Seminar on:

Planning and Organizing Hospital

Units and Ancillary Services
(specifically CSSD, Laundry, Kitchen,
Laboratory services, Emergency
department)

Presented by:
Ms. Blessy Abraham
M.Sc. Nursing 2nd Year
Introduction
 Terminologies:
 Ancillary: helping in a subsidiary way.

 Viability: practicability

 Corporate: shared by members of a group or

united in a group.

 Conceptualization: forming a concept about

something.
 Meteorological: conditions related to atmosphere
and weather.
 Proximity: nearness

 Catchment area: an area from which a hospital

draws patients.

 Auxiliary: services that provides support or help.

 Strategy: the planning and directing of the whole

operation, a plan or policy.
 Procurement: obtain or acquire things with effort.

 Sluicing: a channel carrying off water.

 Entrepreneur: persons who organizes a

commercial undertaking especially involving risk.
PLANNING AND
ORGANIZATION
OF HOSPITAL
UNITS
Aims of hospital planning:

 To enlarge the existing hospital by introducing

new facilities.
 To increase utilization of hospital facilities.
 To increase population coverage
 To increase productivity of hospital
 Modernization of the already existing facilities
 To reduce the cost of operations and maximize
efficiency of services.
Guiding principles in planning:

 Patient care of high quality:

 Provision of appropriate technical equipments
and supplies.
 An organizational structure that assigns
responsibility and requires accountability for
various functions within the organization.
 A continuous review of adequacy of care
provided by physicians, nursing staffs and
paramedical personnel.
 Effective community orientation:
 A governing board made up of persons who
have demonstrated concerns for community and
leadership ability.

 Policies that assure availability of services to all

people.

 Participation of the hospital in community

programmes to provide preventive care.
 Economic viability:
 A corporate organization that accepts responsibility for
sound financial management in keeping with desirable
quality of care.

 A planned programme of expansion based solely on

demonstrated community need.
 An annual budget plan that will permit the hospital to
keep pace with times.
• Orderly planning
 Selection of a site large enough to provide for future
expansion and accessibility of population.
 Recognition of the need of uncluttered traffic patterns
within for movement of staff, patients and visitors and
efficient transportation of supplies.
 Medical technology and planning:
Development in medical technology is taking
place so rapidly that now the use of
sophisticated technology determines the
professional status.
 Classification of hospitals:
On the basis of agencies that finance them:

 Government or public hospitals

 Non-government hospitals
On the basis of ownership:
 Private (personal)
 Partnership
 Private (family) trust
 Public charitable trust
 Cooperative society
 Private limited company
 Public limited company
Hospital planning process:

 Conceptualization of hospital
 Support groups
 Temporary organization and securing funds
 Geographical, environmental and miscellaneous
factors:
 Meteorological information
 Geographical information
 Miscellaneous availability
 Hospital design:
Bed planning
Hospital size
Land requirements

Public utilities: the national building code of ISI

suggests 455 liters of water per consumer per
day (LPCD) for hospitals up to 100 beds and 340
LPCD for hospitals of 100 beds and over.
 Circulation routes:
 Internal circulation: the circulation space involves
corridors, stairways and lifts. Corridors with less
than 8 ft. Width are not desirable in hospitals and
protective corner beading is a necessity in
hospital corridors.
 External circulation: only one entrance to the
hospital for vehicular traffic from the main road is
desirable.
 Distances, compactness, parking and
landscaping:

Distances must be minimized for all movements of

patients, medical, nursing and other staff, for supplies
aiming at minimum of time and motion.
Functional efficiency depends on the compactness of
the hospital, by constructing multistoried as they are
convenient due to compactness as compared to
horizontal development of hospital.
Separate parking for 3-wheelers and scooters,
employees and staff parking areas separate from
public parking should be considered.
 Zonal distribution and inter-relationship of
departments:
 The departments (e.g. Outpatient department,
emergency and casualty) should be isolated from
the main in patient areas and allotted areas closer
to the main entrance.
 The supportive services like X-ray and
laboratory services need to be located near the
OPD’s.
 Gross space requirements:
gross total area (building gross)-780-1005 sq ft,
add walls, partitions: 95-125 sq ft.
The bed distribution is calculated as:
Bed : population= A x S x 100
365 x PO
A= number of in-patient admissions per thousand
population per year
S= average length of stay (ALS)
PO= percentage occupancy
 Medical: 30-40%
 Surgical: 25-30%
 Obstetrical: 15-18%
 Pediatric: 10-12%
 Miscellaneous: 10-15% (including eye and
ENT)
 Climatic consideration in design
 Equipping a hospital:
Physical plant
Hospital furniture and appliances
General purpose furniture and appliances
Therapeutic and diagnostic equipments

 Cost evaluation of construction of hospital

Planning and organization of the
OPD:
 Location

 Space: Generally 0.66-1 sq ft area per annual

outpatient attendance should be provided for
OPD.
 Size
 Zones:
Functional zone
Administrative zone
Diagnostic and supportive zone
Ambulatory zone
Staff zone
Functional management:

 OPD timings
 Records
 Public relations
 Facilities in OPD:
 Staffing of OPD: includes the medical staff (consultant,
professor, senior lecturers, medical officers, residents,
junior and senior should be available), nursing staff
(usually one nurse/OPD/clinic), paramedical staff (for
injection room, dressing room, registration and MRD),
receptionists and medico-social worker.
Planning and organization of
Wards:

Types of wards:
 General wards

 Specific wards

 Units with specialist nursing,

treatment and equipment
 Ward planning:

 Physical facilities:
 Size of ward: size of the ward depends on- types of
patient (an area of 100-120 sq ft/bed is required and
smaller rooms of 2-4 beds are preferable), requirement of
ward staff.
 Patient housing area:
 The area per bed within the ward is 80 sq ft/bed but in
acute ward it is 100 sq ft/bed
 Space left between two rows of bed is 5 ft.distance
between two beds is 31/2 to 4 ft.
 Clearance between wall and side of bed is 2ft.
 Length of bed is 6’6”, width of the bed is 3’.

 Size of rooms:
 Single bed room should have a size of 125 sq ft/bed
 2 bed room 160 sq ft/bed
 4 bed room 320 sq ft/bed
 6 bed room 400 sq ft/bed
 ICU 120-150 sq ft/bed
 Obstetrics and orthopedics 120 sq ft/bed
 support service area:
Nursing station/duty room
Treatment room
Clean work room
Pantry
Unit store
Sanitary area
Auxillary areas
 Ward design:
 Open ward
 Rigg’s ward
 Unilateral rigg’s ward
 Bilateral ward
 T-shaped ward
 OPEN WARD

NS

 NS RIGG’S WARD


 RIGG’S UNILATERAL WARD

NS

RIGG’S BILATERAL
WARD WARD
N
S
 Ward management:

Strategic management

Operational management
Planning and
organizational
consideration of CSSD
Central Sterile Supply Department
(CSSD):

CSSD is a department that furnishes all supplies required for the

nursing units and departments of a hospital- theatres, wards,
out-patient and casualty departments with complete, sterile
equipment ready and available for immediate treatment of
patients.
Planning of CSSD:

The CSSD should be planned in all

hospitals above 100 beds.
Theatre sterile supply unit (TSSU) is to
meet emergent and large requirement of
OT and is established inside OT
complex.
Bed size of the hospital Location of CSSD

Up to 100 beds In operation theatre

100-500 beds CSSD centrally located in service

area

Above 500 beds CSSD in service area and a

separate unit for OT to be called
theatre sterile supply unit
( TSSU).
Areas are to be provided in CSSD:

 Equipment storage room

 Receiving counter and clean up room
 Needles and syringes processing room
 Gloves assembling room with rubber goods processing room
 Clean work area including sterilizers
 Sterile storage area and issue counter
 Gauze and dressing assembly area
Percentage distribution of the
space :

 Clean area including sterilization- 40%

 Sterile storage area-15%
 Equipment storage-14%
 Fluids, needles and syringes- 14%
 Receiving and clean up area-12%
 Glove processing area-5 to 7%
 Additional 25% space located for future expansion
Layout:

 Location should be where the most rapid means of

transportation of supplies and equipment is possible.
 There should be avoidance of back tracking of sterile goods.
 There should be a continuous flow of equipment from the
receiving counter to the dispensing counter.
 The contamination of sterile goods should be avoided.
 Sterilizing area should be the last area before the sterile
storage and dispensing counter.
 The receipt and issue counters are separated by a corridor to
avoid contamination.
Layout of CSSD:

Counter of receipt Decontamination

of used items and cleaning area

Processing
Packing of items
Separation of sterilized items by a partition or corridor

Distribution point Sterilized items Sterilization

store
Area requirements:

It is recommended that the area of 1.64 sq.m/bed for a CSSD

would be appropriate up to 400 bedded hospitals, and for more
than 400 beds an area of 1 sq.m/bed would be sufficient.
Facilities In sq.Meter

Entrance 10.50

Lockers 7.00

Staff change room 7.00

Dirty receipt and 7.00

disassembly
Washing, disinfection and 17.50
decontamination
Assembly 10.50

Linen processing 10.50

Sterilization 14.00

Sterile storage 21.00

Distribution 10.50

Trolley wash 7.00

Trolley bay 10.50

Bulk store 17.50

Duty room 3.50

Toilet 3.50

Total per 100 bed hospital 164.50

Staffing pattern:

Staff for 1000 bedded hospitals is:

Supervisor – 1(senior most and trained technician)
Asst. Supervisor- one of the senior technician
Technicians – 6 (promoted attendants)
Sweepers- 15
Clerk- 1
Equipments and materials
required:

Hot and cold running water

Cleaning brushes and jet water gadgets
Ultrasonic washers
Hot air oven for drying instruments and sterilization
Globe processing unit
Instrument sharpener like needle sharpening machines
Stem sterilizers and boiler for steam
Autoclaves of various sizes including gas autoclave
Testing equipment
Chemicals to clean materials
Wall fixtures like sinks, taps
Trolleys for supply of sterilized items and separate trolleys for
collection of used items are needed
 Methods of sterilization:

 Steam sterilization
 Hot air sterilization
 Gas sterilization with ethylene oxide
 Sub atmospheric pressure sterilization with formalin
 Chemical sterilization with activated glutaraldehyde
 Gamma irradiation sterilization
 Formaldehyde steam sterilization
Inventory management:

 Stock:
 Issue of materials
 Distribution of sterile items
a. Grocery system
b. CSSD is open for limited hours:
Clean for dirty exchange system
Milk round system
Basket system
 Quality control methods:
Routine temperature/pressure and holding time testing of each autoclave.
Steam clox is also very handy and reliable. Changes color from brown to
green.
Heat/time, moisture sensitive tapes may be used in same way as that of
steam clox.
Random samplings of sterilized items are also tested in laboratory.
Culture of wall/floor and scrapings.
Planning and organization of
Laundry services
 Functions of laundry:

 Control of cross infection: it reduces the chances of cross infection.

 Patient satisfaction: the patient likes to have clean linen which is
changed and washed frequently and has a psychological effect on
patient.
 Public relation: the image of hospital also depends on clean look of
linen as it instills confidence in patients and relatives.
Types of laundry:

a. In-plant or in-house laundry

b. Rental system
c. Contract system
d. Co-operative system
Planning and organization :

 Location:
The laundry should be in the same building as the hospital, and
should have separate entrance and exit areas. It is recommended
to have a mechanized laundry in the basement, with proper
drainage arrangements.
 Space requirements:
The requirement for any laundry services has been worked out to be
approx. 10-15 sq. ft./bed.
No.of beds Space
200-300 beds 3750 sq.ft.
300-500 beds 5670 sq.ft.
600.beds 6460 sq.ft.
>650 beds 8210 sq.ft.
Floor area/space requirement
According to Dr. Mc Gibony, the area for a laundry for a
teaching hospital in India should be at least 5800 sq.ft.
 Physical layout:
Straight through flow: the planning of the building and installation of
equipment in a straight flow from the dirty end to the clean end.
U-flow: where the dirty and clean ends are in the same direction.
Gravity flow: this takes advantage of the underground, with dirty end at
the top and clean end at the bottom.
Laundry is divided into two distinct areas:

 Dirty area: it comprises of -

Reception of solid linen
Sorting of soiled linen into suitable quantities for processing
 Clean area: it comprises of-
Drying
Finishing
Discharge
A barrier wall between the clean and dirty area is desirable
 Reception of dirty Decontamination Boiler room
linen and storage and sluice room

Toilet Washer

Laundry Staff room Store of Store of

detergent spare linen

Linen mending Hydro extractor

Issue area Storage of Pressing Drier

clean linen and
laundering
 Ancillaries:
 Laundry manager’s office
 Stores
 Tailoring bay
 Worker’s rest room
 Toilet
 Boiler room
 Material and decor:
The route of soiled linen from the using points to the laundry and
the flow of clean linen from laundry to the using points should be
planned as to minimize the possibility of contamination of clean
linen.
The laundry should be grouped into specific separate areas:
Laundry manager’s office should be located as centrally as possible
to properly supervise the entire laundry operations.
The walls should have large vision panels to allow full view of each
area.
A toilet, locker and shower facilities should be provided in the soiled
linen receiving, sorting and washer loading room and clean linen
processing room.
Supply storage room should be adjacent and connected to the soiled linen
receiving, sorting and washer loading room.
Sufficient space should be provided for the storage of one week’s supply of
detergents, bleaches and others.
The floor for the laundry should have smooth, slip resistant and water proof
surface, the walls should have a smooth washable surface free from all
corners, edges or projections which create maintenance problems.
Utility services like piping, electrical wiring should be designed and
sized with appropriate consideration for future expansion.
The steam supply system should be designed to deliver steam to the
equipment in right quantity at a desired temperature.
Hot water should be available at 1800F by the pipeline to the laundry
at the required temperature from the boiler room.
The power supply to the laundry is usually 220 or 440 volts in three
phases , four wire alternative system and must be accessible
Lighting should be free of glare and shadows.
Fire extinguishers should be located in the laundry near the clean
linen and the processing areas.
There is a need for flow of drains in the sorting and washing areas.
Ventilation system must be able to provide a comfortable
environment for the workers.
Sewing and mending room should be located near to the clean
linen and pack preparation room.
Laundry management:

 Sequence of operation:
Collection of laundry by laundry staffs in trolley with clean and
dirty linen separately
Disinfection is done using disinfectants for infected linens.
Sluicing and washing
Hydro-extractor
Drier tumbler
Pressing
Mending
Repaired linen is again washed in washer and washing
cycle after that is to be completed.
Distribution to ward
 Linen distribution system:
i. Topping up: in this, the ward is given certain number of stock of
linen based on 24 hours requirement and shortfall of linen due to
use is topped up by the laundry staff everyday and used ones are
collected.
ii. ‘Clean for dirty’ exchange: the issue of clean linen to exchange
number of pieces of dirty linen.
iii. Exchange trolley system: In this, total trolley is
supplied which has 24 hours requirement and next day
fresh trolley is supplied with same number of pieces and
old trolley is taken back to laundry irrespective as how
many pieces have been used and linen is brought and
washed.
 Quality control of laundry services: the quality assurance of
laundry should be developed since laundry is important from
where infection can be transmitted to other patients, which
should be seen by the hospital infection control committee.
 Policies and procedures:
 Collection and distribution system of linens with periodicity to
each ward and department.
 Detailed instruction about handling infected and foul linen.
 Charter of duty of each person handling laundry and training
schedule of staffs.
 Sluicing and disinfection procedures.
 Operation of laundry machines.
 Maintenance and service contracts of machines.
 Provision of detergents
 Procedure for condemnation of linen and procurement of new
linen
 Fire safety drills and fire extinguishing measures
 Record of distribution, collection, inventory of detergents and
linen procured/condemned.
 Security arrangements for laundry.
 Regular physical verification of linen and fixing responsibility
of any type of loss.
Kitchen services:
Functions of dietary services:

The dietary services cater for the following:

 Therapeutic diet
 In-patient catering
 Diet counseling
 Education and training
Category of Beds
employees 100 200 300 500 750
Chief dietician - - - - 1
Senior - - - - 1
Dietician
Dietician - - - 1 1
Asst. dietician 1 2 3 5 7
Steward - - 1 1 1
Storekeeper(ra - - - 1 1
tion)
Storekeeper(g - - - 1 1
eneral)
Clerk/typist - - - 1 1
Head cook 1 1 1 2 2
Therapeutic - - 2 2 3
cooks
Cooks 4 6 8 10 16
Asst. cook 6 14 20 28 32
Cleaners, 4 4 6 8 10
waiters
Store - 1 1 2 2
Location and space requirement:

 Location: the dietary department should be located on the

ground floor near wards where the diets need to be taken and
also accessible to road as supplies are to be carried to storage
area.
 Space requirement:
Following space requirements are recommended for different
size of hospitals:
 200 beds or less: 20 sq ft per bed
 200-400 beds: 16 sq ft per bed or 18 sq ft per bed
 500 beds and above: 15 sq ft per bed
Functional areas in department:

 Recipient area
 Storage area
a. Items to be stored at room temperature like onion, potato etc
b. Items require cool temperature (8-100c is maintained) for which
walk-in cooler can be provided to store milk, eggs, butter etc.
c. Deep fridge where temperature is below 00c fish and meat should
be stored.
 Day store
 Preparation area
 Cooking area
 Service area
 Washing area
 Disposal area
Recipient area of Office store Walk-in Dry Fresh store
provisioning keeper cold store
store

Dry store Preparation area

Cooking area Trolley+ pot wash

Dietician area

Supervisor Distribution area and

service
Staff room

Staff toilet
Wards
Distribution of diet:

 Centralized service

 Decentralized service
Dietary store management:
 Storage of food items
 Purchase of food products
 Equipment planning
 Financial control
 Control the labor costs.
 Menu planning should be done in such a way that it reduces the inventory, selection of
items common to many areas of patient care, reduced handling, wastage, use of
automation or more equipment requiring less operational staff are some measures that
can be put to practice for an effective financial control.
Laboratory services:
 Functions:

 To assist doctors in arriving at or confirm a diagnosis and to assist in the

treatment and follow-up of patients.
 The laboratory not only generates prompt and reliable reports, and also
functions as store house of reports for future references.
 It also assists in teaching programmes for doctors, nurses and laboratory
technologists.
 It carries out urgent tests at any part of day or night.
Functional divisions:

 Hematology
 Microbiology
 Clinical chemistry/ biochemistry
 Histopathology
 Urine and stool analysis
Functional planning:

 Determining approximate section wise workload.

 Determining the services to be provided.
 Determining the area and space requirement to accommodate
equipment, furniture and personnel in technical, administrative
and auxiliary functions.
 Dividing the areas into functional units i.e. Hematology,
biochemistry, microbiology etc.
 Determining the number of work stations in each functional
units.
 Determining the major equipments and appliances in each unit.
 Determining the functional location of each section in relation
to one another, from the point of view of flow of work and
technical work considerations.
 Identifying the electrical and plumbing requirements for each
area/ work station.
 Considering utilities i.e. lighting, ventilation, isolation of
equipments or work stations.
 Working out the most suitable laboratory space unit, which is a
standard module for work areas.
Organization:

Location:
it is preferable to have hospital laboratory planned on the ground floor
and so located that it is accessible to the wards.
Outpatient sample collection:
The design of this area should include waiting room for patients,
venepuncture area and specimen toilets separately for male and female
patients, along with provision of containers with appropriate
preservatives and keeping record of each patient.
 Area/space:
a. Primary space: this space is utilized by technical staff for the
primary task of carrying professional work.
b. Secondary space: it is utilized for all supportive activities.
c. Administrative space: Offers for the pathologists and others, staff
toilets etc.
d. Circulation space: it is the space required for uncluttered movement
of personnel and materials within the department between various
technical work stations, rooms, stores and other auxiliary and
administrative areas.

e. Laboratory space unit (LSU)

Layout: Structural flexibility should be achieved by use of movable or
adjustable benching systems in association with an installation of service
mains that has been designed to permit the repositioning of outlets.

Administrative and auxiliary areas: the administrative area is separated

from the technical work area so that the non-laboratory personnel need
not enter the technical areas.
Reception and sample collection
Bar-coding system for samples
Specimen toilet
Pathologist office
Glass washing and sterilizing unit
Report issue
Utility services
Internal design and fitments

Work benches: the height of the work bench on which the

technicians sit while working (revolving stools) vary from 75-90 cm
depending upon the height of the workers.

Lighting: Each work bench should be provided with adequate

electric points especially fluorescent fixtures that give uniform
illumination and minimize heat.
Storage: each laboratory bench length should have storage space for
reagents, chemicals, glass wares and other items, provided in the
form of under bench drawers, cupboards etc.
Partitions: it may be required between some laboratory spaces.
Air conditioning: whole or at least histopathology section of the
laboratory should be air conditioned
Working surface/ flooring: the surface of work benches should be
resistant to heat, chemicals, stain proof and easy to clean.
Staffing:

 The hospital laboratory services should be under the control

and direction of a doctor with qualifications in pathology or a
PG degree in the new discipline of “laboratory medicine”.
 Staff requirement of laboratory technicians can be worked out
empirically on the basis of generally accepted norm which is
about 30 tests per day per technician.
 Equipment:

 Colorimeters/ spectrophotometers:
 Auto analyzers
 Cell counter
 Centrifuge
 Refrigerators
 Pressure sterilizers
 Pipette washers
 Analytical balance
 Semi auto analyzer
 ELISA reader
 Blood gas analyzer
 PCR instrument
 Flow cytometer
Policies and procedures:

 Laboratory samples
 Sample receiving
 Request forms
 Time for accepting specimens
 Containers
 Identification of specimen
 Reports and records
 Blood bank services
 Outpatient samples
 HIV
 Liaison with clinicians
 Motivation and cross-training
 Waste disposal
 Optimal utilization of laboratory services
 Quality control
Emergency services:
Planning and organizational
considerations:

Location:
a. It must be on ground floor and easily accessible to both
ambulatory and ambulance patients
b. Secondly, the emergency department should have ready access to
the acute patient care areas, e.g. Operation theatre, ICU, blood
bank etc.
Stretcher, trolley, wheelchair store: a store for stretcher, trolley and
wheelchairs should be located adjacent to the entrance.

Ambulance attendants, police, mass media room: an equipped room

of about 10 m2 near the entrance hall with attached toilet serves the
needs of above personnel
Work area
Waiting area for emergency department patients
Waiting area for relatives
Visitor’s toilet
Nurse’s station and administrative office
Examination and treatment area
Equipment:

i. Stretchers
ii. On-the wall oxygen unit
iii. On-the wall suction unit
iv. BP apparatus, otoscope, stethoscope, opthalmoscope etc.
v. Spot lights
vi. Utility table
vii. Airways and resuscitation bags
 Resuscitation room

 Operation room

 Fracture room

 Plaster room
 Care of burns
 Isolation room
 Other rooms:
Room for dead bodies
Pantry-7 m2
Storage space
Utility and soiled linen room-7 m2
Cleaners room-house keepers room 4m2
Change room duty rooms 9m2
Conference room and reference library 8m2
 Staffing pattern:

 Full time emergency physicians, especially trained in emergency

medicine.
 A well staffed emergency department needs 8 nurse shifts of 8 hours
each per 100 daily patients’ visits.
 For registration and records, usually 3 clerks work in day and
afternoon shift, and one during night.
 Security should be available round the clock
 Public relations and social worker
Medico-legal aspects of
emergency department:

1. Negligence:
2. Duty to treat all
3. Problem areas in emergency department
 Consent to treatment
 Medical records
 Reporting to authorities
Conclusion
Bibliography:

 A.G Chandorkar. Hospital administration and planning. 2nd edition.

Paras medical publisher. New Delhi. 2009. pg no. 67-72,153-166,167-
179,181-195.
 B.M.Sakharkar. principles of hospital administration and planning. 2nd
edition. jaypee brothers medical publishers ltd. 2009. pg.no-195-207.
 D C Joshi, Mamta Joshi. Hopsital
administration. Jaypee brothers medical
publishers pvt ltd. New Delhi. 1st edition.
2009. pg. no. 186-208.

 The nightingale times. volume II. pg. 32

THANK YOU