junior internship manual (ho)

8/13/2019 Junior Internship Manual (HO)

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JUNIOR INTERNSHIP MANUAL

M. MARIAPPAN


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Contents :

Instructions

Background

Learning Process

Study of the Departments1. Emergency Department2. Day Care Unit

. In!patient "ards#. $ut!patient Department%. La&our room and "ard'. $peration (heatre). *ursing Department+. La&oratory

,. Pharmacy1-. Physiotherapy11. adio/ogy12. Business office 0 front office1 . Bi//ing1#. m&u/ance1%. Catering and Dietetics1'. ousekeeping ser3ices1). Linen ser3ice1+. 4edica/ ecords 5data processing61,. Portering department inc/uding transport2-. Security 5fire pre3ention and car parking621. Steri/e Supp/y22. (e/ephone2 . 7inance and 8 ccounts2#. Personne/ 5inc/uding residents and consu/tants62%. Staff medica/ "e/fare2'. Purchase and stores2). Engineering departments2+. 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. e0she shou/d fo//o" the respecti3e

hospita/ timings gi3en &y the hospita/ super3isor.

. (he Student shou/d maintain 1--< attendance. ny a&sence e=ceeding t"o days/eads to supp/ementary internship "hich means the student has fai/ed and /ater passedin internship.

#. (he attendance sheet shou/d &e signed &y the hospita/ super3isor and shou/d &esu&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 departmentd. (o compare the standard manua/ and rea/ department systeme. (o make suita&/e recommendations "hich "ou/d &e con3enient to imp/ement andshou/d gi3e &etter resu/ts

+. (he /ast date for su&mission of report "i// &e informed to you as and "hen it isfina/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 somuch of information and techni@ues to /earn. So it is ad3ised that the student shou/dtake more initiati3e to go through and /earn the other aspects "hich are not co3eredin this manua/.

#. (ry to find out the physica/ structureA /ocation and /ayout p/anA si>e of thedepartmentA organi>ationa/ structure and staffing patternA human resourcea3ai/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 $#rin" t(einterns(i* *erio$. Ho e/er0 a st#$ent is *ermitte$ to ta1e t o $ays lea/e if (e 2s(e is really #na3le to atten$ t(e interns(i*. T(is lea/e s(o#l$ 3e ta1en ina$/ance in cons#ltation it( t(e (os*ital s#*er/isor an$ it( t(e *rior*ermission of t(e Hea$ of %e*artment. If a st#$ent e)cee$s more t(an 4 $ays oflea/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/ operationsduring the internship


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LEARNIN! PROCESS

1 $n the first dayA the student "i// report to hospita/ super3isor. e0She may spend thefirst day &y going around the "ho/e hospita/ and fami/iari>e himse/f0herse/f "ith in thehospita/.

2. (he student "i// initia//y study the "ho/e hospita/ in terms of goa/A structure andtechno/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 ami=ture of c/inica/ and non!c/inica/ department for the study. In each department thestudent "i// study the fo//o"ing 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 5functionto space6 "ithin each department.

&. (o go through present operationa/ po/icyA systems and proceduresA functions of these/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 3ariousmethods of maintenance.

d. (o go through personne/ matters!such as ?o& descriptionA responsi&i/itiesA reportingsystemsA human resource p/anning ! ade@uacy in shifts and num&erA training andde3e/opments methods.

e. (o get information on financia/ mattersA fund raising methodsA procedures fo//o"edfor 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 ofser3ices.

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.


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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/ organisation !organisationa/ structure *o of staff in each category are "orking in the department. 54anpo"er Status6eporting systemA communications etc.

E@uipment detai/s 5name of the e@uipmentA year of purchaseA Company makeAnum&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 dmission procedures

ith 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 security security for 3io/ent patientsA /iaison "ith Po/ice *on!accidenta/ in?uries to chi/dren Link &et"een other departments! ! 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 *oteDeath eport7ormat of stomach "ash aspirate

*otifia&/e diseases7ormat of Death Intimation 57orm *o.2 and #6 to &e sent to corporation7ormat of Birth Intimation 57orm *o.16 to &e sent to corporation

*um&er of cases per monthemergency casesnon!emergency casesspecia/ties!"iseaccident cases etc.any other important matters

ork /oad ana/ysisstaff and patient ratiodoctors and patients ratiouti/i>ation of human resources and faci/ities


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In patients 9uide/ines aste 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 "astedisposa/ 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 *urse ca// system ard forms! 4edica/ cerificatesA consent forms and a// others ccident to patients and 3isitors! reporting systems Incase of death of the patient! the arrangements 7aci/ities pro3ided /ike ( GA adioA phoneA ir conditioners and other amenities for

the patients!ru/esA maintenance procedures. Procedures of Gisiting ours 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 ppointment 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 m&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 proceduresCost point of 3ie" patientsF opinion


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(o ana/yse the no. of $P treated per dayA "eek A month and yearsCure 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! ospita/ 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@uipmentUsage 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 sectionsList 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/y organisation and accounta&i/ity adio/ogy ser3icesA C! rm 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 aste disposa/A infected /inenA &/ood uti/i>ationA etc! ru/es nesthetics accounta&i/ity for ser3ice and e@uipment


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Preparation of /ists systems and documentation S"a&s need/es and instrument checking procedures naesthetic 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 "iseContro/ of $( Infection ate.

. 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 staff ratio of @ua/ified to un@ua/ified staff. !*urse education

po/icy staffing courses and organisation $rganisation of inser3ice training //ocation of nurses to non!recurring departments such as adio/ogy and staff hea/th and/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 rrangement for cross consu/tation 4aintenance of patients hea/th records 4aintenance of pre!operati3e and postoperati3e cases. Infection contro/ management aste 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/ and/ing of &iopsy specimen e/ationship "ith CSSD department


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4aintenance of /inen and management La&oratory re@uest procedures e/ationship "ith La&oratory!understanding of recei3ing and documentation of

in3estigation reports norma/A emergencyA and important matters Performance ana/ysis

Performance appraisa/ system7urther training re@uirement

ork /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 reception inpatients and outpatients Use of ph/e&otomists 5 ho is dra"ing the &/ood6 Safety procedures

$n ca// ser3ices (raining to ?unior medica/ /a&oratory scientific officers! o&taining appro3a/ from thecounci/ for professions supp/ementary to medicine.

Hua/ity contro/ po/ices Samp/es from genera/ practice 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 procedures re/easing &odies to undertakers Contro/ of infection accounta&i/ity responsi&i/ity of the micro&io/ogist

7unction and contro/ of infection committeeA iso/ation procedures disinfectant po/icyAstaffing re@uirements and systems In3estigations referred to other Centres Bio chemistry functions Centra/ "orking up arrangements for g/ass"are ser3icing apparatus 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 "iseStaff accounta&i/ity in test accuracyHua/ity contro/ check through out side agenciesStaff and no. (est carried out per day(ime/y su&mission of report

*o. of patient got discharged "ith recei3ing the test resu/tse3enue contri&ution &y /a&.


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ny other matters

. P(armacy Physica/ structure /ayout p/an and si>e of the department $rganisationa/ structure and reporting system 54anpo"er status6 Pharmacy /icensing procedures nti&iotic po/icy Steri/e f/uids ! purchase or manufacture Purchase systems and procedures

security check 9 * 59oods recei3ed note6Incoming materia/ register

ecei3ing @uotationsComparati3e statements

ppro3a/ for ordersP/acing an orders

In3oicesA de/i3ery cha//ansBi//s etcInspection of materia/

Procedure purchase returns ard pharmacy ser3ice!issuesA supp/yA storage and administration Inter store transfers systems Sa/es !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


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(ransport of drugs "ithin the hospita/ Prescription forms Dai/y stock 3erification a/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 day0month5*on!stock itemA ne" item in the marketA de/ay in orderingAde/ay from supp/ier etc.6

*o.of times "rong medicines issued &y the pharmacistaiting time per patient per prescription

Stock 3erification at regu/ar inter3a/ !discrepancyDe/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 3ai/a&i/ity of ser3ices in $PDA "ards and ICU ppointment systems and /ink "ith reception Patient records $n ca// arrangements ydrotherapy poo/ Domici/iary ser3ices Procedure for &i//ing (reatment of inpatient and outpatient ny 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


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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 and/ing of specia/ procedures ppointment 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 aste 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

aiting timeDe/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


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En@uiry egistration of patients out 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. ny other important matters Performance ana/ysis

(raining need assessmentork /oad

;no"/edge /e3e/ and communication ski//s of staff

+. 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


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m&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$ %ieteticsa. 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 machinesAstaff &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 pro3ided 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


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(raining of dietetic students Performance ana/ysis

*o. of comp/aints recei3ed from patients0 attenders0usersaiting 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 igh /e3e/ c/eaning C/eaning roof and top portions of the &ui/ding indo" 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 ccounta&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

o" much and type of materia/ used for c/eaningCost of the materia/ used per day0month.

+ . 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


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Issue and return procedures "ards theatresA residences and other departments Uniform e=change procedures /aundry Protecti3e c/othing specification and amount of issue hite coat ser3ice ard /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 etcHua/ity of /inenDura&i/ity of /inenEffecti3e 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 3erify

a6 (he IP fi/es retained for period of se3en years &6 (he $P fi/es are retained for period of fi3e yearsc6 4LC fi/es are retained for period of /ife timed6 Death case fi/es are kept separate/y and retained ten years

7orms and format used ssem&/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 dmission procedures


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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 patients re@uirements and system ny 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 Statistics !admissionA dischargeA &irthsA deathsA etc. Dai/y $ut Patient statistics !*o. of ne" patients registeredA re3isitsA eferred case feed&ack system for referra/s i.e. num&ers of referra/s for "hom the

referring agency "as informed.Interdepartmenta/ referra/ systemAPatients ha3e come direct/y "ithout referenceAPatients 3isit &y consu/tantsAPatients 3isit &y specia/tyA etc.

ecords and documents a3ai/a&/e. Garious ana/ysis

Dai/y a3erage $PD attendanceDai/y a3erage Inpatient admissionsDai/y deaths in 3arious "ards and under 3arious unitsBed turno3erA Length of stayEfficient system of retrie3a/ of records

aiting time in getting case fi/eccuracy and incomp/ete case fi/esA5not a// forms6

+ . 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/ hee/chairs /ocation and maintenance De/i3ery of f/o"ers ospita/ 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


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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 7ire 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 ccess to the site for fire tenders *otices 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 routes 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 managemen t e/ationship "ith purchase and stores departmentA 4aintenance departmentA

LaundryA ouse 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


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(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 process 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 and/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 ard 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

4e of the department $rganisationa/ structure and staff reporting system 54anpo"er6 Department &udgetary contro/ po/icy and system


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(rust funds po/icy and systems Payment of sa/aries and "ages po/icy and systems time c/ocks or signing on registers ccounting 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 ospita/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 ccounta&i/ity for changing accommodation issues keys Staff rest &reaks po/icy ccounta&i/ity for the residences Staff residences po/icy on a//ocation of rooms


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(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 ccident 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 ospita/ 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 ea/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 ppro3a/ 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 arrangements non stock and stock itemsA authority to sign re@uisitions Coding and Bin card system Stores proceduresA arrangementsA use of BC ana/ysisA GED ana/ysis Computeri>ation and In3entory management system


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Security of stores eturn of stores 9oods reception and dispatch systems ccess 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 pp/iances for patients organisation supp/y and systems

ecords and formats a3ai/a&/e Performance ana/ysisLack of maintenance safety stock De/ay in issuing materia/s

pp/ication of effecti3e techni@ues /ike GED and BC ana/ysis$3er and under stock Lack of kno"/edge in negotiation ski//s in price fina/isation

pp/ication effecti3e costing

4 . En"ineerin" %e*artments Physica/ structureA Location and si>e of the department

$rganisationa/ and staff reporting systemA 4anpo"er ccounta&i/ity for specia/i>ed e@uipment such as radio/ogy etc P/anned maintenance system (o maintain an sset 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! ater p/ant checks 4aintenance of E/ectro medica/ e@uipment Painting programme direct or indirect /a&our


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E/ectrica/ safety procedure for checking ne" e@uipment 7ire a/arm checks Upkeep of /ifts orkshops definition of functions and e@uipment re@uirement Supp/ementary heating po/icy 4edica/ gases test procedures maintenance and storage naesthetic 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/ ad3iceContract 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 3isitorsE@uipment for grounds maintenance and its storageatering 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. dministrati3e 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 orks 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


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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


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PER9ORMANCE ANAL8SIS !ENERAL !UI%ELINES

!eneral Analysis :

ssessment 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 dministrati3e &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 ImpactCostCuredImpro3ed

eferredBenefit accruing to community

re peop/e satisfied 5Consumer satisfaction6Do they "ant more and &etter faci/itiesK

S*ecific analysis :

3erage patients recei3ed &y out patient department dai/y0month/y Detai/s of referra/ System out!patients and in!patients

a/k in Patientseferred &y $"n doctors 5Consu/tants6eferred from $ther ospita/s0*ursing omes


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eferred from 9enera/ practitioners3erage admissions of in!patient "ards dai/y0month/y

3erage discharge of inpatients &y age "ise du/tsA Chi/dren and neonates dai/y0month/y

Bed occupancy ate

*o of deaths!&y department "ise 5"ards6A and units "ise dai/y 4orta/ity ateDeath "ithin #+ hours of admissionDeath after #+ hours of admission

Bed turno3er ate3erage /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 utopsiesDisp/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 L 4 E(C.A

junior internship manual (ho)

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