staff reporting system 54anpo"er status6 Inpatient mea/s ser3ice routine and emergency specia/ diet ;itchen organisation Specia/ functions and hospita/ po/icy Staff mea/s ser3ice po/icy and systemsA main dining roomA night mea/s payment po/icy and co//ection of cashA decentra/i>ed ser3ices tea &ars and 3ending machinesA staff &e3erages 4ea/s for patients in iso/ation "ards (heatre staff refreshments 7ood storage Centra/ised "ashing up 4ea/s for 3isitors and re/ati3es .e/ationship "ith dietetic department Hua/ity contro/ and monitoring system Ser3ices pro3ided from "ard kitchens pro3isions issues Purchasing po/icies contacts de/i3ery and storage registration .e/ationship "ith domestic and portering ser3ices re@uirements and accounta&i/ity Safety ru/es and regu/ations Lega/ regu/ations (erms and conditions "ith the management in case contract &usiness 3.%ietetics Physica/ structure!Layout p/an and si>e of the department $rganisationa/ structure and reporting system 54anpo"er status6 Definition of ser3ices to &e pro3idedB inpatients and out patients .e/ationship "ith catering department Diet contro/ and @ua/ity checking Systems for ordering and pro3iding therapeutic diets Pro3ision of diet sheets .esearch pro?ects dietetic re@uirements (he Professiona/ ro/e of the dietician in re/ation to medica/ staff such as consu/tantsA medica/ officers and nursing staff. Specia/ re@uirements to &e assessed for departments such as maternityA geriatricsA psychiatryA rena/ and pediatrics (eaching commitments for other professions

(raining of dietetic students Performance ana/ysis *o. of comp/aints recei3ed from patients0 attenders0users Caiting time of inpatients recei3ing mea/s *o. of times inspection or @ua/ity check carried out

+@. Ho#se 1ee*in" ser/ices $rganisationa/ structureA staffing and reporting system. Definition of functions C/eaning po/icies for different surfaces methods e@uipment and materia/s 2igh /e3e/ c/eaning C/eaning roof and top portions of the &ui/ding Cindo" c/eaning fre@uency e=c/usions checking procedures C/eaning methods of toi/etsA &ath rooms and "ashing areas .outines for c/eaning pu&/ic areas Specia/ re@uirements in theatres de/i3ery suite and iso/ation rooms C/eaning schedu/es for each "ard and department Issue of c/eaning materia/s Use of contract ser3ices or direct /a&our for specia/ tasks 1ccounta&i/ity in departments such as residencesA catering and theatres Super3isory contro/ and .ecord maintenance In3entory of c/eaning materia/sA recei3ing and issue of materia/s 4aintenance and /ocate the nursing materia/s .ecord maintenance Dai/y charts for c/eaning process .o/e of housekeeping super3isor in infection contro/ and maintaining specia/i>ed departments Dai/y reports of housekeeping department Checking the room after discharge and protoco/ for missing materia/s .o/e of house keeping staff in pro3iding comforta&/e to patient .o/e of house keeping staff shifting patients and List of &ooks and formats a3ai/a&/e. Performance ana/ysis *o. of time c/eaning process carried out dai/y *o. of comp/aints recei3ed from users 2o" much and type of materia/ used for c/eaning Cost of the materia/ used per day0month. +A. Linen ser/ice Physica/ structureA /ayout and si>e of the department $rganisationa/ structure and reporting system 54anpo"er status6 Staff uniform specification and amount of issue for each category of staff persona/ issue or poo/ system

Issue and return procedures "ards theatresA residences and other departments Uniform e=change procedures /aundry Protecti3e c/othing specification and amount of issue Chite coat ser3ice Card /inenry ser3ice system (heatre /inenry and protecti3e c/othing specification and system of issue Persona/ /aundry ser3ice 4arketing systems Curtain changing systems Se"ing room "ork functions defined Persona/i>ed c/othing for certain patients specification and system of issue Precautions for transporting and /aundering infected /inen Linen in3entory Stock 3erification Proper record maintenance Indenting of /inen materia/s!re/ationship "ith main stores Preparation of uniforms Interna/ transportation of /inen materia/s .ecords and formats a3ai/a&/e Performance ana/ysis De/ay in recei3ing /inen from /aundry *on a3ai/a&i/ity of /inen in $( "ard etc Hua/ity of /inen Dura&i/ity of /inen Effecti3e disposa/ system

+B. Me$ical Recor$s :%ata *rocessin"; Physica/ structureA /ayout p/an and si>e of the department $rganisationa/ structure and reporting system 54anpo"er status6 .egistration system .etention record po/icy (o 3erifyB a6 (he IP fi/es retained for period of se3en years &6 (he $P fi/es are retained for period of fi3e years c6 4LC fi/es are retained for period of /ife time d6 Death case fi/es are kept separate/y and retained ten years 7orms and format used 1ssem&/ingA CodingA Deficiency check and fi/ing of inpatient fi/e. Computing data and date processing po/icy 4icro fi/ming Confidentia/ity and security of records Information "ith &irthsA deaths and discharges 1dmission procedures

Use of "ard c/erks or secretaries definition ro/e and accounta&i/ity Co//ection of information on patientsA systems throughout the hospita/ Presenting information on patientsI re@uirements and system 1ny GI P patients 3isited or got admitted ho" information passed on to management. $P appointment system Bed state system 54id night census6 .e/ationship "ith diagnostics departments Long term storage 7i/ing system Design of case fo/der 4edico /ega/ cases hand/ing!po/icy to issue 4LC records to patients Dai/y In!patient StatisticsB!admissionA dischargeA &irthsA deathsA etc. Dai/y $ut Patient statisticsB!*o. of ne" patients registeredA re3isitsA .eferred caseB feed&ack system for referra/s i.e. num&ers of referra/s for "hom the referring agency "as informed. Interdepartmenta/ referra/ systemA Patients ha3e come direct/y "ithout referenceA Patients 3isit &y consu/tantsA Patients 3isit &y specia/tyA etc. .ecords and documents a3ai/a&/e. Garious ana/ysisB Dai/y a3erage $PD attendance Dai/y a3erage Inpatient admissions Dai/y deaths in 3arious "ards and under 3arious units Bed turno3erA Length of stay Efficient system of retrie3a/ of records Caiting time in getting case fi/e 1ccuracy and incomp/ete case fi/esA5not a// forms6

+C. Porterin" $e*artment incl#$in" Trans*ort Location and si>e of the department $rganisationa/ structure and staff reporting system 5*o. of staff6 Posta/ arrangement interna/ and e=terna/A franking machineA incoming te/egramsA redirecting mai/ .egu/ar de/i3ery and co//ection ser3ice Definition of centra/ised and departmenta/ ser3ice Co//ection of "aste separation and co//ection disposa/ of sharps and infected materia/ Chee/chairs /ocation and maintenance De/i3ery of f/o"ers 2ospita/ 3ehic/es functions .o/e of porters for duties re/ating to patients mea/sA storesA pharmacyA theatreA admissionsA /inenryA the mortuaryA = ray reha&i/itation. Super3isory contro/ and shift system

.ecords and formats a3ai/a&/e.

4,. Sec#rity :9ire *re/ention an$ car *ar1in"; Physica/ structure and si>e of the department $rganisation definition and functionsA 4anpo"er status E@uipment re@uirements Security patro/s functions and fre@uency Staff identity cards system Lost property Security communication systems Contro/ of entrances /ocking up at night .e/ationship "ith po/ice Locks and keys po/icy systems and contro/ 7ire a/arm systems and check Security if inf/amma&/e goods Security of cash in transit and at the time of &anking and "ages are paid out 7ireB e3acuation procedures training and 7ire dri//s 7ire fighting e@uipment specia/ re@uirements to dea/ "ith f/amma&/e or e/ectrica/ risks Emergency /ighting Po/icy on smoking 1ccess to the site for fire tenders *oticesB no smoking fire escape procedures use of e@uipment Car parking po/icies for patients 3isitors and staff specia/ pro3ision for the disa&/ed am&u/ances and ta=is (raffic routesB pri3ate supp/ies /orries &us am&u/ances and pedestrians Parking of &icyc/esA motor &icyc/es and mopeds etc Discip/ine procedures Procedures for incoming materia/s Procedure for .eturna&/e 9ate pass Procedure for handing o3er keys Procedure for time office management .e/ationship "ith purchase and stores departmentA 4aintenance departmentA LaundryA 2ouse keepingA front officeA transport and administration department. *ight patro//ing procedure Procedure of out pass 9ate passes .ecords and 7ormats a3ai/a&/e 4+. Sterile s#**ly Physica/ structure /ayout p/an and si>e of the department $rganisationa/ structure and reporting system 54anpo"er status6

(heatre steri/e supp/y po/icy type of ser3ice and system of issue (heatre steri/e supp/y c/eaning packing and storage systems Decontamination process of ma?or e@uipment such as I(U and 3enti/ators CSSD ser3ice po/icy type of ser3ice and de/i3ery system Standardi>ation Cata/ogue of pack to &e used Issue and contro/ of specia/i>ed e@uipment processed through the !CSSD issue and return procedures Steri/isation a/ternati3e methods for heat /a&i/e e@uipment Steri/i>ation processB Steam Steri/i>ationA steri/i>ation &y ethy/ene o=ide gas 5E($6A steri/i>ation &y dry heatA Use of autoc/a3es Ser3ices to specia/ist departments such as dentistry the accident cardio/ogyA radio/ogy 2and/ingA co//ection and (ransportation of soi/ed materia/s 4ethod to &e adopted for reusa&/e materia/s prior to disinfection or steri/i>ationA Chemica/ disinfection Chemica/ and &io/ogica/ indicators Dress code of CSSD staff Supp/ies for community ser3icesA Staff training methods 4aintenance of repair of e@uipment List of &ooks and formats a3ai/a&/e.

44. Tele*(one Physica/ structure /ayout and si>e of the department $rganisationa/ structure and reporting system54anpo"er status6 Huick reference system in the s"itch &oard Staff /ocation system Crash ca// communication systems Pay phones Card te/ephone Po/icy on pri3ate ca//s co//ection of charges Entries in directories and year&ooks (e/e= and te/egrams Use of /ong range &/eeps $ffice intercommunication systems (e/ephone directory a//ocation of e=tensions design of directory and updating Distri&ution of post office directories 4<. 9inance an$ Acco#nts Physica/ structureA Location and si>e of the department $rganisationa/ structure and staff reporting system 54anpo"er6 Department &udgetary contro/ po/icy and system

(rust funds po/icy and systems Payment of sa/aries and "ages po/icy and systems time c/ocks or signing on registers 1ccounting procedures Co//ection of cashA &i//ing system .e/ationship "ith &i//ing and cash counter 7inancia/ information systems 9ifts to hospita/ po/icy Standing orders authority to incur e=penditure Losses and compensation Interna/ audit Petty cash Payment of tra3e//ing e=penses 2ospita/ity po/icy financia/ /imits and procedures Patients monies and property

4>. Personnel : incl#$in" Resi$ents0 Cons#ltants; Physica/ structureA Location and si>e of the department $rganisationa/ structure and staff reporting system 54anpo"er6 Definition of the departmentFs responsi&i/ities 4anpo"er p/anning .ecruitment &rochures design Staff records po/icy procedures and design Gisua/ disp/ay systems Joint staff consu/tati3e machinery Staff information systems &u//etins and notice &oards Emp/oyment and training functions and organisations Staff se/ection procedures inter3ie" pane/s accounta&i/ity of !appointing staff Discip/inary procedures appea/ machinery 9rie3ance machinery Staff hand&ook design Day nursery arrangement Staffs socia/ c/u& constitution and faci/ities Staff amenities *ame &adges or 5security cards6 specification and po/icy a&out these &eing "orn 7aci/ities for trade union .est rooms and common rooms Changing accommodation a//ocation of /ockers 1ccounta&i/ity for changing accommodation issues keys Staff rest &reaks po/icy 1ccounta&i/ity for the residences Staff residences po/icy on a//ocation of rooms

(enancy 5occupancy6 agreements .esidents house ru/es for e=amp/e use of e/ectricity app/iances Security of resident staff 9uests staying o3ernight Gisitors to residents ru/es .e/ationships "ith domestic ser3ices .esidents staff representati3e machinery Compensation procedures Lea3e a&senteeism regu/ations Emp/oyee ser3ice ru/es .ecords and formats a3ai/a&/e.

4'. Staff me$ical .elfare Physica/ structure and /ay out p/an Definition of functions 1ccident to staff reporting system $rganisation and accounta&i/ity Immunisation po/icies and other precautions to protect staff Po/icy for chest =!rays of ne" staff Staff records and other forms 2ospita/ safety committee functions 7irst aid!decentra/i>ed systems and e@uipment Staff sick in residences pro3ision of sick &ay or use of hospita/ &eds $ther staff hea/th ser3ices dentistry 2ea/th and safety at "ork po/icies and accounta&i/ity. 4@. P#rc(ase an$ stores Physica/ structureA Location and si>e of the department $rganisationa/ structure and staff reporting system 54anpo"er6 Definition of responsi&i/ities re/ationships "ith catering pharmacy and "orks Pre! purchase systems!procedure Preparation of comparati3e statements 1ppro3a/ and authorisation system of purchase Post!purchase systems!procedure Stock contro/ systems minimum and ma=imum stock /e3e/s .e!order /e3e/ Safety stock maintenance Issue systems and procedure .e@uisitioning arrangementsI non stock and stock itemsA authority to sign re@uisitions Coding and Bin card system Stores proceduresA arrangementsA use of 1BC ana/ysisA GED ana/ysis Computeri>ation and In3entory management system

Security of stores .eturn of stores 9oods reception and dispatch systems 1ccess to stores in emergencies Distri&ution of goods interna/ transport system $rdering procedures authority to incur e=penditure Condemning procedures Liaison "ith "orks department e/ectrica/ safety checks for ne" e@uipment 4aintenance and ser3ice contracts po/icy and fre@uency (ender and @uotation procedures In3entory contro/ Stores /ayout Sa/e of "aste products 1pp/iances for patients organisation supp/y and systems .ecords and formats a3ai/a&/e Performance ana/ysis Lack of maintenance safety stock De/ay in issuing materia/s 1pp/ication of effecti3e techni@ues /ike GED and 1BC ana/ysis $3er and under stock Lack of kno"/edge in negotiation ski//s in price fina/isation 1pp/ication effecti3e costing

4A. En"ineerin" %e*artments Physica/ structureA Location and si>e of the department $rganisationa/ and staff reporting systemA 4anpo"er 1ccounta&i/ity for specia/i>ed e@uipment such as radio/ogy etc P/anned maintenance system (o maintain an 1sset 54a?or and important E@uipment6 .egister Bio medica/ e@uipment maintenance system .epair re@uisitioning procedure routine and emergencies Energy conser3ation .epair of furniture and items such as "hee/chairsA coding and maintain the stock register Storage of materia/s accounta&i/ity and systems $n ca// ser3ices Emergency po"er supp/y checking procedures 9enerator maintenance Precautions against /egionnaires disease! Cater p/ant checks 4aintenance of E/ectro medica/ e@uipment Painting programme direct or indirect /a&our

E/ectrica/ safety procedure for checking ne" e@uipment 7ire a/arm checks Upkeep of /ifts Corkshops definition of functions and e@uipment re@uirement Supp/ementary heating po/icy 4edica/ gases test procedures maintenance and storage 1naesthetic e@uipment test procedures 4aintenance contracts po/icy fre@uency of ser3ice 3isits Industria/ gases storage safety ordering and stock contro/ Incineration Upkeep of grounds Landscaping strategy horticu/tura/ ad3ice Contract ser3ice direct /a&our Use of grounds for recreationa/ purpose .oad c/eaning and system for c/eaning the grounds of /itter Seats for patients and 3isitors E@uipment for grounds maintenance and its storage Catering points Shortcuts o3er grassed areas pro3ision paths .ecords and formats a3ai/a&/e

4B. !eneral Office A$ministration Location and si>e of the department $rganisationa/ structure and staff reporting system 4anagement structure of the hospita/ Lega/ ser3ices to the hospita/ $rganisation of personne/ functions Bui/dingsA surroundings and fencing systemsA 9arden maintenance etc. 1dministrati3e on ca// system Committee and meetings structure inc/uding representati3e !meetings for doctors and staff consu/tation!Use of conference rooms &ooking system Photocopying dup/icating co//ating and "ord processing ser3ices Centra/ fi/ing system Sign posting po/icy and schedu/es 5interna/ and e=terna/6 Supp/ementary signs and notices *aming and num&ering &ui/dings "ards and departments Entrances and entrance ha// reception contro/ en@uiries upkeep Document contro/ headings and uniformity Lifts and e/e3ate and channe/A functions and upkeep Corks of art inc/uding paintings accounta&i/ity PatientsF property custody and return of 3a/ua&/e pensions for !/ong stay patients. Patients dying in hospita/ administrati3e responsi&i/ities coroners cases &uria/s &y the hea/th authority

Use of communa/ rooms po/icy (o see o3er a// hospita/ administrati3e functions Pu&/ishing information "ith regard to patients to pu&/ic!Consent Code of press re/ease 52# hours information ser3ice6 4atters "ith regard to patientF consent is not re@uired

PER9ORMANCE ANAL8SIS !eneral Analysis :

!ENERAL !UI%ELINES

1ssessment of organisation $rganisationa/ o&?ecti3es $rganisationa/ structure Physica/ faci/ities Personne/ Budget 4ateria/s Drugs and supp/ies Se@uencing of operations 7/o" of acti3ities Effecti3e uti/isation of human and materia/ resources 1dministrati3e &acking (he methods Hua/ity and Huantity .ange and amount of diagnostic procedures 4edicines Information a&out treatment etc to/d to patients Po/icies and procedures End resu/ts $utcome and Impact Cost Cured Impro3ed .eferred Benefit accruing to community 1re peop/e satisfied 5Consumer satisfaction6 Do they "ant more and &etter faci/itiesK S*ecific analysis : 13erage patients recei3ed &y out patient department dai/y0month/y Detai/s of referra/ System out!patients and in!patients Ca/k in Patients .eferred &y $"n doctors 5Consu/tants6 .eferred from $ther 2ospita/s0*ursing 2omes

.eferred from 9enera/ practitioners 13erage admissions of in!patient "ards dai/y0month/y 13erage discharge of inpatients &y age "ise 1du/tsA Chi/dren and neonates dai/y 0month/y Bed occupancy .ate *o of deaths!&y department "ise 5"ards6A and units "ise dai/y 4orta/ity .ate Death "ithin #+ hours of admission Death after #+ hours of admission Bed turno3er .ate 13erage /ength of patient stay *o. of operations done per day in 3arious theatres Patients distri&ution &y ageA se=A ethnic groupA geographic distri&ution of patient Confinements Diagnostic procedures 1utopsies Disp/ay on dai/y ma?or acti3ities Statistics of mor&idity and 3arious types of disease pattern Pre3a/ence seasona/ and annua/ 4orta/ity statistics Epidemio/ogica/ pattern of disease Statistics of end resu/t curedA impro3edA died or L141 E(C.A