UNIT IV

SUPPORTIVE SERVICES
Medical Records Department - Central Sterilization and Supply Department - Pharmacy
- Food Services - Laundry Services.
1. MEDICAL RECORDS DEPARTMENT
1.1 Overview
The medical records department maintain records and documents relating to patient
care.
Among a host of activities, its main functions are filing, indexing and retrieving medical
records.
The primary purpose of establishing a medical records department is to render services
to patients, medical staff and hospital administration.
The quality of care rendered depends on the accuracy of information contained in
medical records, its timely availability to and the extent of utilization by the professional staff.
To achieve economy, accuracy of information and good communication which are of
vital importance to the medical records system, all information should be concentrated in the
original medical records of patients.
This should be indexed and filed in the department.
The three basic principles of medical records are:
- Accurately written,
- Properly filed, and
- Easily accessible.
Medical records are used as primary tools to evaluate the quality of patient care rendered
by the medical staff.
To implement this effectively, the medical staff must adopt and self-enforce rules and
regulation for the production of timely, accurate and complete medical records.
Medical records are widely used for teaching and research purposes.
In the context of increasing malpractice liability suits against hospitals and physicians,
well-documented medical records are a good legal protection.
The physician is primarily responsible for the quality of his patient’s medical records.
It is his duty to review correct and countersign records that are written by residents and
junior doctors working under him.
Each entry in the medical record must be signed by the person making the entry, and
the signature should be identifiable so that responsibility for accuracy and authenticity can be
fixed.
The language used in writing medical records should be clear and concise and should
not lend itself to misinterpretation.
Abbreviation, symbols, etc. should be of acceptable standard.
The medical records department should maintain a list of acceptable abbreviations and
symbols for everyone to follow.
Every hospital should formulate policies, rules and regulations for the production,
completion and maintenance of medical records.
In many hospitals, registration is an integral part of medical records.
 The front office, which registers all patients, assigns each new patient a unique number,
collects patient demographics and other necessary data, assigns/directs patients to physicians,
and creates records.
In the case of returning patients it retrieves their records and updates them.
It maintain a master patient index for all patients.
Registration is the starting point for outpatient visits and all patient-related activities.
1.2 Functions
i) Planning, developing and directing a medical record system that includes patient’s
original clinical records and also the primary and secondary records and indexes. These may
be in the central record room, the clinical service area, adjunct departments or the outpatient
department of the hospital.
ii) Maintaining proper facilities and services for accurate and timely production, processing,
checking, indexing, filing and retrieval of medical records.
iii) Developing a procedure for the proper flow of records and reports among the various
services and departments including clinical services and the outpatient clinics where they are
needed.
iv) Developing a statistical reporting system that includes ward census, consolidated daily
census, outpatient department activities, and statistics in relation to services such as radiology,
clinical laboratories and pharmacy.
v) Preparing vital records of births, deaths, reports of communicable diseases, etc. for
mandatory and regulatory agencies, and statistical reports. These relate to number of
admissions, discharges by major clinical services, discharge diagnoses and length of stay by
diagnoses, types and number of surgeries performed, etc. for use by administration, medical
staff communities and the education and research departments.
vi) Coding all diagnoses and operators according to international classification of disease
for statistical purposes.
vii) Safeguarding the information in the medical records against theft, loss, defacement,
tampering or use by unauthorized persons.
viii) Determining in coordination with medical staff and administration the action to be
taken in medico-legal cases relating to the release of medical records in a variety of situations
and determining the legality and ethical appropriateness of such actions in conformity with the
laws of the land.
To appreciate the several activities that take place during the medical record’s journey
after admission and after discharge of patient, see flowcharts in Fig.1.1 and Fig.1.2.
1.3 Location
In order to provide prompt medical record service for the care of all patients at all hours
and to foster a close working relationship and good communication among the related
departments, the medical records department should be located close to the admitting area,
outpatient department, emergency room and the business office.
It should also be close to or on the corridor leading to the doctor’s lounge so that the
medical staff can conveniently stop by and complete their records and study cases.
Proximity to admitting, outpatient and emergency departments eliminates delay in
procuring medical records.
 Fig. 1.1 Flowchart of Medical Records on admission of a patient

Fig. 1.2 Flowchart of Medical Records on discharge of a patient

It also permits a skeleton staff to manage the worse of the medical records department
during the evening and night shifts.
While carrying on their normal duties like filing, etc. the night crew can also furnish
records to the emergency department.
Location is important particularly in small hospitals where the records department
usually remain closed during the night. In that case, it should be within easy walking distance
for the authorized admitting or emergency department staff to enter the department and retrieve
records for emergency patients.
The need for security surveillance to safeguard medical record information also has a
bearing on the location.
1.4 Design
The front office of medical records – the registration together with the enquiry – is often
the patient’s first point of contact with the hospital.
It is here that public relations plays a vital role.
In addition to courteous and helpful staff, the physical design should be one that projects
a warm and welcome feeling.
Good functional design, logical placement of work areas and a good system of
communication among the various sections of the department and between other departments
are vital.
The department should also be designed with the best possible means of transportation
of medical records through all stages of their use and processing.
1.5 Organization
The medical records department may be headed by a medical record administrator or
officer who reports to the director for medical or administrative services.
He should be a graduate with a degree or diploma in medical records administration.
The remaining staff in the department consists of medical records technicians and
medical records clerks.
The Christian Medical Association of India and various medical colleges offer degree
and diploma courses in medical administration.
In large hospitals, there may be an assistant medical record officer and supervisor for
major functional areas such as filing and indexing, coding and abstracting, transcription,
discharge analysis, medical audit, utilization review and registration.
1.5.1 Unit Record
The unit record is a single record that documents the entire medical care provided to an
individual in all the services of the hospital, namely, is the inpatient and outpatient sections
and the emergency room.
The single unit consolidates and retain all the records in a chronological order, that is,
in the order of occurrence of events and findings.
This way, the record provides the doctors with the necessary references to a patient’s
current and past conditions all tests and procedures on him and his response to therapy.
Some hospitals maintain separate records for inpatient and outpatient visits.
The disadvantage of this system is that the patient’s complete history cannot be
reviewed quickly and easily.
Other methods of assembling medical records are:
1. Chronological by source of information or section (physician’s notes, nurse’s
notes, lab reports, etc.)
2. Problem- oriented medical record
1.5.2 Numbering System
The most widely used method for numbering is the unit numbering, used in conjunction
with the unit record system.
 In this system, a single, permanent number is assigned for each patient (as against
different number each time a patient is admitted).
The unit number ensures accurate identification of the patient and complete information
about his investigation, tests and the accounting records.
1.5.3 Filing System
The most popular method of filing is the straight numerical filing, starting with the
lowest number and ending with the highest.
Activities relating to filing and retrieving are most concentrated in the area where
records with the highest numbers are stored because they are the most recent and active files.
This is the easiest method of filing as the staff is familiar and comfortable with it.
However, the chances of misfiling and not finding the misfiled charts are high in this
system.
The other method of filing is the terminal digital filing.
This provides equal distribution of medical records in the storage area and therefore
allows the staff to be evenly spread within the area.
The filing is based on the last two digits of the medical record number.
The entire file is divided into hundred sections from 00 to 99 and the records are stored
in there sections according to their last two digits.
For example, all records ending with 14 are filed together.
In an advanced system, the terminal digits are also colour-coded.
The great advantages of this system is that the filing clerks can visualize the actual
location of the records.
It also speeds up filing and retrieval of files and virtually eliminates any chance of
misfiling.
1.5.4 Dictating and Transcription System
Various dictating and transcription systems are available.
In an advanced system, doctors dictate their notes or discharge summaries from various
location in the hospital – from the words, operating room, ICC & CCU complex, emergency
room, etc. – using either a remote dictating equipment or the telephone which is linked to the
central transcription room in the medical records department where the dictation is tape
recorded.
The medical secretaries then transcribe the recorded dictation.
With the advances in telephones, doctors can now dictate their notes from anywhere
from their homes or even from moving cars using car phones.
1.6 Space requirements
The medical records department requires space and facilities for the following:
1. Reception and registration area.
2. Offices for the medical records officer and assistant medical records officer.
3. Space for sectional supervisors.
4. Work area for record processing, assembling, numbering, indexing, utilization review,
discharge analysis, correspondence, work processing, quality assurance, etc.
5. Record storage for active and inactive files.
- Active files are the files where the data of discharge or last visit is within three
to five years of the current date. These files should be readily accessible.
 - Inactive record storage should also be located near the active files area as far
as possible. These may be stored in a computer assisted system.
6. Space for copies that is used to a considerable degree.
7. A room for medical staff to complete records, study cases review and abstract records
with tables, chairs, dictating equipment, etc.
8. An area with bookcases or shelves to temporarily house medical records pending
completion or temporarily used by the medical staff.
9. Transcription area with space for the central recording equipment, tables, computers,
etc. for medical secretaries to transcribe dictation.
10.Space for master patient index depending on the kind of system used, for immediate
identification of current and past patients. Computer-assisted system are now widely
used.
11.Storage area for medical record carts.
12.Supplies storage area for unused medical record file folders, forms, etc.
13.Staff facilities.
1.7 Other Consideration
i) Ownership of Medical Records
Medical records are created and maintained for the benefit of patients, medical staff and
the hospital.
The hospital has the right to restrict removal of the records from the records room or
from the hospital premises, determine who may have access to them, and lay down as a policy
the kind of information that may be taken from them.
Except for authorized patient care purposes within the hospital, medical records may be
removed from the department only on the order of a court of law and with the prior permission
of the chief executive officer.
Even when the records are given out, it is a wise policy not to part with the original
records.
Only photo copies should be given except on the orders of the court.
ii) Confidentiality of Information
While the information contained in the identification section of the medical record is
not confidential, the clinical data obtained professionally is confidential and it should be
safeguarded.
Employees are obligated to safeguard the confidential information of patients.
Many hospitals require employees having access to patient records sign an undertaking
not to divulge any patient information that may have come to their knowledge in the course of
their work.
A great deal of harm can be alone to patients by employees divulging confidential
patient information.
Confidential information may be released with appropriate authorization.
However, the information acquired by a physician in doctor-patient relationship in
privileged information that the physician may not disclose even in a court of law.
iii) Record Retention
Apart from patient care, records are retained for various reasons such as for legal and
research purposes.
 It is not necessary to retain records permanently for any purpose, and certainly not for
the purpose of proving birth, age, residence, etc.
It is generally accepted that hospitals are seldom required to produce medical records
older than 10 years for clinical, research, legal or audit purposes.
iv) Computerization
Computers are widely used in the access of registration and medical records.
In registration, they are used to maintain information and patient’s personal date
(demographics), for assigning patient numbers, making appointments and assigning to
physicians, creating records, etc.
In medical records, computers can be used for patient records and medical records
administration.
For the most part, however, computers have not made much inroads into the patient
records area, but in the records administration area they are used for chart abstracting, medical
record indexing, diagnosis coding, chart locating, master patient index, statistics, etc.
Authorized personnel can have access to all current and historical data.
On-line abstracting can be done using screens and conditional editing.
All editing is done in real time.
An on-line master patient index gives immediate access to essential, episodic patient
information.
Medical records reporting gives optional access to essential, episodic patient
information.
Reports can be sorted and sequenced in a variety of ways.
They can be generated on a daily, monthly, quarterly, semi-annual and annual basis.

2. CENTRAL STERILIZATION AND SUPPLY DEPARTMENT

2.1 Overview
Despite the unprecedented advances made in the medical field, hospital-acquired
infection remains the hospital’s single most serious concern that negates some of its otherwise
good work.
It is acknowledged that even in advanced countries, approximately five percent of all
hospital patients develop infection after being admitted.
Given the poor standards in our hospitals, this figure is likely to be much higher in India.
The intangible and tangible cost of this by way of unnecessary suffering, extra
hospitalization and loss of working days can be high.
To combat this ubiquitous menace of infections caused by pathogenic micro-organisms,
hospitals have over the years developed a scientific method commonly referred to as the
central sterile and supply system.
The method basically involves cleaning, disinfecting and sterilizing before use all
instruments, materials and equipment utilized in patient care.
From various parts of the hospital like operating room, wards, outpatient clinics and
other departments, all soiled items are collected in the CSSD for processing, and then
transported back to the end users.
In the CSSD, the process of cleaning, disinfecting, packing, sterilizing and distributing
is carried out by specially trained personnel.
 This ensures better control and reliable result and reduced risk of infection.
Sterilization of instruments, operating packs, trays, etc. is performed by heating them
with pressurized steam or by gas sterilization.
Steam sterilization is called autoclaving.
However, certain items such as rubber, plastic and delicate instruments cannot be
autoclaved and so have to be sterilized by using ethylene oxide or similar gases.
Gas sterilization requires certain safety precautions such as aeration prior to use and
special exhaust ventilation.
Under both systems, sterilization is performed on cleaned instruments wrapped in
special linen.
In the decentralized system, the sterilization facility is located near the area where the
sterilized items are used.
This is called Theatre Sterile Supply Unit (TSSU).
The advantage of this system is that it allow for direct communication, the number of
instruments in small and transportation is more or less eliminated.
The CSSD services the nursing units, the operating rooms, ICUs, labour-delivery suites,
the nursery, outpatient department, radiology, pharmacy and the clinical laboratories.
The primary activities of the department are sterilizing, storing and distributing the
dressings, needles and syringes, rubber goods (gloves, catheters, and tubing), instruments,
treatment trays and sets, sterile linen packs, etc.
Disposable sterile supplies are being increasingly used in hospitals
They need only to be stored and not processed for reuse.
Since these disposable items are expensive, their use in Indian hospitals has not
significantly affected the workload of the CSSD.
2.2 Objectives
1. Process and sterilize equipments and materials under controlled conditions by trained
and experienced personnel thereby contributing to total environment control in the
hospital.
2. Effect greater economy by keeping and operating the expensive processing equipments
in one central area.
3. Achieve greater uniformity by standardizing techniques of operations.
4. Gain a higher level of efficiency in the operations by training personnel in correct
processing procedures.
2.3 Functions
1. Receiving and storing soiled material used in the hospital.
2. Determining whether the item should be reused or discarded.
3. Carrying out the process of decontamination or disinfection prior to sterilizing.
4. Carrying out specialized cleaning of equipment and supplies.
5. Inspecting and testing instruments, equipment and linen.
6. Assembling treatment trays, instruments sets, liner packs, etc.
7. Packing all materials for sterilizing.
8. Sterilizing.
9. Labelling and dating materials.
10.Storing and controlling inventory.
 11.Issuing and distributing.
2.4 Location
Accessibility to elevators, dumb waiters and stairs is of utmost importance in
determining the location of CSSD.
It should be close to the depth which use its services the most.
Generally, the largest users are the surgical department, including the recovery room,
and the nursing units.
Hospitals are continuously searching for new ideas to maintain aseptic condition of the
highest order, particularly in the surgical suites.
In advanced countries CSSD is located in a lower floor directly under the surgical suite.
The surgical suite and the CSSD are connected by means of two dedicated dumb waiters
– small elevators that deliver trays, medicines, etc. – one sterile and the other soiled.
The sterile dumb waiter, located in the sterile area of the CSSD, opens into the sterile
area of the surgical suite and transports all sterile items without being contaminated in transit.
The solid dumb waiter is located in the less sterile area of the surgical suite and brings
down the soiled items to the soiled area of the CSSD for reprocessing.
2.5 Design
The workflow pattern should be planned in such a manner that the personnel traffic and
the movement of supplies and equipment is accomplished in an efficient manner, the flow of
work in continuous from receiving to issuing without retracing steps, and the receiving and
clean up areas are physically separated from the rest of the department.
Workflow must be so planned as to allow a separate entrance to receive soiled and
contaminated materials from departments, and another for issuing clean and sterile supplies
and instrument.
There could be a third entrance, if necessary to receive materials from general stories
and laundry.
In a well-designed, state of the art CSSD, there are three organized zones:
1. Soiled area
2. Clean area
3. Sterile area
Soiled items from various departments of the hospital are received at the solid reception
area in the same trolleys, instrument trays, baskets or containers as they were delivered in.
Most of them are loaded straight onto the pass-through washer-disinfector.
Trolleys and some instruments are cleaned and disinfected manually.
Steam and hot water are the most common of disinfection agents used in hospitals.
In the clean area, clean disinfected materials are sorted, inspected and packed.
After packing, the instrument trays are put into baskets for sterilization in the double-
door, pan-through autoclaves.
Fabrics are sorted out and packed in a separate area before sterilization.
The double-door pan-through autoclaves of the required size are built into the wall
between the clean and sterile areas.
Materials are loaded on the clean side and unload on the sterile side.
Both automatic and manual loading and unloading autoclaves are available.
 Autoclaves with formaldehyde and ethylene oxide for heat-sensitive goods and cycles
for fluid production are also available.
After sterilization, the autoclaves are unloaded in the sterile area and the materials stored
these. The storage area should be dry and free of dust.
It is advisable to have one high-speed autoclave, preferably in the operating room, to re-
sterilize the instruments needed immediately or these that have been dropped accidently.
Flash sterilization is autoclaving an instrument when it is unwrapped.
Plan of CSSD is given in Fig. 2.1.

Fig. 2.1 Plan of CSSD

2.6 Some procedures
1. Cleaning and working of instruments, trays, etc., should be performed before
reassembling and wrapping instrument kits.
- Cleaning and waiting can be done wither manually or by automatic washers.
- Ultrasonic cleaners are considered most effective in cleaning joints, hinges,
etc.
- They, however, erode the surface of instruments and shorter their life.
2. Surgical linen is inspected before wrapping instruments or linen packs to check for
holes, tears or rips by passing it over a light table.
3. Linen packs of sheets, drapes, wraps, etc. are assembled for operating room, labour
rooms and delivery suites.
- Special linen packs are prepared to suit special procedures such as
laparoscopy, mastectomy and orthopaedic hip surgery.
4. Processing of instruments, one of the activities of the CSSD, includes assembling
appropriate instruments and supplies into kits and wrapping the kits with sterile linen.
 - Kits and trays may be of various types, such as surgical instrument kits for
operating room, suture kits for nursing units and emergency departments, cut
down trays for nursing with and special trays for radiology.
5. Instruments used regularly are sometimes assembled to make pre-wrapped kits and
stocked, or they are prepared when needed as per order.
6. Sterilization is done in batches, which means that several packages are sterilized in a
single load.
- For infection control, these packages are labelled, and dated, and later
reviewed periodically against test indicators.
- If a batch is found to be below standard, the packages are removed from the
shelves.
- A wrapped and sterilized kit in considered sterile for a certain length of time
after which it has to be re-sterilized.
- The length of time a kit remains sterile depends on the type of wrap used, that
is whether the kit is wrapped with single or double thickness surgical quality
linen.
- Labelling and dating of package is one of the important steps in the
sterilization process.
7. The CSSD may also be engaged in the manufacturer of parenteral solutions, normal
sterile saline solution and sterile distilled water.
- However, because of risks involved, only a few hospitals prepare parenteral
solution.
- Even in the case of saline solutions and sterile water, the trend is to purchase
them from outside in plastic pouch containers.
- These reduce breakage and are also convenient to handle.
2.7 Organization
Traditionally, CSSD has been a part of the nursing service department supervised by a
nurse or a person with para medical training and reporting to the director of nursing or the
nursing superintendent.
This pattern prevails in many hospitals.
It is also not uncommon for operating rooms to perform their own sterilization and not
have much interaction with the CSSD.
The sterilization room in located next to the operating rooms so that sterile packs are
transported easily.
In developed countries, the department goes by the name of “Central Service
Department” and encompasses many other functions in addition to sterilization, such as
purchasing, stocking and distribution of supplies under a materials manager or an assistant
administrator.
Personnel in the CSSD comprise a supervisor who may be a nurse and one or two nurses.
The remaining staff typically consists of assistants, technicians, aides, orderlies and
messengers who are trained on the job.
Usually in a new set-up with sophisticated equipment the firm that supplies the
equipment trains personnel in handling it as part of a package deal.
 There is now a growing trend towards putting the CSSD in the charge of an experienced
manager.
The chief of CSSD is generally a number of the hospital infection control committee.
2.8 Facilities and Space Requirements
1. Reception control and disinfection area workspace and equipment are needed to clean
and disinfected medical and surgical instruments that are sorted, racked and passed
through washer-sterilizers to the clean area.
2. Facilities for washing and sanitizing carts.
3. Staff change rooms, lockers, toilets, etc.
4. Supervisor’s office. It should be out of the flow of activities but provide unobstructed
view of the processing area. For this a glass-walled office is recommended.
5. Clean work area. Space for preparing special instruments, inspecting and testing
instruments, equipment and linen for assembling treatment trays and linen packs for
preparing gloves and for packing materials for sterilizing.
6. Assembling area. Requires workstations for assembling medical-surgical treatment
packs, sets and trays, work benches with multiple drawers for instruments and supplies
should be provided. The linen pack area requires large work tables, and for inspection,
a special inspection (light) table for examining linen wrappers for minute instrument
holes.
7. Supply storage area.
8. Double-door, pass-through autoclaves. These are high-vacuum steam and gas
sterilizers.
9. Adequate space for loaded sterilizer carts or trolleys prior to sterilization for carts during
the cooling period following sterilization and wherever applicable for carts for sterilized
supplies for the surgical suites and labour-delivery suits prior to delivery of these
supplies.
10.Sterile store.
11.Issue counter.
12.Clean cart storage area.
13.Provision for supply of steam, hot and cold water and other utilities and services.

3. PHARMACY
3.1 Overview
The pharmacy is one of the most extensively used therapeutic facilities of the hospital
and one of the few areas where large amounts of money are spent on purchases on a recurring
basis.
It is also one of the highest revenue-generating centres.
A fairly high percentage of the total expenditure of the hospital goes for pharmacy
services.
This emphasis the need to plan and design the pharmacy in a manner that results in
efficient clinical and administrative services.
A good pharmacy is a blend of several things:
- qualified personnel,
- modern facilities,
 - efficient organization and operation,
- sound budgeting,
- the support and cooperation of the medical, nursing and administrative staff
of the hospital.
Automation, pre-packaging, unit dose drug distribution, decentralization are some of
the methods that are being increasingly used in addition to computer-based ordering system,
computer-assisted pricing, billing, cash collection checking of reorder level, out-of-stock and
overstock over-stock position, expiry dates and a host of other function.
Pharmacy is a specialized area and its operation calls for intimate knowledge of drugs
and drug therapy.
Because of this and the amount of drugs and supplies involved, pharmacists usually
handle their own purchases and stocking of drugs rather than leaving it to the purchasing
department.
In large hospitals, there is a pharmacy and therapeutic committee of which the chief
pharmacist is a member, to oversee the activities of the pharmacy.
3.2 Functions
The following are the primary functions of the pharmacy, some of which are performed
directly by its chief:
1. Purchase, receive, store, compound, package, label and dispense pharmaceutical item.
2. Serve as a source of drug information to physicians, pharmacists and other health care
professionals, and the patients. This involves compiling storing, retrieving and
disseminating drug information and providing pharmaceutical advice and consultation
regarding drug therapy.
3. Participate in hospital’s educational programmes.
4. Plan and organize the pharmacy department, establish policies and procedures, and
implement them in accordance with the hospital’s policies.
5. Serve as a member of the pharmacy and therapeutics committee, be actively involved
in its functions and activities, and implement its decision.
6. Carry out research and participate in the evaluation of new drugs.
7. Participate in performing therapeutic assessment of drugs and in the preparation of a
hospital formulary so that equally effective but less expensive drugs may be put on the
formulary.
(A formulary is a list of drugs approved by the medical staff and the pharmacy
committee for hospital use and kept in the inventory).
8. Keep track of drugs and formulations or combinations banned in the country and
elsewhere, and keep abreast of WHO’s revision of “essential list of drugs” and other
notification.
9. Carry out quality assurance programme to ensure quality when in doubt of the efficiency
or potency of a drug by sampling and analysing it either in the hospital or through the
drug inspectorate.
10.Comply with statutory regulations, initiating licenses to be obtained maintaining records
as legally required.
11.Wherever recognized, provide pharmacy students practical training which is in partial
fulfilment of their course requirements.
3.3 Drug Distribution
The pharmacy distributes drugs primarily to nursing units, where they are administered
to inpatients. Generally, the drugs distributed or dispensed by the pharmacy fall into three
categories.
1. Drugs sent to the nursing units for floor stock inventory. These are items generally
stored in the units for the use of patients but not charged to them.
2. Drugs that are sent to nursing units specified for individual patients as prescribed by the
doctors and are changed to them. In most of our hospitals this is not done. Patients are
asked to buy their medicines from the pharmacy which are then give to the unit nurse to
be stored in medication carts with individual drawers for each patients.
3. Prescription drugs by the pharmacy on the strength of a prescription given by a
physician. These are largely paid for in cash and represent the vast majority of drugs
both in terms of quantity and cost.
3.4 Location
In determining the most suitable location for the pharmacy, the following factors should
be considered:
- Flow of outpatient traffic through the hospital.
- Flow of drugs and other raw materials into the pharmacy.
- Flow of drugs and services from pharmacy to the inpatient areas and other
departments.
- Need for future expansion.
These factors make it evident that pharmacy should be conveniently accessible from the
outpatient department, central receiving store and the inpatient areas.
A ground floor location close to the outpatient department and to elevators servicing the
inpatient areas is ideal.
It is assumed that the outpatient and inpatient dispensing activities are combined.
Many hospitals, however, find that when the outpatient department is the overriding
consideration in determining the location of the pharmacy, the result is a less than optimal
location for the inpatient dispensing activities.
They may soon find that one or more separate inpatient or satellite pharmacy facilities
need to be established.
In many of our hospitals, inpatients are required to buy their requirements of medicines
directly from the pharmacy on a cash down basis.
Medicines are not supplied and billed.
Every hospital, sooner than later, and much to its consternation discovers that its
pharmacy facility is woefully inadequate.
Keeping in mind, the pharmacy should have at least one outside wall to allow the
expansion, and must be adjacent to an area that can be relocated easily, for example, a
storeroom.
3.5 Design
Each hospital must its own pharmacy and solve its individual pharmacy-programming
problems, while adhering to the accepted norms of good pharmacy practice and legal
requirements.
The pharmacy has 4 main functional areas:
 1. Dispensing area
2. Production/ preparation area
3. Administrative area
4. Storage area
These areas must be designed and located for convenient access, staff control and
security.
3.6 Organization
The head of the pharmacy services is usually a chief pharmacist who may possess a
B.Pharm. or M.Pharm. degree and adequate experience.
He is normally responsible to the medical director or the medical superintendent.
In large hospitals, he may be required to work in conjunction with the pharmacy and
therapeutics committee.
Every pharmacist has to register with the pharmacy council without which he cannot
practise.
Other personnel in the pharmacy department are the registered staff pharmacists,
pharmacy aides or helpers, pharmacy storekeeper and pharmacy clerks.
The normal working hours of the pharmacy in most hospitals are from 7.00.a.m to
11.00.p.m, seven days a week although some pharmacies provide round-the-clock service.
Where 24-hour service is not available, coverage during the late night (between
11.00.p.m and 7.00.a.m) is provided by on-call staff.
3.7 Facilities and Space Requirements
3.7.1 Dispensing Area
1. Patient working area. It should be recessed so that the usually large waiting crowd does
not obstruct the free flow of traffic on the corridor nor is it jostled by it.
2. Patient dispensing counter, preferably glass panelled with pan-through windows, with
space for computer-assisted pricing, billing, and receiving cash on one side and for
dispensing on the other.
3. Active storage. Adequate space for a large number of active drugs stored in routine
shelves laid out efficiently.
4. Pick up and receiving counter and space for temporary storage of carts.
5. Area for review and recording of drug orders.
6. Extemporaneous compounding area.
7. Work counters and cabinets for pharmacy activities.
8. Refrigerated storage.
9. Storage for alcohol and for volatile and flammable substances.
10.Second storage for narcotics and other controlled drugs.
11.Space for maintain patient medication profiles and cross-checking of medication, for
providing drug information, and a room for pharmacist to meet patients who require
extensive consultation, instructions or counselling, if these functions are performed.
3.7.2 Manufacturing Area
1. Bulk compounding area.
2. Provision for packing and labelling.
3. Provision for packing assurance activities.
4. Clinical sinks and hand washing facilities.
 Preparation of parenteral fluids comes under the mandatory regulations of the Drug Control
Act that has now been made stricter and more comprehensive.
Hospitals which want to manufacture these fluids are advised to thoroughly study the
regulations and procedures.
3.7.3 Administrative Area
1. Reception and clerk-typist’s area for clerical functions including filing, communication,
references, etc.
2. Chief pharmacist’s office and office space for assistant chief pharmacist and clinical
pharmacist.
3. Waiting area for visitors, medical representations and salesman.
4. Conference room-cum-library.
5. Staff facilities like lockers, toilets, lounge, duty room for on-call duty pharmacists, etc.
3.7.4 Storage Area
1. Bulk storage.
2. Active storage.
3. Refrigerated storage.
4. Volatile and alcohol storage.
5. Secured storage for narcotics and controlled drugs.
6. Storage for general supplies, equipment, filter, stationary, etc.
3.8 Other Considerations
Traditional pharmacy services are rapidly undergoing a change all over the world,
especially in the dispensing and distribution system.
Many innovative approaches and methods have been introduced in recent years.
Though not all hospitals can implement these changes, it is hoped that some of the larger
and progressive hospitals in our country will introduce and test these newer systems and set
the pace for other hospitals, some of these changes are described below:
i) Clinical Pharmacy
In most of our hospitals, the pharmacy is engaged in traditional activities such as drug
ordering, preparation, distribution and dispensing.
Of these, dispensing prescription as ordered by physicians is the most important.
Except for monitoring drug incompatibilities occasionally, pharmacists have no role in
determining what to order.
But hospital pharmacists are now increasingly becoming involved in what is called
“Clinical Pharmacy”.
This includes activities like taking medication history, monitoring drug use, drug
selection, patient counselling and surveillance of adverse reaction of drugs.
In other words, they are becoming involved in determining what to order, thus becoming
a part of the team effort in determining treatment.
ii) Unit Dose Dispensing System
Another important change that has taken place in the field of pharmacy is in the
medication dispensing system – from the traditional pharmacy system to a considerably
refined unit dose system.
In the traditional system, the pharmacy sends to each patient in the nursing unit, several
day’s supply of medication.
 The nursing unit then prepares the individual dose from the supply.
In the unit dose system, the doses are premeasured by the pharmacy so that the nurse
has only to administer the medication.
The system uses a cassette mechanism that designates one drawer for each patient in the
medication cart or cabinet.
The nurse rolls the unit dose cart to each individual patient room, removes the dose of
medication to be given from the respective patient drawer in the cart, and administers it to the
patient.
In the emergency cart maintained in the nursing units, certain drugs are kept in single-
dose packages that are ready and convenient to administer.
While the unit dose system is expensive-initial one-time cost largely involves the
purchase of unit dose carts and packaging equipment and increased pharmacy personnel these
are several advantages.
It reduces nursing time for pouring, counting and dispensing, reduces medication errors,
and increases control and recording of medication by the pharmacy.
iii) I.V Additive System
The concept of a unit dose system can be extended to intravenous (IV) solutions, for
which there are two methods:
- The traditional method
- IV additive method.
The activity relates to mixing medications with IV solutions.
In the traditional system, IV solutions are stocked in the nursing unit.
Medications are sent to the unit by the pharmacy, and the nurse mixes or adds
medications to the IV solution.
In the additive system, the medications and the IV solutions are mixed in the pharmacy
itself.
The pre-mixed bottles are then sent to the nursing unit and the nurse merely administers
the solution.
As in the case of the unit dose system, this saves the nurses time and prevents wastage
and medication errors.
iv) Pharmacy and Therapeutics Committee
Every hospital should have a pharmacy and therapeutics committee consisting of
physicians representing the various divisions of medical staff, pharmacists, and representatives
of administration, to oversee the work of the pharmacy.
The following are some of the duties and responsibilities of the committee:
1. Develops a formulary of accepted drugs for use in the hospital.
2. Serve the medical staff, pharmacists and hospital administration in an advisory
capacity in all matters pertaining to the use of drugs and in the selection of drugs to
be stocked.
3. Evaluate clinical data concerning new drugs requested to be included in the
formulary and for use in hospital.
4. Add or delete specific drugs from the formulary.
5. Prevent unnecessary duplication of the same basic drugs to be stocked.
6. Recommend drugs to be stocked in the nursing units and other areas.
 7. Study problems or reported adverse reactions to the administration of drugs.
8. Issue communication(s) to physicians, pharmacists, nurses and administrative staff
regarding proposes change in the formulary such as addition to and deletions from
the list, changes in the working of the system and in the contents of the formulary.
9. Adoption of a policy that the inclusion of drugs in the formulary should be by their
non-proprietary names.
10.Ensure that the labelling of medication containers be by the non-proprietary names
of the contents.
11.Issue written communication to the nursing and pharmacy staff regarding the
existence of a formulary in the hospital and the policies and procedures governing
its operation.
12.Issue guidelines for the control, appraisal and use of drugs not included in the
formulary, investigational drugs and non-formulary drugs.
v) Hospital Formulary
One of the major responsibilities of the pharmacy and therapeutics committee is to
develop or adopt a suitable formulary of selected medication.
A formulary is the official compilation of drug products that have been selected and
approved for use within the hospital.
The two main objectives of the formulary are:
1. It promotes rational therapeutics
2. It prevents unnecessary duplicates, waste and confusion and thus promotes
economy for both the hospital and the patient.
When many brands of the same drug are shocked and prescribed, it result in a loss to
the patient as well as to the hospital.
It should be remembered that a mere list of medications placed on the shelves does not
constitute a formulary.
The drug list should be expanded to include specifications about how a medication
should be used.
Formularies should also include recommended daily dosage and a cautions, warnings,
restrictions, pharmacology and other similar information to facilitate correct use of drugs.
The following steps are some of the steps involved in the process:
1. Appointment of a pharmacy and therapeutics committee by the medical
staff composed of physicians, pharmacist(s), and representatives of the
administration.
2. Outlining the purpose, organization, function and scope of the committee
and an organized method for this committee to evaluate the therapeutic
claims of competing or suggested drug products.
3. Periodic publication of authorized drugs.
4. Procedures for revising the list.
3.9 Problem Situations: - Theft in Pharmacy
The pharmacy is one of the most theft-prone places in the hospital and what is worse,
pharmacy theft can be costly, difficult to check and may go unnoticed.
Theft is usually by the employees themselves or in collusion with them.
 The most common points where thefts take place are the dispensing area, stores,
purchasing process, receiving and invoice payment and the nursing units.
Substantial losses may take place in the dispensing and purchasing areas and continue
for a long time without being discovered.
The chief pharmacist or the person responsible for purchasing may in collusion with the
vendors, manipulate supply or bills and divert part of the supply to privately owned drug stores.
With an incredibly large number of items kept in open shelves of the dispensing
pharmacy, the task of exercising any meaningful control over the drugs is a formidable one
even with all checks and balances and control measures.
The problem becomes serious during evening and night shifts when there may be only
one pharmacist on duty and even more serious when, in smaller hospitals, the pharmacist
doubles up as the cashier as well.
Every hospital must recognize that it has a moral obligation to make theft and found as
difficult as possible; if not altogether impossible by instituting proper control systems.
Too often, the general climate in the hospital provides ample scope for employees to
indulge in such activities without anybody taking cognizance of such offences or punishing
the offenders.
A sound system of controls acts as a deterrent and creates fear in the employees that
frauds and thefts will be detected and punished.

4. FOOD SERVICES
4.1 Overview
Good food is important in the treatment of the patient and in a part of his total care.
The food service department in today’s modern hospitals ranks as one of the major
department.
It is headed by a specialist who is either a professional manager or a chief dietitian.
Most people tend to pass judgements on the cleanliness of the hospital, the personnel
care and attention given to them as patients and visitors and on the quality of food.
The coffee shop is one of the places where a visitor often stops by on entering the
hospital and it sets the overall impression of the hospital for the first-time visitor.
An irritated customer may give vent to his feelings at the patient’s bedside and look for
faults in patient care.
Hospitals have long recognized the public relations value of the food service
department.
Unfortunately, criticism of food is one of the most frequently heard complaints in any
hospital.
The major share of this criticism can be avoided by a properly planned and administered
food service department.
4.2 Functions
1. Provide the best possible food at a cost consistent with the policy of the hospital.
2. Buy to specifications, receive supplies, check their quantity and quality, and store,
produce, portion assemble and distribute food.
3. Establish standards for planning, menus, preparing and serving food, and controlling
meals. Standards must be established before setting up food purchase specifications.
 4. Establish policies, plan layouts and equipment requirements.
5. Plan and implement patient therapy, education and counselling; advise patients and their
families on special dietetic problems prior to their discharge from the hospital or when
referred from the outpatient clinics.
6. Train dietetics interns.
7. Impart instructions to nurses, medical and dental students, interns and residents about
principles of nutrition and diet therapy.
8. Cooperate with medical staff in planning, preparing and serving experimental metabolic
research diets.
4.3 Location
Earlier, hospital kitchens were generally allocated space unusable for any other purpose.
A food service department located below the ground level is certain to have a deleterious
effect on the quality of food and efficiency of the department.
A kitchen is the basement, for example, is likely to be dingy, dark and poorly ventilated.
A ground floor location is preferable, and is who convenient to deliver supplies.
Current cooperation/municipal by laws in most places prohibit locating kitchens in
basement floors.
Older hospitals that had this kitchens below the ground level found themselves in a
quandary when municipalities in cities started enforcing this rule.
The department should be close to the materials management department and the storage
area should be close to the unloading dock.
Easy access to vertical transportation system serving patient care units is important to
facilitate delivery of patient meals and return of used trays and utensils.
The cafeteria and dining room should be close to the food preparation and production
area and within convenient access to the hospital staff.
4.4 Design
The design and physical facilities of the food service department have an important
bearing on the standard of food service, labour costs and the morale of employees.
For example, storage rooms for removed from the work area, poor arrangement of the
preparation and production areas for work flow and a long travelling distance for prepared
food lower the employees efficiency levels and increase unnecessary steps resulting in
increased costs.
In general layout, the most important factor to be borne in mind is the logical work flow-
receiving supplies, storing and refrigerating them, preparing and serving food, returning trays
and washing dishes.
There should be adequate space and facilities to perform the work in each of these
functional areas.
Fig. 4.1 shows a typical food service department flowchart.
Fig. 4.2 shows a plan of food service department.
4.5 Functional Areas
i) Receiving Area and Control Station
The food service department requires a substantial amount of supplies and materials.
The receiving area that may be common to other hospital supplies and should be large
enough for handling bulk supplies.
 The receiving clerk inspects and checks all the supplies both for quantity and quality.
In the case of dietary supplies, the direction or a staff member of the food service
department personally checks the supplies.
The receiving area should be equipped with scales to weigh materials and supplies.
All internal control measures described under materials, management apply to this area
too.
 Fig. 4.2 A typical food service department

ii) Storage and Refrigeration Room(s)

The storage area, which comprises dry and refrigerated storage, should be adjacent or
close to the receiving area.
Dry storage is for staples and refrigerated storage for perishables.
Hospitals generally stores several days’ supplies to meet any eventuality.
Some dry foods are bought and stored in bulk.
Wooden, or steel racks and platforms are used for storage.
Large hospitals have walk-in coders and refrigerators with varying degrees of
temperature for meat and meat products and poultry, dairy products and eggs and fruits and
vegetables.
As in restaurants, it is a common practice in such hospitals to freeze all leftover foods
for later use.
The refrigerators should have a thermometer in each unit to check temperature daily.
 The walk-in refrigerator should also have an alarm connected to a place with a 24-hour
personnel coverage in case someone gets locked imide accidently.
iii) Preparation and Production Areas
Some hospitals prefer to have a separate pre-production preparation area where sorting,
peeling, slicing, chopping and washing may be done prior to cooking.
A double sink with draining beards, worktops, peelers and grinders are the necessary
facilities and equipments.
There should be efficient arrangements in the production area so as to permit the best
workflow and minimum cross traffic.
Special attention should be paid to the size of the production area.
Early in the planning stage, it should be decided whether the hospital will serve only
vegetarian food or non-vegetarian food as well.
There should be a separate kitchen for non-veg foods.
Some raw foods, when cooked may produce disagreeable odours and also taint other
food. This may be necessary to handle separately.
Food in hospitals is prepared using the progressive approach.
In progressive cooking, food is prepared in small batches at regular intervals during the
serving-time.
This provides freshness and palatability and the food remains hot.
The essentials of good production are:
• Good physical layout that ensures easy flow of work.
• Use of standardized recipes.
• Correct techniques of preparing each kind of food that preserve natural flavour
and nutritional value.
• Progressive cooking and preparation in the shortest possible time.
• Good management and supervision.
iv) Serving Room
The serving room is a place where patient food trays are assembled or made up.
It receives prepared food in bulk from the kitchen and the refrigerators.
After the trays are assembled, they are loaded on to tray carts or food trolleys and sent
to the patient floors.
It is imperative that the serving area be close to the elevators.
The equipment and facilities in the serving room includes refrigerators, table-tops and
cupboards for storing trays, dishes, cutlery and other articles necessary for assembling trays.
The dietitian has the overall responsibility for inpatient food.
She has the last immediate duty of checking the trays for proper identification, accuracy
and temperature of foods and ensuring that the food is palatable and served attractively.
v) Food Delivery
Food trolleys that can be plugged into an electrical outlet to keep the food hot are now
available.
An airline track is a tray truck with separate heated and refrigerated sections for hot and
cold foods, and bulk thermal containers for liquids.
The hot bulk cart contains hot food in bulk that is dished on to the patient trays on the
patient floors.
 Many hospitals distribute foods in individual hot food containers carried in open food
carts.
Smaller hospitals may serve them in ordinary tiffin carriers.
Beverages like coffee and tea are poured in the patient rooms.
Whatever the method of distribution is used, the patient serving should not take more
than 45 minutes; if it does, the system should be evaluated.
vi) Special Diet Kitchen
This is an integral part of the hospital kitchen.
The special diets should be prepared under the supervision of a qualified dietitian the
actual preparation being carried out by student dietitians or interns as part of their training.
Since special diets are usually modification of the basic menu and since the special diet
kitchen derives its supplies from the main kitchen and transports the trays through the same
tray carts, it should be located in the main kitchen or close to it.
It also requires pots, pans vessels, etc. like the main kitchen but on a much smaller scale.
In addition, it requires scales for weighted diets.
vii) Dishwashing Area
Dishwashing, an otherwise noisy job, is made easy with large modern dishwashing
machines.
In these, a continuous stream of soiled dishes are loaded at one end and clean dishes
unloaded at other side.
Wire baskets may be used to place glasses and cups in individual compartments.
In smaller hospitals, washing of dishes, etc., is generally done manually in the scullery.
An abundant supply of hot and cold water should be piped to the dishwashers and sinks.
Drainage and plumbing should be well engineered.
Soiled dishes are brought to the dishwashing area and scraped.
The waste is collected in a garbage receptacle.
Dishes are then checked and placed in dishwashing trays, and loaded for washing.
After this, they are stacked in appropriate places for reuse.
viii) Pot Washing Area
Washing of pots, pans and utensils is usually done by hand.
It is best done in a separate room.
The place must have deep sinks, abundant supply of hot and cold water and drying racks.
Pots and utensils should be identifiable so that they can be returned to their respective
user units.
ix) Cafeteria
While accepting the proper nutritional care of patients as the primary responsibility of
the food service department, most hospitals also provide food to non-patients and non-patient
areas, such as the hospital staff, visitors and patient bystanders.
They also cater to functions and meetings through the cafeteria, coffee shop and the
snack bar.
In planning the cafeteria, the following factors should be considered:
1. The number and kinds of groups to be served-day staff, resident medical and
nursing staff, visitors, patient attendants and bystander.
 2. Whether these should be separate dining rooms for medical staff, officers, VIPs
and other staff.
3. Types and extent of food selection-vegetarian or non-vegetarian, number of food
items, a complete meal for a fixed price or items by selection
4. Kind of service – self-service at the counter or table service; whether there should
be a separate counter for doctors.
5. Size of the dining room and number of shifts – whether all persons can be
accommodated in two or three sittings during a one or one-and-a-half-hour meal
period.
6. Method of clearing table. If self-service, whether personnel will be required to
return their trays to a designated area, e.g. a trolley or a cart, and whether they
will be required to dump garbage in the garbage bin before depositing the trays.
The hospital cafeteria works like a fast food business operation – cash down.
The customers buy coupons at the counter, pick up food items in exchange for them,
carry their trays to the tables and eat.
Alternatively, they pick up their food items in a tray and pay the cashier who will be
seated at the far end of the food counter.
The hospital cafeteria should be designed for this kind of operation.
A customer-oriented menu is the key to the successful management of a hospital
cafeteria.
The chief of food service must recognize certain fundamental principles that ensure an
efficient and profitable running of the cafeteria. They are:
- Satisfaction of the customers who enjoy good food. In the case of hospitals,
they are more of semi-captive customers.
- Variety in food. Patients may or may not be accustomed to luxury but most of
them are used to variety in their diets at home. If it is not provided, they may
quickly develop a distaste for the food.
- Purchase of high quality food at economical prices.
- Receiving and storing food supplies properly.
- Exercising effective control on supplies at the point of receiving, storing and
issuing.
- Preparing foods according to standard recipes and standard quality and serving
them attractively in standard portion.
- Accounting for sale of food.
x) Coffee Shop and Snack Bar
The coffee shop and snack bar should preferably be away from the main kitchen and
dining rooms to cater largely to in-between-the-meals coffee, tea and snacks to outpatients,
visitors and personnel.
This way, the main cafeteria can remain closed except for breakfast, lunch and dinner
as keeping the whole cafeteria open over two shifts in costly.
The coffee shop should be easily accessible to outpatients, particularly emergency
patients.
This is important in the night when the cafeteria is closed and the patients need
refreshments.
 It should be designed like a fast food restaurant for a quick turnover of patrons and not
as a lounge where people settle down for an informal chat over a cup of coffee or tea.
4.6 Organization
Traditionally, a dictation has been the chief of the food service department, also called
the dietary or nutrition department.
But in larger hospitals, professional managers with degrees in management and food
service or hotel management are now becoming more common with dietitian as the dietetic
supervisor.
In smaller hospitals, the dietitian may serve a dual role as both dietetic supervisor and
department manager.
The manager usually reports to one of the associate administrators.
The department has two main functional divisions: one relating to the administration of
the department and food production, and the other relating to therapeutic food service and
instructions to patients, and their counselling.
Administrative duties ranging from purchases to planning of menus occupy most of the
manager’s time.
The therapeutic duties include diet therapy, planning patient menus and special diets,
supplying a special diet list to patients and counselling.
Educational activities include teaching students and training dietitian trainees.
The bulk of workers in the department are unskilled.
The trend in hospitals is to employ workers at the lowest salary level
The results in instability, lack of responsibility, and poor quality of work.
The department is often a hotbed of unions and union activities.
Many hospitals make it mandatory that those working in the food service department
undergo physical examinations regularly to ensure that they are free of communication
diseases.
Dietary aides, if properly trained, can perform a variety of functions such as checking
supplies, writing requisition, checking and reporting census, making out time schedules,
checking routine tray line, and making out charge slips.
Early in the planning and design development stage, hospitals should decide as a matter
of policy whether hospital food is to be compulsory for all patients or whether they can bring
food from home, perhaps with the exception of special diets.
The size of the department and the primary functions of this department.
- It is the determination of meals that are to be served to the patients and the
non-patients.
- Cycle menus that are commonly used consists of a series of skeleton menus to
be served over the length of the cycle-weekly, biweekly, or monthly.
- Variation are sometimes made to take advantage of seasonal foods.
Some progressive hospitals allow the patients to select their own meals using menu
cards as in restaurant.
Dietitians help patients in giving their orders.
Therapeutic nutrition requires a qualified dietitian to assist in patient therapy.
In most case, nutrition therapy, as ordered by a physician, requires modification of the
normal diet in its content, consistency and preparation.
 Therapeutic and special diets and meals should be clearly marked, preferably by colour
coded labels.
4.7 Facilities and Space Requirements
1. Food service manager’s office. It should offer an unobstructed view of all the parts of
the department, and be ventilated and preferably soundproofed.
2. Secretarial, clerical office with space for file cabinets and other equipment, seating for
visitors, vendors, etc.
3. Office space for chief dietitian and staff dietitians. Some hospitals locate the office of
therapeutic dietitians on the patient floors so that they can be available quickly to the
medical staff and patients.
4. Receiving area.
5. Storage and refrigeration area with walk-in refrigerators, coolers and drug storage.
6. Pre-production preparation area.
7. Cooking or food production area, separate for vegetarian and non-vegetarian foods.
8. Special diet kitchen.
9. Tray assembly or make up area.
10.Dishwashing area.
11.Pot washing area.
12.Trolley, cart washing area and clean act storage area.
13.Deep sinks and hand washing facilities in various places.
14.Garbage disposal facilities.
15.Storage with racks and cabinets for clean trays dishes, cutlery etc.
16.Storage with racks for clean pots, pans, vessels, etc.
17.Employee facilities like lockers, staff toilet, etc.
18.Janitor’s closet.
19.Dining hall with self-service counter, cashier’s booth, clean tray storage area, seating
for adequate number of people, used tray depositing area, hand washing facilities,
drinking water fountain, etc.
20.Special (private) dining rooms for officers, medical staff, special guests, meetings, etc.
21.Coffee shop/snack bar, preferably off site.
4.8 Problem Situation
4.8.1 Conflicts
Conflicts often arise between the food service staff and the nurse service staff and the
nursing and admitting staff when patient admission, discharge and transfer result in last minute
requests, cancellation, or changes in preparation and delivery of scheduled meals.
Sometimes, food gets wasted.
A degree of tolerance, understanding and effective communication will help reduce such
conflicts.
Another point of conflict between the food service and nursing department is who
should pass and pick up patient trays. This is an administrative decision.
It is hard to provide a menu that pleases everyone.
Complaints against the food service department are common and frequent.
The work of the department is rendered more difficult because of the need to contain
costs.
 Dietitians can play an effective role in this regard both in the preparation of the menu
and in talking to patients, especially in the matter of special diets which may not always be
palatable or pleasing to the eye.
Many hospitals provide subsidized food to personnel and charge a much lower rate to
them to visitors and patients.
Some hospitals provide free food to employees of the food service department while on
duty.
Most hospitals like to continue this tradition, but it because of the rising cost, they have
to reduce or abolish the subsidy, and it may bread resentment among employees.
4.8.2 Theft
Petty theft and pilferage are common in the food service department.
These mostly involve food dishonest consumed on the premises, stealing patient food,
eating food left in patient trays, and pilfering food from the store room and pantries on the
patient floors.
The biggest offenders are the employees of the department, housekeeping, maintenance
personnel and guards.
An effective method to curtail this is to lock the place where food is stored. Good
supervision is necessary.
Bigger frauds can take place in materials management level, particularly in the
purchasing process.

5. LAUNDRY SERVICES
5.1 Overview
Laundry and linen service is one of the vital department of the hospital.
Criticism of linen service is one of the most frequently heard complaints in the hospital.
Attention to patient’s personal needs and comfort is as important as the physician’s
medication, the care tendered by the nurse and appetizing food served promptly and
attractively.
An adequate supply of clean linen sufficient for the comfort and safety of the patient
thus becomes imperative.
Besides helping in maintaining a clean environment which is aesthetically significant to
patients, clean linen is a vital element in providing high quality medical care.
The other aspect of this is the personnel appearance of the staff who attend on patients.
Pleasant, neatly-dressed employees in fresh, neat, uniforms go a long way in creating a
positive image of the hospital.
A reliable laundry service is of the utmost importance to the hospital.
In today’s medical care facilities, patients expect daily linen changes.
In some areas, linen has to be changed even more frequently.
This rigorous schedule can be very exacting on both the laundry and the capacity of
linen to withstand repeated cycles of use and wash.
To enable the laundry to meet such a demand, the hospital should have a sufficient
quantity of linen for circulation and to provide a rest period in storage.
5.2 Functions
1. Collection of or receiving soiled and infected linen.
2. Processing soiled linen through laundry equipment. This includes sorting, sluicing and
disinfecting, washing, extracting, conditioning, ironing, pressing and folding.
3. Inspection and repair of damaged articles, their condemnation and replacement.
4. Assembling and packing specially items and linen packs for sterilization.
5. Distributing processed linen to the respective user departments.
6. Maintenance and control of active and back-up inventories and processed linen.
5.3 Location
The laundry should be located as to have ample daylight and natural ventilation.
Ideally, it should be on the ground floor of an isolated building connected or adjacent to
the power plant.
This is because laundry is one of the largest users of power, steam and water.
A location that allows movement of linen by the shortest route saves effort and time.
The department should also be close to service elevators.
Some hospitals have chutes through which linen bags are dropped to a designated place
from where they are picked up by laundry personnel.
Every time a load of linen is handled, the cost of laundry services goes up.
The location and physical plan are important in keeping the cost down.
One way of doing this is to keep the traffic flowline as short as possible on vertical and
horizontal transportation between the laundry and the user departments.
This can be more easily accomplished in a vertical multi-storeyed building where the
services are in the basement.
5.4 Some Planning Elements
5.4.1 Size of Active Inventory.
In planning and maintaining linen stock, a stratified inventory system is generally used.
This means that for every piece of linen in use, there are four others either being
processed or held in store.
Therefore, the active inventory consists of items used daily multiplied by five.
For example, for each hospital bed in use, one sheet or pillowcase will be found in the
following places:
- A soiled one is use on the patient’s bed.
- A clean one in the linen closet in the nursing unit.
- A soiled one in the hamper or dirty linen collection area.
- One piece being processed in the laundry.
- A clean one in the linen store or back-up store for replacing active store.
5.4.2 Laundry capacity and Load
A final assessment of the plant and machinery required for a laundry can be made only
by compiling a list of types and quantity of articles to be laundered weekly.
At the planning stage, the information required can be projected by using the following
guidelines:
1. American Standard: An average of 15 pounds (6.80 kilograms) per bed per day
plus 25 pounds (11.33 kilograms) for each operation or delivery.
2. British Standard: 60 articles per bed per week at 0.39 kilogram per article.
 3. Indian Standard: the rule of thumb is three to five kilograms per bed per day.
All soiled linen in hospitals can be classified into two categories:
a) Ordinary or normally soiled linen
b) Fouled or infected linen
All babies’ soiled napkins should be treated as infected.
For arriving at the actual daily workload, the total load of seven days soiled linen should
be washed on six working days of the week.
The laundry should have the capacity to process at least seven days collection within
the regular six-day workweek.
Soiled and infected linen comprises large flats (sheets, etc.), small flats (pillowcases,
etc.), tumble work (both towel, bedspread. Blankets, etc.), presswork (garments, etc.),
operating room and obstetrical linen, nursing and paediatric linen, and isolated linen.
5.5 Design
The laundry functions effectively only when it is planned strictly in accordance with the
work sequence, namely, receiving, processing and dispatching.
Fig. shows the flowchart of the laundry showing trends of traffic.
The activities of the hospital laundry are in many ways similar to those in hotels and
other institutions.
However, the hospital laundry also handles speciality items and tasks.
The most important of these being disinfection and infection control because hospital
laundry processes not only ordinarily soiled linen but also infected or fouled linen.
It should be designed for asepsis and for removal of bacterial contamination from linen.
Hospital planners and administrations by and large fail to see that the layout and system
of processing linen in a hospital laundry should follow the principles involved in the central
sterilization and supply department.
There should be a strict barrier separation between the normally soiled linen and fouled
or infected linen on the one hand, and between the soiled area and the clean processing area
on the other.
The latter can be accomplished by installing double-door, pass through washing
machines in the wall separating the soiled area and the clean processing area.
Linen is loaded on the soiled side and unloaded on the clean side.
This physical separation of soiled and clean areas has an important bearing on the design
of laundry and infection control.
Traditionally, the various steps involved in the processing of linen are carried out, in the
same room as, say, in a hotel laundry.
An enormous quantity of bacteria is released into the air of the processing area while
sorting linen before wash.
This airborne contamination pervades the whole area and eventually settles down on
clean processed linen that is delivered to the patient care areas.
This should be avoided by separating clean and soiled areas.
The plan of a hospital laundry is given in following Fig. 5.1.
 Fig. 5.1 Plan of a Laundry
5.5.1 Disinfection Area
Fouled or infected and normally soiled linen should be handled and washed separately.
Fouled and infected linen goes to one section of the reception-control area where it may
be temporarily stored and later sorted and loaded into washing machines.
This area should be separated from the rest of the reception area and from the post-wash
clean area of the laundry.
This latter separation is best done by double-door, pass-through washer-extractor
machines installed in the barrier wall.
Some laundries provide a separate slicing machine for sluicing and disinfecting before
they are loaded into the washing machine on the clean side of the reception-control area.
The normally soiled linen is stored, classified and loaded into the washing machine on
the clean side of the reception control area.
Some hospitals use a double door pass through a hygiene washer for infected or fouled
linen at the initial decontaminating stage of washing.
5.5.2 Utilities
Early in the planning and design stage, a careful study and projection of the utility and
services needed for the laundry should be made.
The important requirements are water, power, steam and compressed air.
Laundry consumes a great deal of water.
There should be a source sufficient to meet the entire need.
Discharge of effluents should also be dealt with at the earliest stage.
Adequate power must be available. Hundred percent of the normal power should be
provided as standby.
 Adequate quantity of steam and correct temperature are also important.
Steam should be delivered by the shortest route to minimize line losses and at the same
time provide ample heat to flat work ironers and presses.
The laundry also needs compressed air to operate these flat work ironers and presses.
5.6 Organization
The operational chief of the laundry is a laundry manager who may have been trained
in laundry operation or has adequate experience in the field.
He reports to one of the associate or assistant administrators.
Many laundry managers come up through the ranks.
However, with increased automation and better opportunities to train people in technical
schools, more and more hospitals are recruiting ITI-trained personnel to head their in-house
laundries.
No formal training is required for the other personnel and most of them learn their
responsibilities on the job.
Hospitals will do well to recruit personnel who are able to read and understand simple
instructions.
5.7 Facilities and Space Requirements
1. Reception control area with facilities for receiving, storing, sorting and washer loading
of soiled linen.
2. Sluicing and disinfecting/decontaminating area.
3. Clean linen processing room.
4. Laundry manager’s office with provision for an unobstructed view of the laundry
operation.
5. Sewing, inspection and mending area. A light table is necessary for inspection.
6. Staff facilities.
7. Supply storage room.
8. A lockable store to accommodate materials for re-clothing calendars and presses.
9. Solution preparation and storage room.
10.Hand washing facilities in each room where clean and soiled linen is handled or
processed.
11.Provision for supply of water, power, steam and compressed air.
12.Cart washing and cart storage area.
13.Clean linen storage room.
14.Clean linen issuing counter.
15.Electrical distribution switchgear room.
16.Water recovery and recycling plant, if necessary.
17.Water softening plant, if necessary.
The following facilities are required off-site:
1. A central clean linen storage and issuing room.
2. Clean linen (lockable) storage in every nursing unit and user department.
3. Separate room(s) to receive and hold soiled linen from the wards and departments
until ready for pick up by the laundry personnel.
5.8 Selection of Equipment
Automatic machine and labour saving devices have resulted in economics in the number
of personnel and operational time, increased productivity, better utilization of water, heat
power, steam and washing materials, and maximum utilization of men and machines.
Some of the features commonly focused are automatic formula dispensers, automatic
operation controls, sorting and counting devices, machines combining washing, rinsing and
extraction, and flat work folding machines for automatic folding.
The solution of equipment of a proper size is of utmost importance for balanced and
economical production.
Laundry equipments should be carefully selected.
The following factors should be kept in mind:
1. Reasonable capital cost.
2. Reliability of design and compliance with the Bureau of Indian Standards.
3. Availability of spare parts and ease of maintenance.
4. Efficiency in working under normal conditions.
5. Economy in consumption of utilities like water, power, steam, etc. and in
washing materials and other consumables.
6. Continuity of workflow and reduction of manual effort.
5.8.1 List of Equipment
1. Washer-extractor sluicing machine.
2. Double-door washing machine.
3. Hydro-extractor.
4. Machines combining washing, rinsing and extraction.
5. Flat work ironer, also called rotary iron or calendar.
6. Tumble dryer.
7. Utility press.
8. Mushroom press.
9. Table trolley.
10.Hand iron.
11.Dry linen trolley.
12.Wet linen trolley.
13.Linen hamper.
14.Hanger trolley.
15.Distribution trolley.
16.Motorized sewing machine.
17.Platform scale.
18.Air compressor.
5.9 Problem Situations
Theft of linen
Linen in good condition is a very marketable commodity.
Besides, people use sheets and pillowcases in their homes and pilfered linen items
becomes handy.
Theft of linen takes place usually at night on the patient floors and departments.
Interestingly, soiled linen is not a significant target of theft.
 All linen should be kept under lock and key, and linen in stock should be made
accessible only to there who need it as part of their duty.
The linen closet in the nursing unit should be located directly facing the nurses’ station
to deter pilferage.
The supply of linen in the wards should be kept low to correspond with the bed
occupancy.
Theft are proportionally higher when a large quantity of linen is accessible to the
employees, visitors and patients.