Aurosiksha

Introduction

World Health Organization defines hospital as an integral part of a social and medical organization. Its function is to provide for the population complete health care both curative and preventive. Its out-patient services reach out to the family and its home environment; the hospital is also a centre for the training of health workers and biosocial research.

A good hospital would build its services on the knowledge and understanding of the community it is to serve; its success will depend upon the involvement of many professional groups, within and outside the hospital.

Hospital is an institution whose primary function is to provide in-patient services, diagnostic and therapeutic, for a variety of medical conditions both surgical and non surgical. It is meant to serve people with various diseases. It should have a pleasant ambience, the building should be planned to allow smooth patient flow, and the staff of the hospital should be trained to provide the patients high quality treatment with compassion. The hospital should also ensure safety for the patients. It has been found that 7% of the patients are admitted to hospitals with nasolacrimal infection. Hence it is important to have a planned set up which ensures an infection free environment. This chapter aims at facilitating the reader's understanding of the important factors that contribute to an ideal hospital set up.

Hospital setup

Need identification

Need for starting a new hospital is identified through a needs assessment survey in the community. The information which needs to be gathered from the survey includes:

Total population in that area
Major prevalent illnesses
Mortality and morbidity rates
Economic status of the people
Presently available medical facilities
Present accessibility of services by the people
Areas requiring clinical services
Availability of human resource
Accessibility of civic amenities such as water, electricity, road and transport
Local cultural practices

This data will help to justify the need for a hospital in that particular area

Selection of site

In the selection of site, two very important factors are the level of sub soil water and the structure of the soil. Also,

It should be accessible to the people living around. The catchment area should be about 15-25km radius if the transport facilities are good
The selected place should have good ground water resources and also domestic water supply for the hospital's daily use
The hospital requires water, sewage, electricity and telephone lines. These facilities should be acquired at the earliest through the concerned public authorities
Proper canalisation for good drainage should be made and general sanitary measures should be taken
Both the patients and the personnel need clean air and quiet surroundings. The location should be free from noise, dust, smoke, vapors and other annoyances like atmospheric pollution coming from roads, industries, factories, and play grounds
When planning the construction it is advisable to keep in mind plans for future expansion
Cost is also an important factor that should be considered while selecting a hospital site. Total cost incurred to build a hospital should be calculated at the initial stage, and the budget should be planned well in order to avoid unnecessary problems in the later stage of construction

Hospital environment

Hospitals should be highly sensitive to noise and dust. It is good for the hospital to be surrounded by green trees and a garden (Fig. 1.1). If the site of the hospital does not have trees, they should be planted; the hospital must have a well maintained garden. This will prevent dust inside the hospital, help to keep the noise out, and provide a pleasant environment.

Out-patient area

Out-patients are those who do not require admission to the hospital. Departments which cater to this category of patients are called Out-patient Departments (OPD). All the patients should access a hospital through the out-patient department. Good out-patient services constitute one of the most important elements of an ideal hospital. Since it is the first area of the hospital, it reflects the image of the hospital (Fig. 1.2).

Objective of the OPD is to provide diagnostic, curative, preventive and rehabilitative services to the community. The hospital may provide a mobile service to reach out to the underserved areas.
The patient registration counter registers the patient as an out-patient and the staff then guides them to the relevant departments for diagnosis and treatment procedures.
The out-patient area should have proper ventilation, lighting, and sufficient space to accommodate patients and their attenders.
Since all the patients enter through the out-patient area it is the duty of House keeping Department to ensure cleanliness.
The out-patient area should have an aesthetic ambience which helps the patient relax.
Health education posters in the out-patient area help create awareness in the patients and attenders on various diseases. This is also the area to put up posters educating people on basic hygiene and health.
Sign boards and directional graphics in large hospitals helps patients to find their way around.
Waiting areas should have the provisions of televisions, enquiry desk, touch screens and a separate play area for children.

Out Patient Area — Fig. 1.2 Out-patient area

In-patient department

A patient who is admitted to a hospital or a clinic for treatment that requires at least one night stay is called an in-patient. Areas which cater to these patients are wards or in-patient areas. In-patient areas should be located away from main roads and the OPD area. This is to ensure quiet and peace. Also, rooms which overlook the main road are a potential source of cross infection. The in-patient area should be easily approachable from the operation theatre and supportive services. (Fig. 1.3).

The prime objective of in-patient department is to provide accommodation for patients.
In-patient units are grouped into general wards and special wards. In each type of ward the patients may choose the kind of accommodation based on their economic condition. Patients who are critical and need special care are put into the intensive care unit (ICU).
General wards accommodate patients who are not critically ill but need continuous care or observation and have to be in bed.
Speciality wards cater to patients who need hospitalisation in particular specialties such as orthopedics, paediatrics, gynecology etc. This is applicable to a multi speciality hospital. In the case of eye hospitals, whether big or small the ulcer ward should be separate so there will not be cross infections. In bigger hospitals where patient flow is higher, ward can be split for each speciality like cataract, retina, pediatric, glaucoma and so on.
Intensive care units: These are specially built for the patients who need close monitoring and observation. It should contain equipment like pulsoximeter, defibrillator, and oxygen supply and it should be away from the public area of the hospital.
There should be a policy for regulating visitors and attenders which helps the hospital provide a safe and peaceful environment. Some hospitals do not restrict visiting hours. So the patients feel good if people come and see them.
Every room of the ward should have all the facilities the hospital has assured the patient at the time of admission. There should be immediate response from housekeeping in case of any query from the patient.
All the wards should have required staff, cleanliness and supportive facilities to ensure patient satisfaction.

Cleaning and waste management

A clean and hygienic environment has a tremendous psychological impact on the patients and visitors of the hospital. Proper and frequent cleaning of hospital floors keeps the patient free from infections. Good housekeeping is essential in a hospital to ensure cleanliness and an infection free environment.

Dust is tiny particles which carry infection, create irritation of skin and allergies, and cause damage to the instruments and equipment.

Wastes generated in the hospital should be treated and disposed of properly, to provide a safe environment for patients. If waste is not treated and disposed of properly, it is prone to spread diseases.

It may not be possible for small hospitals to maintain a separate department for hospital housekeeping. People could be appointed to maintain cleanliness and an OA could be in-charge.

Infections can be avoided by following these steps

Dust management is an important concept that should be followed strictly in a hospital set up.
Proper maintenance of drainage system will help keep the environment free from insects, including mosquitoes.
Keep the environment green.
Sprinkling water in the space around the hospital avoids airborne dust inside.
Reduce speed of vehicles by keeping speed breakers in the roads around the hospital (with the permission of the concerned government authority).
Keep carpets at the entrance of out-patient department and in-patient department.
Frequent cleaning of the floors and periodic cleaning of walls with appropriate disinfectants reduce the risk of infections.
Proper covering of equipment after use and regular maintenance of air conditioning.
Instructing the patients and hospital personnel to follow waste management practices.
Educate patients, attenders and hospital personnel about the importance of a clean environment with posters and pictures in various locations of the hospital.
Follow proper waste management system in the hospital by disposing of waste as directed by the rules laid down by the pollution board.

People visit hospitals with high expectations believing that every disease is fully and quickly curable. The average health care consumer regards contemporary hospitals as the panacea to his health problems. They cannot appreciate the limitations of the hospital. Hospitals which are designed only to meet the health professionals' needs will fail to develop an environment which meets the patient's needs.

Culture and values

Culture is very important in a health care organisation. Culture is a way of life. Culture exists in every organisation. Culture is valuable for both the organisation and the employee. Culture is valuable for the organisation because it enhances organisational commitment of the employees. It guides employees about how things are done and what is important for them.

Definition of culture
Types of culture
Function of culture
Creating, sustaining and changing culture
How culture is learnt
Aravind Eye Care as an example. The culture and values of Aravind Eye Care System
Conclusion

1. Definition of culture

Organisational culture can be defined as a pervasive underlying set of beliefs, assumptions, values, shared feelings and perceptions, which influence the actions and decisions taken by the organisations. Culture is something which is created and resides in the minds of the people. Otta Klin Berg defines culture as a "way of life"

Organisational culture is marked by a number of characteristics

Observed behavioural regularities: When people in the organisation interact with one another, they generally use common language, terminology, and other rituals that relate to deference and demeanor.
Norms: The expected patterns of behaviour are known as norms. Norms represent an unwritten code of conduct. Standards of behaviour are set to guide the organizational members how much work to do. This, in many organisations, is expressed as "Do not do too much, do not do too little".
Dominant values: Organisations advocate some major values and expect the same to be imbibed by its organisational participants. A few examples of such popular values are high product quality, regularity, and efficiency.
Philosophy: Organisations set forth certain beliefs about how employees and / or customers are to be treated.
Rules: There are guidelines stating how the new participants have to adapt to be accepted as full-fledged members of their group in the organisation.
Organisational climate: This is an overall "feeling" that is conveyed by the physical layout, the way organisational participants interact with one another, and the manner in which organisational members behave with outside persons.

2. Types of cultures

Dominant culture and subculture

A dominant culture is marked by a set of core values shared by a majority of the organisational members. When we talk about an organisation's culture, we refer to its dominant culture. The dominant culture gives a macroview of an organisation's personality. For example, most of the employees at the Reliance Group share a concern for the value of time. This creates a dominant culture in the organisation that helps guide the day-to-day behaviour of employees.

Subculture

Subcultures expresses a set of values shared by the members of a division or department. Subcultures typically are a result of problems or experiences shared by members of a department or unit.

Strong and weak cultures

A strong culture is characterised by the organisation's core values being intensely held and widely shared. The more intensely the core values are shared, the stronger the culture. The degree of sharedness depends on two factors

Orientation and rewards

In order for people to share the same cultural values, orientation programmes are organised to tell the new comers about the organisation's philosophy and method of operation. Orientation may be done through both word of mouth and day-to-day work habits and examples. Rewards also effect sharedness. For example, promoting employees who hold the core values helps others better understand the core values. This, in turn, results in lower employee turnover. When core values are not shared with high degree of intensity, a weak culture is formed. Weak culture is usually characterised by high turnover of employees.

3. Functions of culture

Culture performs several functions in an organisation

Culture provides shared patterns to cognitive perceptions or understanding about the values or beliefs held by the organisation. This enables the organisational members to think and behave as expected of them.
It provides shared patterns of feelings to the organisational members showing them what they are expected to value and feel.
It provides a boundary that creates distinctions between an organisation and others. Such boundary-defining helps identify members and non-members of the organisation.
Culture facilitates the generation of commitment to something larger than one's individual self-interest.
It enhances social stability by holding the organisational members together, providing them appropriate standards.
It serves as a control mechanism that guides and shapes the attitudes and behaviour of organisational members. It helps organisational members stick to the prescribed and expected modes of behaviour.
Culture ensures that everyone is focused in the same direction.

4. Creating, sustaining and changing a culture

Creating a culture

Beliefs and values have their base on past happenings. It implies that the ultimate source of an organisation's culture is its founders. The founders start their organisation with a vision. The vision is imposed on all organisational members. The members imbibe the vision through interaction and their own experience.

Tata is an example that typifies this type of culture creation. His supportive-consultive role, his belief in professionalism, and assumption that only honesty and fair dealings will pay have made the vast Tata empire what it is today.

Luthans has outlined a distinct process involved in the creation of a culture. The process involves the following steps:

A single person (founder) has an idea or vision for an enterprise.
The founder brings in people and creates a core group that shares a common vision. All in the core group accept the idea or vision and work for it.
The founding core group begins to act in concert to create an organisation by raising funds obtaining patents, incorporating, locating space, building and so on.

Sustaining culture

Culture once established may fade away if it is not reinforced. Once a culture is created, it must be sustained through reinforcement practices of human resource. Three such practices particularly important in sustaining a culture are selection practices, the actions of top management, and socialisation methods.

Selection

The first step involved in sustaining culture is the careful selection of entry level candidates. The basic purpose of selection process is to appoint the right people for the right jobs. For this, the trained recruiters interview candidates and attempt to screen out those whose personal styles and values do not fit with the organisation's culture. Thus, by identifying suitable candidates who can culturally match the organisational culture, selection helps to sustain culture.

Top management

Subordinates emulate their superiors. The actions of top management such as what the managers say and how they behave has a major impact on the employees working at lower levels. This filters down the entire organisation and becomes a common feature or culture of organisation. Managerial actions like a degree of freedom granted to the subordinates, prescriptions for the employee uniform, pay off in terms of raises, promotions, and other rewards also help create a common history i.e., culture in the organisation.

Socialisation

Socialisation can be conceptualised as acquisition of work skill and abilities, adoption of appropriate role behaviours and adjustment to the norms and values of the work group. In simple words, socialisation is the process of adaptation. New organisational members coming from different backgrounds may disturb the common customs and beliefs already established in the organisation. Therefore, the new employees need to be educated to the organisational culture. This adaptation process is called socialisation.

Socialisation process involves three phases

Pre-arrival
Encounter after induction
Metamorphosis

Pre-arrival refers to all learning that occurs before a new member joins the organisation.

Encounter is the stage of induction which the new recruit joins the firm and is put on the job. The role playing starts here. The recruit starts comparing expectations, the image which he had formed during pre-arrival stage with reality. If expectation and reality concur, the encounter is smooth. When the two differ, stress and frustration set in. What follows is a mental process of adjustment. In this adjustment, the individual tries to replace their own values and norms with those of the organisation at least in vital areas, if not in all. In the other extreme, the recruit simply cannot reconcile with the values and norms of the organisation, get disillusioned and quits the job.

Metamorphosis is the completion stage of changes and consolidation of changed behaviour. In this stage, the employees master the skills required for their new roles, and make the adjustment to the organisation's norms and values. This is, of course, a voluntary process and a conscious decision which enables them to become compatible with the group and organisation. This signals the completion of socialisation process.

Changes in organisational culture

As organisations do not remain the same over a period of time, so is the case with culture. Culture established in one type of environment may not remain effective in a changed environment. If so, the organisation must adapt to new conditions of environment or it may not survive. Hence, there is need for change in organisational culture.

Changing culture is important but not simple. Changing a strong culture is particularly difficult because the cultural values and assumptions have taken deep roots and employees become committed to them. It is easier to change the culture when it is weak.

Deal and Kennedy identified five situations which facilitate change in the culture.

When the environment is going through rapid changes, and the company has been highly value-driven.
When the industry is highly competitive and the environment changes quickly.
When the company is mediocre, or worse.
When the company is truly at the threshold of becoming a large corporation.
When the company is growing very rapidly.

A dramatic crisis

At times, there can be shocks that undermine the status quo of culture and question its relevance. Examples of such crises are a surprising financial setback, the loss of a major customer, or a dramatic technological breakthrough by a competitor which can change the market structure. For example, once the Maruti car was introduced in the Indian market, it shocked the sedate passenger car market, and forced other companies to take a more productive stance. Similarly, the economic reforms initiated during the 1990's as well as the opening of the global market forced many companies to attempt changing their cultural orientation.

Change in leadership

Changing top leadership also has major impact on organisational culture. It is correct to say that the top leadership is the personification of the culture. The top leadership sets the norms, values and formal reward systems for achieving organisational goals.

How is culture learnt?

Since the term organisational culture refers to the underlying beliefs and values that are shared by organisation members, culture can't be dictated by the top management. Organisational culture is transmitted to employees in a number of forms. The most potent ones are stories, rituals, symbols, and language.

Stories

Most stories are narratives based on true events about the organisation's founders, rule breaking, rags-to-riches successes, reductions in work force, relocation of employees, reactions to past mistakes, and organisational coping. Some stories are considered legends because the events are historic. Stories are useful because they preserve the primary values of the organisation by anchoring the present in the past.

Rituals

Rituals are a means of transmitting culture. Activities such as award ceremonies, weekly Friday prayer meetings and annual general meetings are some examples of rituals. These rituals reinforce the key values of the organisation, what goals are important, which people are important and which are expendable.

Symbols

A symbol is a representation of something else. Physical symbols in organisations are used to represent and support organisational culture. The value of symbols is that they communicate important cultural values. Symbols become more powerful facilitators of culture if they are consistent with stories narrated to the organisational members.

Languages

Language is a means of universal communication. Most organisations tend to develop their own language in the forms of jargon, phrases, acronyms, slogans, etc. By learning this language, the members attest to their acceptance of the culture and help preserve the organisational culture. Organisations use a specific slogan, metaphor, or saying to convey special meaning to employees. Slogans can be readily picked up and repeated by employees as well as customers of the company.

Values

A value is defined as a belief upon which a person acts by preference. Values guide human behaviour. As described earlier, the culture and values of an organisation are necessarily linked. Thus, the values and behaviours of employees must support the existing culture for the organisation to flourish.

When the culture and values of an organisation are in harmony and 'lived' by all employees, the organisation will prosper.

Vision and Mission

Aravind Eye Care System - A Model

It is '' to eradicate needless blindness by providing appropriate, compassionate and high quality eye care for all.''

The eye care system mission statement embodies much of the culture in the organisation - that of quality and excellence in service and products and a dedication to treating all patients without discrimination.

Together with mission statements, one of the key elements in the symbolic material of an organisation 's culture is that of shared stories.

Stories about Dr.V. are commonly told and act as an ongoing reminder of his influence on the organisation. They remain a powerful way of communicating the organisation 's ethics.

Spirituality

Aravind Eye Care System was founded very much on a spiritual basis. There are meditation rooms in each building. Dr. V spoke of a ' divine life in a divine body ' and a higher state of consciousness. Sri Aurobindo ' s teachings help people develop higher levels of consciousness, away from feelings such as hate and anger.

Unity

The way in which people work together in an organisation is a key indicator of culture. This relates to how the organisation works as a group of people, how it interacts with patients and how it is regarded in the community. Employees treat other employees as members of their own family.

Community based approach

Standing in the community remains extremely important to the culture of Aravind Eye Care System. Local people (and those not so local) feel that Aravind Eye Hospital is their hospital and many patients were able to cite examples of family and village members who had recommended the institution. Aravind Eye Care System takes pride on its close relationship with local communities and its proactive approach in providing help and awareness through camps and other programmes. In short, Aravind Eye Care System has an enviable reputation.

Patient care

Within the values of Aravind Eye Care System the most important is the emphasis put on patient centered care. Employees are taught to meet the needs of their patients, remove their fears and satisfy their reasonable needs.

Other associated traits are: warm, friendly, compassionate, humane, kind, sympathetic, peaceful, and calm.

Hardwork

The hard working culture at Aravind Eye Care System is imbibed from the leaders and management team. Initiative, drive and a willingness to take in new ideas are encouraged throughout the organisation. A high level of responsibility is given to employees who often take the work beyond the specification of the role. Excellence and quality are inherent. Other associated traits are: organised, efficient, flexible, and responsible.

Selflessness

Employees are in minimum pursuit of position and title. Service is placed before self, along with the interests of the patients and institution. Other associated traits are: self-sacrificing, altruistic, noble, gallant.

Integrity

Aravind Eye Care System is honest and acts with integrity. Employees have good moral values, and are dedicated and loyal to the hospital. Patients are always told the truth and gifts or bribes are not accepted. Other associated traits are: humble, respectful, courteous, polite, and tolerant.

Discipline

This relates not only to behaviour of the staff (they must exercise a good level of self control and perseverance) but also their attitude towards resources and limiting wastage. Employees must be punctual and have a good attendance record. The hospitals are kept immaculately clean and staff have a high level of personal hygiene. Other associated traits are: regulation, order, restraint, control.

Team work

Employees facilitate a good working environment with consideration to other employees, team work and relationship building. No individual can be allowed to undermine the team spirit, each has respect from and to the institution. Other associated traits are: cooperation, collaboration, fellowship.

Rules and Regulations of the hospital

Hospital provides patient care services with the help of physicians, surgeons and other paramedical staff. Despite the size of the hospital and number of patients it must have its own rules and regulations for the smooth flow of work.

Following rules and regulations

Every one should follow the rules and regulations. Some of the rules and regulations are listed below

OA should be a dependable person. Once work is entrusted to them, they must execute it with enthusiasm and devotion. This will make others realise their trustworthiness.
Report to work on time. As a medical person punctuality is a must. It is not enough to report to work punctually. They must discharge their duties punctually.
Keep absence to a minimum.
Be loyal to the institution. Staff may be dissatisfied with a colleague or official; this should not be discussed with a patient.
Dress code is essential to an employee because it gives them dignity.
Respect elder people
Remember that the patient is an important person in the hospital. As Mahatma Gandhi said the customer (patient) is never an interference but gives us an opportunity to serve him.
Patients should be treated with respect and courtesy. The patients come from different walks of life, different economic background, and different educational backgrounds. Every one should be treated with compassion without discrimination.
Care should be given to the patients without discrimination as to race, colour, religion, sex, national origin, value, beliefs or ability to pay
Job description for each employee should be in file.
Written consent from the patient should be obtained for special procedures.
Confidentiality should be maintained by all department staff regarding patient's prognosis.
Don't waste time
Don't waste supplies
Documentation should be true e.g., (record keeping)
Strict visiting timing should be followed. (Depends on the general policy of the administration).
Purchasing should be through proper channel.
Provide proper and regular care and preventive maintenance to all equipment and instruments. All necessary instruments should be covered under annual maintenance contract and insurance policy.
Infection control team should be in place to control infections.
Quality management programme which includes measuring, evaluating and improving patient care.
All services (nursing, pharmaceutical, food and dietary, imaging and therapeutic radiology, laboratory, and emergency) should be provided within the hospital premises.

Organisational structure and functions

Hospital Administrator - ensures maximum patient satisfaction.
Personnel Manager - plans and coordinates disbursement of salary, monitoring leave and attendance procedures.
Office Manager - Attend to all administrative work and assist the administrator in the duties.
Equipment Maintenance Manager - ensures effective purchase and maintenance of all major medical equipment.
Finance Managers - Manage financial resources of hospitals and submit periodic reports.

Summary

Physical ambience alone is not enough to provide satisfactory services to the patient. The ophthalmic assistant (OA) plays a vital role in offering patient care. They know why and how a hospital is started and the importance of maintenance in different areas. Beyond this, they know the culture and values of the institution, mission and vision, and rules and regulations of the hospital. When they are familiar with the mission and their contribution towards it, they discharges their duties with devotion and enthusiasm. An institution must have a set of rules and regulations so that the work flow will be smooth.

Key points to remember

Needs assessment survey is to be conducted in the community before starting a hospital in that area.

In the selection of site, the level of subsoil water and the structure of the soil are two important factors.

The out-patient area should have proper ventilation, lighting and sufficient space.

The in-patient area should be away from the main road.

Waste should be disposed of properly.

The culture and values of an institution guide its employees on how things are done and what is important for them.

Rules and regulations of a hospital enables a smooth flow of work.

Student exercise

Answer the following

What is the information collected in the need identification survey?

What are the important factors looked at in the selection of site?

Give a short note on placement of
a. Out-patient department
b. In-patient department
c. Intensive care unit

What are the steps followed to avoid infections in the hospital?

Give the definition of organisational culture.

What are the characteristics of organisational culture?

Explain the functions of culture in an organisation.

How do we teach culture to trainees?

Mention some of the rules and regulations followed in the hospital.

TitanX

Hospital Orientation