PLANNING (Hospital Management)

DEFINITION:

Planning is a process whereby management decides where it is at present, and where it wants to be at some time in the future. It involves considering the six questions:

•       What we expect to do?
•    Why it will be done?
•    Where it will be done?
•    When we expect to do it?
•    Who all are going to do it?
•    How it will be done?

THE PURPOSE OF PLANNING:

The purpose of planning is to assure the most efficient utilisation of resources and economy of performance. The need for planning is felt because a particular situation presents an opportunity to do something and achieve something positive or, the need for planning is felt because a particular situation poses a problem and draws attention to that problem.

Given the scarcity of resources, hospital managers require to establish long and short range plans in order to avoid haphazard utilisation of resources. Planning involves the choice of objective along with policies, strategies, programmes, procedures and rules that are necessary for their accomplishment.

FORECASTING:

Forecasting is inherent in planning. Whether it is forecasting the utilisation of a mechanical laundry or demand for a new specialist service, forecasting is common to all types of planning. It involves addressing two important issues:

• Forecasting demand: forecasts of demand should be made as far ahead as the maximum lead time- the period of time it will take to implement a decision. Future based forecasting techniques may require minimal data if simple correlations are to be used, or a large number of observations if a significant number of influential factors are to be employed.
• Forecasting utilisation: in forecasting utilisation, it has to be determined what the future utilisation of a specific service will be. A change in utilisation in future may be expected or desired. Factors which are likely to cause expected change will need to be analysed. Strategies which will affect the desired change should be selected and implemented.

CATEGORIES OF PLANNING:

Planning in the health care field can be broadly divided into two categories:

1. Strategic planning: it carries a wider perspective for the whole of the organisation. It is concerned with developing the main mission of the institution, developing broad objectives, followed by determining the services required, and determining the means of fulfilling the same.
2. Operational planning: this generally focuses on programme formulation and implementation. It concerns itself with systems planning at all levels of the institution- when a new service or department is added, when there is a need for upgrading of an existing service or department, or when a new system of organisation is being introduced.

CRITERIA FOR EFFECTIVE PLANNING:

Plans provide an opportunity for the institution to be proactive rather than reactive. This calls for short-range planning dovetailed into long-term planning.

1. Plans should be based on a thorough study of the end results desired.
2. Planning should involve participation of the medical staff, other concerned service representatives.
3. Plans should be comprehensive.
4. Plans should be flexible.
5. Plans should be continually updated.
6. Plans should be realistic.
7. Plans should be time phased.

STEP BY STEP APPROACH TO PLANNING:

Planning involves the following steps: 

1. Analysis of the situation: whether it is strategic planning or operational planning, the planners do have some idea of the problem they want to solve. Nevertheless, an analysis of the situation connected with the broader problem must be carried out. The analysis aims at addressing the questions as to what is the core problem, and what opportunities does it present. Analysis of the situation leads us to all the facets of an institution’s functions and resources. The problems which are highlighted may relate to the following:

• Personnel 
• Physical facilities 
• Equipment 
• Finance 
• Information 
• Extramural factor

2. Identifying priority problems: after the general analysis of problems, the focus should shift to the important ones. For that, certain factors need to be taken into consideration:

• Is the problem in question really the one to be solved, or is it simply a part of a still larger problem which requires study?
• Is there a good chance of achieving success?) (What are the attitudes of personnel towards the existing situation?
• Are there any management policies or professional requirements that might influence this planning?

3. Formulating objectives: Having selected the problem, the next step is to formulate objectives. A hospital achieves its objectives through its various service departments. Therefore, each departmental head must establish his own departmental objectives, consistent with the institutional objectives. Objectives must be relevant and realistic, achievable and measurable.  

4. Setting of goals: Goals articulate a specific strategy. The management team now prepares statements of goals, both short-term and long-term. 

5. Reviewing limitation/constraints: obstacles which may be encountered in meeting objectives and goals should be considered. The limitations and constraints can be in the form of personnel, equipment, finance, information, time, government policy, geographical aspects, etc. Both external and internal analysis develops a balanced picture of the hospital’s limitations, strengths and opportunities for corrective action. 

6. Laying down operational policy and operational systems: operational policy is a statement of objectives and principle functions for each department. Operational functions are designed to fit in the constraints set up earlier by the policy. The purpose of both is to determine the way the institution will operate. 

7. Writing down the plan: a plan has no value if it remains only in the mind of the planner. There are many others in the organisation who will have to be associated in putting the plan into practice and understanding the rationale behind objectives, goals, limitations and resources in operationalising plans.

TYPES OF DECISIONS:

The selection from among alternatives of a course of action is called decision making. The type of decision that all executives have to take can be as follows:

1.       Considered decisions: these require reflection and deep thought. They affect overall operations, require data gathering, require time for consultation and proceed from multiple alternatives.

2.       Operational decisions: these are decisions that executives make practically every day as a routine either to solve problems or to prevent them. They have immediate impact and ensure smooth flow of operations.

3.       Uncomfortable decisions: these are the decisions that impinge on interpersonal relationships with subordinates and others. Also termed as swallow-hard decisions.

4.       Hurried decisions: these are also made during daily operations. They require quick thought as they are made under pressure.

THE DECISION PROCESS:

The principal goal in decision making is to achieve maximum payoff at minimum cost. A management decision model comprises of five elements.

1. A clear idea of what is to be achieved: The result to be achieved must be subject to some degree of quantitative measurement besides qualitative. The administrator should answer the question: What is to be achieved, and to What degree? In making this determination, market analysis, interviews, surveys, sampling techniques and other data gathering tools are helpful.
2. Resources allocation: Quantitative and qualitative characteristics of the resources available, and required, should be studied. The resources must be calculated in terms of cost, quality, quantity and degree of substitutability. Linear programming, break-even analysis, discounted cash flow analysis and some other management concepts will be useful in this process.
3. Non-resource constraints: Such constraints can be legal, social, or political or a combination of these. Such constraints must be estimated for their impact on all parts of the decision.
4. Risk factors: In spite of every effort, the constraints and chances of achieving the objective cannot be known with certainty. Therefore, the degree of risk in achieving the payoff of the activity or project should be determined as clearly as possible.
5. Comparison of payoff and inputs: The payoff must be equal to or greater than the cost of resource inputs. The decision maker must compare the payoff that might result from allocating resources to one project or activity with the payoff that might result from allocating the resources to another project or activity.

STRATEGIC PLANNING:

Definition: The continuous process of making present entrepreneurial (risk-taking) decisions systematically and with the greatest knowledge of their futurity, organising systematically the efforts needed to carry out these decisions, and measuring the results of these decisions against the expectations through organised, systematic feedback.

Strategic planning requires a refocusing of the planning activity, and a shift from the service-oriented master planning to market- oriented planning.  Three important features of effective strategic planning are as follows:

1. A shift in orientation from producing services: Instead of asking what services does the hospital want to deliver, it needs to be asked as to “what services are needed”, and “who will purchase them”?
2. A statement of purpose is not the starting point of planning: Assumptions can lead to planning for inappropriate roles in a context of unrealistic expectations. In strategic planning, the goal and role elements of a strategic plan are derived only after external assessments are completed. 
3. Understanding that planning and management are concurrent: Strategic planning is integrated within the hospital’s day-to-day management concerns. Therefore, unless representatives of all hospital constituents are involved in resources allocation decisions, strategic planning cannot become an integral dimension of management.

STRATEGIC PLANNING APPROACH:

                                                         

1. External analysis: This assessment covers the actual and potential markets, identifying constraints, and studies how the competitors affect it. All this involves detailed examination of some critical factors which include: 

• Demographic forecasting
• Regulatory aspect of government laws and professional regulations
• Competitive assessment
• Consumer needs, demands, preferences
• Service delivery trends
• Third-party payment systems, industrial employers’
• Willingness for affiliation of workers with the hospital.

2. Internal analysis: A comprehensive internal assessment develops a balanced picture of the hospital’s limitations, strengths and opportunities for further development. This analysis covers:

• Utilisation of hospital services
• Types of cases treated
• Admitting patterns
• Physician characteristics
• Financial performance
• Equipment and facility inventory
• Organisational assessment. 

3. Analysis of key issues and identification of strategic options


4. Development of the institution mission: A mission statement has to be broad enough to allow creativity and the development of a vision. By its nature it provides guidance to institutional leaders. 

5. Development of goals and objectives: Goals articulate specific strategies, objectives specify and operationalise the strategy.

PLANNING FOR GROWTH AND DIVERSIFICATION:

1. Growth:  it serves to bring more patients to the hospital, and increase utilisation of services by those who need to be there but who would not otherwise have gone to the hospital.  

• Extending the area of service by creating or adding a new facility.  
• Provide a new service in the hospital which expands the role of the hospital.  
• Create community awareness by publicizing special services, hoping it will increase the use of hospital facilities.

2. Diversification: areas of diversification may be related or unrelated to the hospital’s basic function. Diversification may become necessary for:

• Generating capital from non-operating sources of revenue for financing replacement, expansion or enhancement of technology
• Surviving competition by offering a service not offered by competitors or other hospitals 
• Improving the hospital’s long-term ability to survive. Areas of diversification may be related or unrelated to the hospital’s basic function.

DECISION MAKING FOR GROWTH AND DIVERSIFICATION:

1. While planning for diversification, application of marketing techniques for measuring the need for a specific product becomes necessary in the decision making process.
2. It will also require a thorough financial study of the proposed diversification effect. Evaluation of the risk/ return trade off among various strategies and a study of alternate sources of capital will be required. The expense of providing the new product, projected operating results, cash flow from cost payers and third party payers, and the rate of return on investment should be worked out for a short to medium term of three to five years.
3. Pricing strategy will have to be carefully evaluated while planning, because pricing plays a vital role in the success of a new programme. The analysis takes into account the expected volume of workload, revenues, costs and cash flow.

References:
Principles of Hospital Administration and Planning- BM Sakharkar

CENTRAL STERILE SUPPLY DEPARTMENT (CSSD)

The central sterile supply department (CSSD) becomes responsible for processing, sterilising and dispensing of almost all items of sterile equipment, sets and dressings in the hospital in one single department for efficiency and effectiveness.

Centralisation of sterilising activities in one department has resulted in many advantages. The chief among these are improved efficiency, sterile supplies available at all times of the day or night, economy of trained manpower, as it is no longer necessary for nurses to waste their time in sterilisation activities, sterilisation safety and quality control.

FUNCTIONS OF CSSD:

Broadly, the functions of the department are as follows.

1.       To receive and process used and unsterile supplies and sets from nursing units, OPD, operation theatres, labour rooms, etc.

2.       To sterilise and dispense sterile articles to user units.

3.       To maintain an uninterrupted supply of bacteriologically safe supplies at all times.

4.       To undertake studies for improvement of sterilisation practices and processing methods to provide supplies economically.

5.       To impart training to hospital personnel in safe hospital practices.

6.       To participate in hospital infection control programme.

7.       To advice hospital administration on suitability of supplies and equipment from sterilisation point of view.

STAFFING:

There should be a properly qualified supervisor in charge of the department. The chief of the department, the CSSD supervisor, has traditionally been a senior nurse. The supervisor can be a person from any other stream of hospital personnel provided he or she has a grounding in the basics of patient care. The other staffs required are usually in-service trained CSSD attendants, semiskilled workers who can be called CSSD assistants, CSSD technicians and sweeper.

A 200-bedded hospital with door delivery system to user departments would require 12 personnel, whereas a 500-bedded hospital has about 17 personnel. The number of workers will be influenced by the following:

1.       Method of collection and delivery.

2.       Quantum of work—one shift, two shifts, or one shift with only emergency issue counter after normal working time.

3.       Hospital’s philosophy on use of disposables.

4.       Availability of mechanical aids.

Flowchart of CSSD

EQUIPMENT:

The main item of equipment in the CSSD is the autoclave. At least one additional autoclave other than the main one should be provided to cater for failure or extra workload. Other equipment in the CSSD includes the following.

        ·         Dry oven

        ·         Gauze cutter

        ·         Ultrasound washer

        ·         Needle flushing device

        ·         Autoclaves

        ·         Ethylene oxide steriliser

        ·         Work benches with marble or stainless steel top

        ·         Storage cupboards and racks

        ·         Linen folding table

        ·         Soaking sinks

        ·         High pressure water jets.

Ultrasonic cleaner: One of the essential items of equipment in CSSD is the ultrasound cleaner. Ultrasonic cleaner cleans by bombarding the item with sound waves. These waves while passing through the detergent solution produce sub-microscopic bubbles which collapse on themselves, generating tiny shock waves that knock debris off nooks and corners of instruments that are not easy to reach.

POLICIES AND PROCEDURES:

Central sterile supply is most effective when it provides a limited basic range of articles for the greatest possible number of users. The list of items and special trays commonly processed in the CSSD are as follows.

        ·         Instruments

        ·         Appliances

        ·         Dressings

        ·         Sponges

        ·         OT linen

        ·         Special packs

        ·         Gauze and cotton materials

        ·         Gloves

        ·         Bowls and trays.

CSSD is one department where policies and procedures must be unambiguous and scrupulously followed in letter and spirit. The smallest mistake or carelessness on part of the staff can have serious repercussions elsewhere in the hospital. The policies should cover the following:

         1.       Responsibility: The responsibility for supervision of sterilising tasks should be clearly understood and vested under one person. Due to repetitive work, workers may be tempted to be careless in sterilisation procedures and differentiation between sterilised and unsterilized packs.

         2.       Disposables: The advantages and disadvantages of using disposables should be fully taken into account when considering the replacement of traditional materials by their disposable equivalents, remembering that some disposables give more value for money, while as some others have no specific advantages.

         3.       Segregation of Sterile and Unsterile Supplies: Sterile supplies and packs and contaminated articles should never be carried on the same trolley or by the same staff. The term “sterile supplies “covers all articles which have either been sterilised in CSSD or disposable sterile packs distributed through CSSD.

         4.       Standardisations of Packs: Special trays and sets to be processed by CSSD should be standardised by the hospital. In standardising, the aim is to have a standard surgical pack containing all the items required for that procedure by the operating personnel. This system has the advantage of having standardised sets ready at hand even for emergency operations, irrespective of special preferences of particular personnel.

         5.       Packing procedures: Step by step packing procedure for each pack should be determined, and should specify the quantities of materials required and their arrangement on the workbench, and the sequence of the packing operation.

         6.       Manual of operations: A procedure manual listing all procedures followed in the CSSD for each process and their correct sequence is essential for effective operation of the department. It must be realised that more costly and sophisticated the equipment, more training and precision is required to operate it.

         7.       Packing material: Packing material used as wraps for articles for sterilisation differs with the process of autoclaving or hot air oven. Linen and Kraft paper are commonly used, paper being a better bacterial barrier. The wrap should be easy to open without spilling the inside items. Articles for hot air sterilisation can be kept in suitable stainless steel containers. Syringes and needles are packed in paper wrappers. Gloves can be packed either in paper or linen.

AUTOCLAVING:

Use of saturated steam under pressure is the safest and dependable method of sterilisation, in universal use for destruction of all forms of microorganisms.

The minimum time and pressure for sterilisation by autoclaving process is 121°C at 15 lbs psi in 15 minutes. If the temperature is raised to 126°C, the time can be reduced to 10 minutes. At 134°C, it is 3 minutes, and only a minute at 150°C. The last process is utilised in “flash sterilisers” installed in some operation theatres for spot sterilisation of urgently required instruments during operation.

STERILITY INDICATORS:

          1.       Mechanical indicators are those which are monitoring instruments record time, temperature, humidity and pressure during the sterilisation cycle.

          2.       Chemical indicators are devices with a sensitive chemical or dye to monitor one or more parameters of a sterilisation cycle.

          3.       Biological indicators employ the principle of inhibition of growth of microorganism of high resistance to the mode of sterilisation. Subsequent failure of growth of microorganisms indicates adequacy of sterilisation.

No single method is capable of monitoring completely all parameters necessary for a fool-proof sterilisation.

         ·         Recording instruments on the autoclave which give a progressive graphic record of temperature, pressure, etc.

         ·         Chemical indicators change colour when conditions necessary for sterilisation have been met. These are available as tapes and strips.

         ·         To achieve a high degree of certainty that the autoclave is functioning properly, biological indicators should be placed in the most inaccessible location in the load and then cultured.

CHEMICAL STERILIZATION:

Ethylene oxide (EO) is a gas which is now commonly used as sterilising agent for heat-sensitive and moisture-sensitive materials like rubber, plastics and fibreglass. Effective sterilisation by EO depends upon the following:

          1.       Concentration of gas: 450 mg/litre or higher is essential for complete sterilisation.

          2.       Temperature: Exposure time can be reduced by increasing the temperature. Two temperature ranges are generally provided in the EO sterilisers 49° to 63°C and 30° to 37.8°C.

          3.       Humidity: In automatic sterilisers, steam is injected under vacuum before admitting the gas. In some a wet gauze or sponge is required to be placed. Other sterilisers depend on ambient humidity, and compensate for lower moisture by a higher exposure time.

          4.       Packing: The type of wrapping used should be penetrable by ethylene oxide and water vapour. Polyethylene is commonly used for loose wrapping.

          5.       Period of exposure: In automatic sterilisers, the time ranges from 110 to 260 minutes. Up to 12 hours may be required in others.

Ethylene oxide sterilisers generally fall into two categories-manually operated and automatic. The source of the gas is provided by large compressed gas cylinders or by a unit dose cartridge sufficient for one cycle. Simple sterilisers carry out sterilisation at room temperature and ambient humidity, with single-use glass ampoule of ethylene oxide seated inside a gas-release bag. On breaking, liquid ethylene oxide vaporises and diffuses out of the gas-release bag into a larger bag in which the material to be sterilised has been placed. This bag performs the function of diffusing chamber and allows the gas to retain long enough to achieve sterilisation.

Sterilisation Process: After the steriliser chamber is sealed and the controls set,sterilisation process goes through the following phases:

1.       Warming the chamber

2.       Evacuating residual air to partial vacuum

3.       Introduction of moisture to ensure that it penetrates wrappings and material

4.        Introduction of EO

5.       Raising the temperature (if required)

6.       Exposure for the required time

7.       Release of chamber pressure

8.       Removal of the gas under vacuum (called the “Purge cycle”)

9.       Re-establishment of atmospheric pressure by introduction of filtered air into chamber.

CSSD DISTRIBUTION SYSTEM:

Distribution system for sterile article should also be decided at the planning stage itself. The following four systems are in use. The last two are door deliveries.

            1.       Clean for dirty-exchange: A sterilised articles is issued at the CSSD issue counter on return of a used one at any time.

            2.       Requisition system: Articles needed are requisitioned by users on a daily or regular basis and collected by them at CSSD counter.

            3.       Grocery system: Each user’s requirements for all items for a specific period are delivered at suitable interval irrespective of whether the contents have been used or not and the previous basket or container withdrawn.

            4.       Quota system: Predetermined stock levels (quota) of various items for each user unit are maintained by delivery personnel from CSSD through regular deliveries.

The choice of system will ultimately be dependent on local circumstances. A combination of the systems may be more appropriate in most hospitals.

References:
Principles of Hospital Administration and Planning- BM Sakharkar