MHH-103

Organization and
Management of Hospital &
Indira Gandhi National Open University
School of Health Sciences Health Services

Block-1
Overview of Hospital Care System 7

Block-2
Challenges in Hospital Management 89

Block-3
Hospital Engineering Services 211
CURRICULUM DESING COMMITTEE
Prof. A.K. Agarwal Surg. Capt. N.A. Khan Dr. S.B. Arora
Director, Academy of Hospital Reader,
School of Health Sciences Administration, School of Health Sciences
IGNOU, New Delhi-68 New Delhi-16 IGNOU, New Delhi-68
Maj. Gen. S.K. Biswas Dr. B. Dayal
Academy of Hospital Part-time Consultant,
Administration, New Delhi-16 IGNOU, New Delhi-110 068

COURSE REVISION TEAM (1st Revision)

Prof. A.K. Sood Prof. Sidhartha Satpathy, Prof. S.B. Arora
Public Health consultant HOD, Dept. of Hospital BU225, Vishaka Enclave
A-18, Parijat Apartments Administration, AIIMS, Pitampura, New Delhi
Plot no.28, Sector-4 New Delhi-29
Prof. T. K. Jena
Dwarka, New Delhi-07
Dr. D. K. Sharma Director
Prof. Jayanta K. Das Medical Superintendent School of Health Sciences
Former Director, AIIMS, New Delhi-29 IGNOU, New Delhi-68
NIHFW, New Delhi-67
Dr. Bidhan Das
Prof. A.K. Agarwal Managing Director,
290, Nilgiri Apartment Octavo Solutions Pvt. Ltd.
Alaknanda, New Delhi New Delhi–110 048

BLOCK PREPARATION TEAM

Writers

Unit 1 Unit 5 Unit 9

Prof. Jayanta K. Das Dr. S Vivek Adhish Lt. Col. (Dr.) Murli J Saboth
Former Director EX-HOD, CHA, NIHFW Sr. Registrar & OC Troops
NIHFW, New Delhi-67 C4 E, DDA Flats, Munrika
155, Base Hospital-901213
New Delhi-110067
Unit 2 Prof. R.K. Sharma(Pre-revised)
Maj. Gen. S.K. Biswas(Pre-revised)
Prof. Jayanta K. Das Department of Hospital
Academy of Hospital Administration
Former Director Administration
New Delhi-110 016
NIHFW, New Delhi-67 AIIMS, Ansari Nagar
Unit 6
Brig. V.K. Singh(Pre-revised) New Delhi-110 029
Lt. Col (Dr) Deepti Sahran,
DDG Medical Services (OPP&P) OIC Automation Unit 10, 11
Army Headquarters, AFMSD Lucknow-226002 Lt. Co.l (Dr) Anupam Sahu
New Delhi-110 001 Dr. Prashant(Pre-revised) OIC TT School,
DMS, Batra Hospital Army Hospital (R&R)
Unit 3
New Delhi Delhi Cantt.- 110010
Prof. Jayanta K. Das
Former Director Unit 7 Shri S.R. Doraiswamy(Pre-revised)
NIHFW, New Delhi-67 Prof. Jayanta K. Das Hospital Management Planning
Former Director Consultant,
Dr. R.M. Kulkarni(Pre-revised) NIHFW, New Delhi-67
New Delhi-110 016
Hospital Management Consultant
Dr. Sidharth Satpathy(Pre-revised)
11, Gulab Nagar Unit 12
Associate Professor, AIIMS
Pune-411 043 Lt. Col. (Dr) Anupam Sahu
Ansari Nagar, New Delhi-110 029
OIC TT School,
Unit 4 Unit 8 Army Hospital (R&R)
Prof. Jayanta K. Das Prof. Jayanta K. Das
Former Director Delhi Cantt.- 110010
Former Director
NIHFW, New Delhi-67 NIHFW, New Delhi-67 Sh. L.R. Lalla (Pre-revised)
Col. R.N. Basu (Pre-revised) Maj. Gen. S.K. Biswas(Pre-revised) Hospital Management Planning
HAI Medicare and Research Institute Academy of Hospital Administration Consultant
Patna-800 014 New Delhi-110 016 New Delhi-110 016
Editors
Block 1, 3 Block 2 Format editing
Dr. Bidhan Das Dr. Ashok Singhal Prof. T.K. Jena
Managing Director, Flat No.12042, School of Health Sciences
Octavo Solutions Pvt. Ltd. ATS Advantage, IGNOU, New Delhi-110 068
New Delhi – 110 048 Ahinstha Khand
Dr. Anika Sulania
Indirapuram,
School of Health Sciences
Ghaziabad – 201 014
IGNOU,
New Delhi-110 068

CO-ORDINATORS
Prof. RuchikaKuba Prof. T.K. Jena
Director Programme Coordinator
School of Health Sciences School of Health Sciences
Indira Gandhi National Open University Indira Gandhi National Open University
New Delhi-110 068 New Delhi-110 068

PRINT PRODUCTION
Mrs. Promila Soni
Assistant Registrar,
MPDD, IGNOU, New Delhi-110 068

October, 2022
 Indira Gandhi National Open University, 2022
ISBN : 978-93-5568-628-2
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Further information about the School of Health Sciences and the Indira Gandhi National Open University
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COURSE INTRODUCTION
Managing health care settings involves a thorough understanding on how the
health care delivery system is established in your country and your state per say.
Understanding these principles will help in taking better decisions while managing
and hospital or similar units. The basic principles and the various organizations
in management is what we are going to learn in this Course.
Broadly the course comprises of six Blocks namely:
Block 1 : Overview of Hospital Care System- Deals with general principles
of hospital care system.
Block 2 : Challenges in Hospital Management–Curtails the various challenges
in managing hospital and how to deal with them.
Block 3 : Hospital Engineering Services–How the principles of engineering
are used in providing services in any hospital will be discussed
here.
Block 4 : Community Health–how the concept of community health is
evolved in our country and what is the current status will be
discussed in this unit.
Block 5 : Health System in India- Contains the brief history of health care
delivery system in India and how the different system curtails to
different strata of population will be discussed in this unit.
Block 6 : National Health Programmes- Finally in this block we will discuss
different health care programs being run by govt. of India to target
few diseases which are more prevalent in our country. All
programmes are run with certain guidelines and strategies we will
discuss these in the unit.
The course will help you understand the basics of establishing health care in any
area. You will learn the guidelines and regulations on the basis of standard care
is provided to patients irrespective of areas and means of providing services.
 MHH-103
Organization and
Management of Hospital &
Indira Gandhi National Open University
School of Health Sciences Health Services

Block

1
OVERVIEW OF HOSPITAL CARE SYSTEM
UNIT 1
Evoolution and Classification of Hospital 11
UNIT 2
Hospital Organisation 31
UNIT 3
Role of Hospitals 43
UNIT 4
Role of Hospital Administration 59
BLOCK INTRODUCTION
In the first block of this course you will learn Evolution and classification of
Hospitals. For the convenience of understanding, the Block have been classified
into four units which are:
 Unit 1 : Evolution and classification of Hospitals
 Unit 2 : Hospital Organisation
 Unit 3 : Role of Hospitals
 Unit 4 : Role of Hospital Administration
As a student of health care and hospital management, you must be fully
familiarised with the hospitals as you are professionally brought up in the hospital
environment while undergoing graduation courses. In the Unit 1, you will learn
about history and evolution of hospitals and hospitals as a system. You should
also be able to relate hospital as an organisation within larger spectrum of health
care which you will learn in second unit. You will also learn the peculiarities of
hospitals which dictate the management needs, and the problems and challenges
required to be handled by hospital Administration. The hospital administrator
basically works at the background to make things happen and to ensure that the
hospital runs effectively and efficiently. You will learn about the functions of a
hospital administrator in the last unit.
In every unit there is check your progress for your own self-assessment. See that
you attempt those after every section read. Also maps and diagrams are given at
appropriate places to make to understand the topic more clearly.
Overview of Hospital
Care System

10
 Evolution and Classification
UNIT 1 EVOLUTION AND CLASSIFICATION of Hospital

OF HOSPITAL
Structure

1.0 Objectives
1.1 Introduction
1.2 Definition of Hospital
1.3 History of Hospitals in India
1.3.1 Development of Hospitals in Ancient India
1.3.2 Development of Hospital Services after Independence
1.4 Classification of Hospitals
1.4.1 According to Directory of Hospitals
1.4.2 According to Ownership and Control
1.4.3 According to the Systems of Medicine
1.4.4 According to the Bed Strength
1.4.5 According to Clinical Basis
1.4.6 According to Length of Stay of Patients
1.5 Hospital as System
1.6 National Health Policy
1.6.1 National Health Policy-1983
1.6.2 National Health Policy -2002
1.6.3 National Health Policy -2017
1.7 Role of Hospitals in Health Care Delivery System
1.8 Let Us Sum Up
1.9 Answers to Check Your Progress

1.0 OBJECTIVES
After going through this unit, you should be able to:
 define a hospital;
 discuss the evolution of hospitals;
 classify the various types of hospitals; and
 describe role of hospital in health care delivery system in India.

1.1 INTRODUCTION
You must be fully familiarized with the hospitals as you are professionally brought
up in the hospital environment while undergoing graduation courses. But to
become a full-fledged Hospital Administrator, you must know how the hospitals
are organised and what its expected functions are. To understand these aspects,
11
Overview of Hospital you must be knowledgeable that how the hospitals evolved from early civilization
Care System
to modern era and also the classification of hospitals by various ways. In this
Unit, you will learn all about the above mentioned aspects i.e. definition of
hospitals, history and evolution of hospitals, classification of hospitals and
hospitals as a system.

1. 2 DEFINITION OF HOSPITAL
The Hospital is an organisation that mobilizes the skills and efforts of widely
divergent group of professionals, semi-professional and non-professional
personnel to provide highly personalized services to individual patients. Like
other large organisations, hospital is established and designed to pursue certain
objectives through collaborative activity. The main objective of the hospital is,
of course, to provide adequate care and treatment to its patient (within the limits
that may be imposed by the scarce resources and by extra-organisational forces).
Its principal product is medical, surgical and nursing service to the patient, and
its central concern is the life and health of the patient. A hospital may, of course
have additional objectives, including its own maintenance and survival,
organisational stability and growth, financial solvency, medical and nursing
education and research and various employee-related objectives. But, all these
are subsidiary to the key objectives of service to the patient, which constitutes
the basic principle that underlies all activities in a hospital.
Various literatures while describing the origin of hospitals stated that religious
forces and institutions was the main force behind the development of hospitals
rather than the development in the medical services. It is at times difficult and
complex task to dissociate development of hospitals from religion as in some
cases like early Roman or Greek civilization; temples of Gods were utilized as
hospitals. But in 400 BC Hippocrates made it possible to separate medicine from
religion on rational grounds.
Modern hospitals are very complex socio-economic, scientific and highly labour-
oriented organisations. Still they owe their origin to the sufferings and ailments
of people and to the compassion and zeal amongst some philanthropers, to relieve
these sufferers from agony of suffering and discomfort.
Today hospital means an institution in which sick or injured persons are treated.
A hospital is different from a dispensary because hospital being primarily an
institution where in-patients are received and treated while the main purpose of a
dispensary is distribution of medicine and administration of out-door relief.
There are many definitions of hospital available in literature and dictionaries,
but not a single definition is perfect in defining a modern hospital and its
multifarious services. Even with WHO, there is no proper definition available.
The WHO expert group has defined the role of hospital as:
“Hospital is an integral part of a social and medical organisation, the functions
of which are to provide the population complete health care both curative and
preventive with out-patient services reach out to the family in its own
environment and also to carry out training of health workers/functionaries
and the bio-social research”
12
Other than this WHO definition, the definition given in the “Directory of Hospitals Evolution and Classification
of Hospital
in India, 1988” is to some extent simple and short. According to this definition,
“A hospital is an institution which is operated for the medical, surgical and/or
obstetrical care of in-patients and which is treated as a hospital by the Central/
State Government; Local Bodies or licensed by the appropriate authority”.

Check Your Progress 1

1) Fill in the blanks:
i) The term ‘Hospital’ is derived from the word.........................................
ii) As per WHO definition a hospital is a.............................................. and
...............................organisation.
2) Write True (T) or False (F):
i) The main objective of the hospital is to provide adequate care and
treatment to its patients. (T/F)
ii) Modern hospitals are not labour oriented organisations. (T/F)
iii) A hospital and a dispensary serves the same purpose. (T/F)

1.3 HISTORY OF HOSPITALS IN INDIA

The Hospitals in India have a long history in its development starting from the
ancient time i.e. from the Era of Emperor Ashoka or may be much earlier than
that of Vedic Era to the more recent modern hospitals. The brief accounts of the
same are as follows:

1.3.1 Development of Hospitals In Ancient India

In India, the history of hospitals can be traced back to the times of Emperor
Ashoka (273-232 BC), who not only built the most outstanding of the early
hospitals for human beings, but also for animals with the motive and intention to
spread Buddhist ideology of sympathy for the sick and every creature in his
kingdom should be healthy without ‘soka’ (i.e. without lamentation and
depression). Charaka and Sushrutha of ancient India were famous physicians.
13
Overview of Hospital Medicines based on the Indian system (basically Ayurveda) were taught in the
Care System
University of Takshilla and Nalanda, which probably contributed to the advances
in Arabic medicine. The “Upakalpa-viyamAdyayam” of Charake Suthresthanam
gives specifications for hospital buildings, labour rooms and children wards.
The qualifications for hospital attendants and nurses as well as specifications for
hospital equipment, utensils, instruments and diets have also been given. There
is evidence to show that there were many hospitals in South India in the olden
days, as observed in Chola and Malakapuram edicts.
The historical account of the ancient Indian medicine cannot authentically be
described for want of inscription and manuscripts or other records as are
available of other system of medicines such as of Egypt. But we do find from
the books written by Arabian and European travelers (about 600 A.D.) that the
study of medicine in India was in its bloom. Every major city had a medical
school. The decline of Indian medicine started from the Mohammedan invasion
in the 10th century A.D. which was a period of unrest. The zeal of the native
“Vaidyas” for the investigation of the Indian flora slackened for want of
encouragement.
The invaders brought with them their own physicians called “Hakims” who
followed Greek system of medicine generally worded as “Unani”. Under imperial
patronage, the “Hakims” began to prosper at the expense of “Vaidyas”. The
maintenance of hospitals in India declined during this period considerably but it
gained impetus only in British period in the 16th century A.D.
Thus, in ancient period, roughly up to 18th century, system of medicine and
practice known as “Ayurveda”, -Siddha” and “Unani” were in practice. Except
these practices and functions the ancient hospital did not cater to the acute and
serious sickness as do the hospitals of modern times. But they were mainly
concerned with the care of the sick for the balance of their lives.
The use of “Allopathic” system of medicine commenced in the 16th century
with the arrival of European missionaries in South India. It was during British
rule that there was once again progress in the building of hospitals. Though the
first hospital in India was probably built in Goa, as mentioned in Fryer’s Travel,
the East India Company established its first hospital in 1664 for its soldiers and
another in 1684 for civilians at Madras. The establishment of a hospital in Bombay
was under discussion in 1670 but apparently it was not actually taken up till
1676. The earliest hospital inCalcutta was built in 1707-1708 and in Delhi in
1874.
During 17th and 18th centuries, there was a slow but steady progress in the growth
of the modern system of medical practice in India and the indigenous system was
pushed to the background. In the 19th century, modern medicine took firm root.
Medical care based on this system spread all over India, mainly through the efforts
of the missionaries.
The Portuguese organised hospitals of the European type at Calicut (Kerala),
Goa and Santhome (Madras) through missionary organisations. They set up
treatment centres and trained local men and women as dressers, nurses etc. In the
early stages, missions were financed by foreign sources but later on when the
14 people realized their value, local support and subsidies were available.
Organised medical training started in the 19th century and precisely in 1822, the Evolution and Classification
of Hospital
East India Company established a medical school at Calcutta and in 1835 made
it a medical college, followed by one in Madras. In the beginning both the modern
system and Ayurvedic system were taught. Later on when the universities were
started, some of the medical schools were taken over and converted into medical
colleges. At the end of the 19th century, there were four medical colleges in India
in addition to a number of medical schools with lower levels of instructions i.e.
L.M.P. etc.
By the end of 19th century, the attitude of community towards hospital system
also began to change. They started realizing that hospitals are not meant for the
terminal stages of disease and life, and hence the dumping place for the patients
of chronically ill or at the terminal stage of the disease. As a result of this,
importance was given to the hospitals and thevolume of work increased and the
whole picture (i.e. structure, administration, functionary etc. greatly changed.
In the early years of 20th century, more efforts were made to remove the stigma
on the performance and a bad image of the hospitals by transferring their
administration from “Public Assistance Powers of Local Administration” to the
“Health Committees”, and these hospitals, later were named as “Public Health
Hospitals”. Many hospitals and dispensaries, originally started to treat army
personnel, were handed over to the civil authorities for treating the civilian
population. Local governments were encouraged to start hospitals at the taluk
and district levels and gradually they were taken over by the states or provincial
governments and run as taluk and district hospitals. The members of the Indian
Medical Service ran many of these district hospitals at the provincial headquarters.
Some hospitals at the provincial headquarters were converted into teaching
hospitals and attached to medical colleges.
Between the World War I and II much thought had been given to the reorganization
of hospital services by the constitution of number of Commissions of Inquiry on
the subject. Further, after the wars, the civilian hospitals were encouraged to
adopt the methods of “rehabilitation” or “fitness” centres as a means of restoring
the lives of patients to working capacity. Thus, these centres, really and
undoubtedly did valuable work, not only in surgical conditions, but in a wide
range of medical treatment as well.

1.3.2 Development of Hospital Services After Independence

After attaining freedom, there was rapid industrialization in the country, but at
the same time there was continuous growth of population which caused a number
of medical and health problems. On the eve of independence, there were about
7,400 hospitals and dispensaries in India. There were around 1,13, 000 beds,
giving bed population ratio of 0.2 per thousand population. There were 19 medical
colleges and 19 medical schools. It was also realized that due to rapid increase in
population which was unable to cope up with the limited availability of resources
in all forms i.e. man, money and materials, the poverty went on increasing. Also
as a consequence the various medical and health problems started cropping up in
a big way for whole of India. Special efforts were, therefore, made to solve those
health problems and various committees were set up from time to time with
definite terms of references. These Committees as per their objectives and terms
of reference, gave their recommendations about health care, medical care and 15
Overview of Hospital hospital administration. Some of these important Committees were: Bhore
Care System
Committee, Mudaliar Committee, Jain Committee, Shrivastava Committee, Sidhu
Committee, Rao Committee; Bajaj Committee etc.
According to Health Information India (1995-96), as on 1st January 1996, India
had 146 medical colleges, also more than 15,097 hospitals with over 6,23,819
beds admitting about 30 million patients each year (with a bed population ratio
of about 0.67 beds per 1000 population) and giving treatment to an un-estimated
number of out-door patients.
Out of all these hospitals and beds, there are 4621 rural hospitals with over
1,22,453 beds available. In the urban areas there are about 10,416 hospitals with
the number of beds around 5,01,368. When these hospitals are divided into the
Government, local bodies and private and voluntary, 4473 Government hospitals
have 3,75,987 beds, 335 local bodies’ hospitals have 19,677 beds and 10,289
private and voluntary hospitals have 2,28,115 beds.
Since independence, though lot of advancement has been made in the field of
medical sciences in the country, still the availability of beds for the general
population is far helm% than its actual requirements. The total number of beds
available at the time of independence was roughly about 0.25 per 1000 population.
Though this figure has increased to 0.75 beds per 1000 population till 1991, but
again in 1995 this figure has come down to 0.67 beds per 1000 population (Refer
Table 1.1). Still all these figures are far below the national target of at least 1 bed/
1000 population that was recommended by Mudaliar Committee way hack in
1961. Even to maintain this current bed/population ratio with the existing trend
of need population growth, require that 6000-7000 beds still need to be added
every year. If this much number of beds are not added then the availability of the
beds will go on decreasing and will result to overcrowding and further mis-
management of the existing Hospitals.
Table 1.1 : No. of Hospitals, No. of Hospital Beds and No. of Beds all types
along with Bed/ Population ratio
Years No. of Hospitals No. of Hospital Beds
(As on 31/12/92) Actual Ratio per1000
population

1951 2694 - -

1961 3054 - -

1971 3862 - -

1981 6804 476226 0.68

1982 6897 486805 0.68

1983 7189 500628 0.69

1984 7369 514989 0.69

1985 7474 535735 0.71

1986 8067 555264 0.72

16
 Evolution and Classification
1987 9803. 585889 0.74 of Hospital

1988 10840 598059 0.74

1989 11079 602490 0.74

1990 11571 629453 0.75

1991 11174 642103 0.75

1992 13692 596203 0.70

1993 14867 615156 0.69

1994 15033 621250 0.69

1995 15097 623819 0.67

2000 15888 690723 0.65

2001 15622 682886 0.64

2002 15393 683545 0.63

2008 11289 494510 0.41

2009 11613 540328 0.44

2010 12760 576793 0.47

2011 11993 784940 0.63

2012 23916 622628 0.49

2013 19817 628708 0.49

2015 20582 708570 0.58

2016 19930 607810 0.48

2017 14656 668077 0.53

2018 23992 778794 0.55

2019 26055 749272 0.54

2020 40883 818396 0.56

2021 41533 858135 0.57

Source : Directorate of Health Services and World Health Organization via the World Bank

Source of these figures are mainly from Directorate of Health Services, Ministry
of Health and Family welfare, Govt. of India and some figures (those not available
with Directorate of Health Services)are taken from World Health Organization
via the World Bank. As most of these figures are taken from Directorate of Health
Services, hence, the data for some years, from Private Sectors/ Voluntary
Organisation are not possible to include in this Table No. 1.1. Also complete data
17
Overview of Hospital (in regards to other public sectors like Railways, ESIC, Defense etc.) was not
Care System
available for some years and for some years no data was available. As a result,
there are some visible discrepancies in the figures of successive years.
As for calculation of bed/ population ratio, by and large the beds of the private
sector hospitals were taken into account, as a result the bed/ population ratio is
shown as below 1, whereas if the beds of private hospitals are also included then
this figure comes to 1.2 to 1.4. Even this ratio of 1 bed/1000 population is far
below than the bed/population ratio available in other developed and developing
countries. The figures in some of these countries are:

Japan/South Korea About 10-14 beds/ 1000 population

North America/USA About 8-16 beds/1000 population

Russia About 8-10 beds/1000 population

European Union (average) About 6-10 beds/ 1000 population

United Kingdom About 5-8 beds/ 1000 population

Sri Lanka About 3-5 beds/1000 population

Thailand About 3 beds/1000 population

Number of Hospital beds all over the world (except for few countries like Japan,
South Korea, Monaco) are decreasing as bed turnover rate on an average has
become high, to cope up with the rising cost of Hospitalisation.
Also another striking feature observed over the last one decade was that the
number of hospitals/beds available with the Government set-up is decreasing
considerably in comparison to the number of hospitals/beds ‘available with private
and voluntary set-up. (Refer Table 1.2)
Table 1.2 : No. of Hospitals and Beds Available with Government set-up and
with Private and Voluntary Organisations in Various Years
S.No Year No. of Hospitals/ Hospital Beds Total
Govt Pvt and Vol,
(Including Organisation
Local Bodies)
1 1983 3879/352539 3022/134266 6901/486805
2 1989 4504/421025 5641/177034 10145/598059
3 1992 4757/435215 6417/206888 11174/642103
4 1993 4579/385216 9113/210987 13692/596203
5 1995 4808/395664 10289/228155 15097/623819
6 2000 4571/430539 11317/260184 15888/690723
7 2002 4034/421478 11334/262067 15393/683545
8 2020 41166/851215 43487/1215706 84653/2066871

18 Source: Health Information India

To begin with more number of hospitals and their beds were available with Evolution and Classification
of Hospital
Government set-ups. The private and voluntary organisations were not that much
involved. But over these years with the change in policy of the Government the
trend is gradually changing. Now, asin
it is shown in Table 1.2, more number of Hospitals and their beds are available
with private and voluntary organisations. Government is investing proportionately
less for construction of hospitals and increasing the number of beds in its existing
infrastructures. The main reasons for this may be:
i) Lack of resources and trained manpower available with Government.
ii) Recent change in policy with the Government i.e. to induct and encourage
the private and particularly the voluntary and non-governmental
organisations to be involved in health care delivery system and mainly in
the secondary and tertiary level of health care in which hospitals are one of
the important aspects, and to channelize its limited resources for
strengthening the primary level health care.

Check Your Progress 2

1) Documented mention of Hospitals was found in which ancient period in
India?
2) What are the traditional systems of medicines present in medieval India?
3) When did ‘Allopathic’ System of Medicine come in India?
4) What is the recommended bed/population ratio in India? What is the current
ratio?
5) In which year and city of India the first hospital was established?

1.4 CLASSIFICATION OF HOSPITALS

As you know, there is no universally accepted method for classification of hospitals
available. In the year 1988 for the first time an effort was made and it was published
in the Directory of hospitals in India. The Directory of Hospitals in India-1988
lists the various types of hospitals and the types of management. Based on this
the hospitals can be classified in many ways. They can be classified according to
their objectives or according to the type of patient treated or according to ownership
and control. The various commonly accepted criteria for classification of the
modern hospitals are as follows:

1.4.1 According to Directory of Hospitals

a) General Hospital: All establishments permanently staffed by at least two or
more medical officers, which can offer in-patient accommodation and provide
active medical and nursing care for more than one category of medical
discipline (e.g. general medicine, general surgery, obstetrics, pediatrics etc.).
b) Rural Hospital: Hospitals located in rural areas (classified by the Registrar
General of India) permanently staffed by at least one or more physicians,
which offer in-patient accommodation and provide medical and nursing care
19
Overview of Hospital for more than one category of medical discipline (e.g. general medicine,
Care System
general surgery, obstetrics and pediatrics).
c) Specialized Hospital: Hospitals providing medical and nursing care primarily
for only one discipline or a specific disease/affection of one system (e.g.
tuberculosis, ENT, eye, leprosy, orthopaedic, paediatric, cardiac, mental,
cancer. infectious disease, venereal • diseases, maternity, etc.). The specialized
departments, administratively attached to a general hospital and sometimes
located in an annexes’ or separate ward, may be excluded and their beds
should not be considered in this category of specialized hospitals.
d) Teaching Hospital: A hospital to which a college is attached for medical
education.
e) Isolation Hospital: This is a hospital for the care of persons suffering from
infectious diseases requiring isolation of the patients.

1.4.2 According To Ownership And Control

Hospitals can also be classified on the basis of ownership and control. The
hospitals classified according to this are shown in Fig. 1.1. Few of these types
are discussed below:

Hospitals

Non-
Government Government

State Local Under

Public Central
Govt. e.g. Self the Act Profit Non-
Sector Govt.
L.N.J.P. Govt. e.g. of Oriented profit
e.g. NTPC,
Hospital Corpora- Legisla- Oriented
SAIL, Coal tion
Delhi tion
India Hospitals
State

Under Under Under Private Corporate Regis- Trust Act Corporate

Under
Ministry Railway Ministry Ministry Nursing Hospitals tered e.g. Hospitals
Labour
of Health Hospital of of Home Homes under Charita- e.g. as in
Ministry
e.g. RML Defence e.g. BSF. Registra- ble Mahara-
e.g. ESI
Hospital e.g. Army CRPF tion Act. Hospital shtra
Hospital
Delhi Hospital 1860

Fig. 1.1 Classification of Hospitals on Ownership Control Process

a) Public Hospitals: Public hospitals are those run by the Central Government,
State Governments, Local Bodies and public sector undertakings etc. on non-
commercial lines. The hospitals may be general hospitals or specialized
hospitals or both. General hospitals are those that provide treatment for
common diseases, whereas specialized hospitals provide treatment for specific
diseases like infectious diseases, cancer, eye diseases, psychiatric ailments,
etc. General hospitals can diagnose patients suffering from infectious diseases,
but refer them to infectious disease hospitals for hospitalization, as general
hospitals are not fully equipped to treat infectious disease patients.
20
b) Voluntary Hospitals: Voluntary hospitals are those which are established Evolution and Classification
of Hospital
and incorporated under the Societies Registration Act, 1860 or Public Trust
Act, 1882 or any other appropriate Acts of the Central or State Governments.
They are run with public or private funds on a non-commercial basis. No
part of the profit of the voluntary hospital goes to the benefit of any member,
trustee or to any other individuals. Similarly, no member, trustee or any other
individual is entitled to a share in the distribution of any of the corporate
assets on dissolution of the registered society. A board of trustees, usually
comprising prominent members of the community and retired senior officials
of the government, manages such hospitals. The board appoints an
administrator and a medical director to run such voluntary hospitals. These
hospitals spend more on patient care than what they receive from the patients.
There is, of late, a trend among voluntary hospitals to charge reasonably
high fees from rich patients and very little from poor patients. Whatever they
earn from the rich patients of the private wards is spent on the patients of
general wards. However, the main source of their revenue are public and
private donations, and grants-in-aid from the Central Government, the State
Governments, and from philanthropic organisations, both, national and
international. Thus, voluntary hospitals run on a ‘no profit no loss’ basis.
c) Private Nursing Homes: Private nursing homes are generally owned by an
individual doctor or a group of doctors. They accept patients suffering from
infirmity, advanced age, illness, injury, chronic disability, etc. or those who
are convalescing. They do not admit patients suffering from communicable
diseases, drug-addiction or mental illness. ‘There is, however, no uniform
definition for nursing homes. The phrase may refer to out-of-home care
facilities that offer a range of services similar to many found in a hospital.
These nursing homes are run on a commercial basis. Naturally, the ordinary
citizens usually cannot afford to get medical treatment there. However, these
nursing homes are becoming more and more popular due to the shortage of
government and voluntary hospitals. Secondly, wealthy patients do not want
to get treatment at public hospitals due to long queues of patients and the
shortage of medical as well as nursing staff leading to lack of medical and
nursing care.
d) Corporate Hospitals: The latest concept is of corporate hospitals which are
public limited companies formed under the Companies Act. They are normally
run on commercial lines. They can be either general or specialized or both.
Some of the other criteria for classifying the hospitals are as follows:

1.4.3 According To The Systems Of Medicine

The hospitals in very broad terms may also be classified according to the system
of medicine that is been practiced there. Hence the hospitals are named as
“Allopathic”, “Homoeopathic”, “Ayurvedic”, “Naturopathic”, “Unani”, and
“Siddha” etc.

1.4.4 According To The Bed Strength

Arbitrarily the hospitals can be classified into large, medium and small, depending
upon the number of beds available in that hospital. Roughly any hospital having
21
Overview of Hospital more than 500 beds is a large hospital, one having the bed strength between 200
Care System
to 500 is a medium hospital, and a hospital having less than 200 beds is a small
hospital.

1.4.5 According To Clinical Basis

A clinical classification of hospitals is another basis for classification. Some
hospitals are termed as “General Hospitals” whereas others are “Specialized
Hospitals” according to the specialty it is dealing with. In a general hospital,
patients are treated for all kind of diseases but in a specialized hospital, patients
are treated only for those diseases for which hospital has been set-up, such as
heart disease, cancer, eye, maternity, gastroenterology, neurology, psychiatry etc.

1.4.6 According To Length Of Stay Of Patients

Hospitals can also be classified according to the length of stay of patients. A
patient may stay for a short-term in a hospital in the diseases like gastro-enteritis,
fever etc. or may stay for long-term for the treatment of diseases such as
tuberculosis, cancer, schizophrenia, etc. Therefore, a hospital may fall either under
the category of short-term or long-term (now known as acute and chronic-care
hospitals respectively) according to the period of stay in the hospital.

Check Your Progress 3

1) Enumerate types of Hospitals in India according to Directory of Hospitals in
Indi
2) Classify hospitals according to management and control in India.
3) Classify hospitals according to systems of medicine in India.
4) Classify hospitals according to bed strength in India.
5) Classify hospitals according to clinical basis in India.

1. 5 HOSPITAL AS SYSTEM
The hospital system has its external environment and linkages. Therefore to
understand the hospital system one has to look at the hospital as an open system
within the immediate environment of healthcare organization and the larger
environment are independent. The hospital services have to be considered as a
socio-technical system within the healthcare system that copes with the constraints
from both the internal and external environment.
Definition of System
A system has been defined in the Oxford English Dictionary as simply “a set or
assemblage of things, connected, or interdependent, so as to form a complex
unity; a whole composed of parts in orderly arrangement according to some
scheme or plan.” To be more precise a system is a hierarchical chain of systems
and sub-systems, interconnected and independent having clear objectives at each
level of the systems or subsystems obtains enough inputs from its environment
to offset its output, and operate with varying process or methods to achieve the
22 ultimate objective of the system. As per Katz and Khan social systems are anchored
in the attitudes, perceptions, beliefs, motivations, habits and expectations of human Evolution and Classification
of Hospital
beings.
The systems as defined are illustrated below.
The Fig.1.2 represents a model of a system or subsystem, which has a clear
objectives and consists of three basic elements, i.e. input, process, and output.
Each component of a system is controlled in a manner as to achieve the ultimate
objectives of the system or subsystems.

Fig. 1.2 Hospital as a system

In hospital patient is key input, but human resources, personnel of various

categories and other resources like drugs and supplies, equipments, information,
research findings and feedback from the output also constitute part of the total
output.
In the systems approach, quality of output is an important variable that affects
input in any part of the hospital. With increase4d concern for sick patients or
beneficiaries, attention has also to be directed towards external environment
outside hospital organisation. This complicates the problem because under the
circumstances hospitals has become the impact point because when patient enters
a hospital a great many groups get involved both inside and outside the hospital
to treat him and help him to recover.
Inside patient is concerned with admissions, diagnosis, treatment and provision
of ancillary house-keeping services. Outside he is involved with relatives, hospital
rules and regulations and the community. This makes hospital a much more
complicated system and the character of the hospital would much depend on the
patients flow in the hospital. Thus patient system becomes basic to the hospital
systems.
Functions of Hospital
The size of a hospital, the patient flow and the community needs also determine
the nature of sub-systems required for effective functioning. The main functions
of the hospitals are:
a) Restorative or Curative
This includes diagnosis, treatment, rehabilitation and to provide emergency
medical care. 23
Overview of Hospital b) Prevention of Diseases and Promotion of Health
Care System
Supervision of MCH and family welfare includes immunization, control of various
communicable and non-communicable diseases, health education. Also hospital
is a centre where the health education activity for the community can be done
very effectively. As the patients and their relatives are in a right frame mind to
accept and subsequently practice the preventive and health promotive measures
for the diseases from which they are suffering.

c) Surveillance Centre
Surveillance centre for both communicable and non-communicable diseases can
also generate most reliable mortality and morbidity data for the area or community
to which this hospital is rendering its service.

d) Education and Research

Basic education, various inductions and in-service training programmes for

graduate and post-graduate doctors, nurses and other paramedical staff.

e) Professional Support

Intellectual and professional support need to be provided to medical practitioners

at stipulated cost.

f) Early detection of epidemics

Hospitals particularly the outpatient departments play a very important role in
early detection of the epidemic along with the definite geographical mapping of
that area and the population at risk. As the OPDs are the places where the first
patient of the potential epidemics usually arrives well before the epidemic is
actually breaking out.
g) Primary Health Care (PHC) Programme

To become a part of primary health care (PHC) programme, every hospital need
to take some role such as:

i) To provide support to PHC.

ii) To promote community health development action.

iii) Basic and continuing education to workers engaged in PHC.

iv) Research on PHC (How to remove various socio-cultural barriers)

etc.
The hospital should regard health as a value and focus on prevention, use of
appropriate technology, community involvement and multi-sectoral approach.
The strengthening ofco-ordination through improved exchange of information
collected through passivesurveillance by the hospital is an important aspect. The
value of information feedback with regard to referrals and communicable diseases
from the field to hospital and hospital to field is essential. Moreover, it is important
for undertaking epidemiological measure and saving the community from lots of
serious diseases.
24
 Evolution and Classification
1.6 NATIONAL HEALTH POLICY of Hospital

India, being one of the member countries, adopted the declarations and
recommendations made at the end of the International Conference held on Primary
Health Care in Alma Ata (1978). They agreed to provide ‘Health for All by 2000
AD’ and hence adopted the resolution and formed its National Health Policy in
the light of Health for All by 2000 AD, through the universal provision of
comprehensive primary health care services
Since the inception of the planning process in the country, the successive five
year plans have been providing the framework within which the States may
develop their health services infrastructure, facilities for medical education,
research, etc. Similar guidance has sought to be provided through the discussions
and conclusions arrived in the Joint Conferences of the Central Councils of Health
and Family Welfare and the National Development Council. While the broad
approaches contained in successive plan documents have generally served the
needs of the situation, in the past, it was felt that an integrated, comprehensive
approach towards the future development of medical education, research and
health services requires to be established to serve the actual health needs and
priorities of the country. It was in this context that the need had been felt to
evolve a National Health Policy.

1.6. 1national Health Policy -1983

The National Health Policy 1983 laid down restructuring of the health services
with the following board approach:
1. Achievement of small family norm, through voluntary efforts, and moving
towards the goal of population stabilization.
2. Review of general and health education at all levels as per national needs
and priorities.
3. Establishment of well dispersed network of comprehensive health care
services integrally linked with extension and education approach, taking into
account that large number of health functions can be performed by well trained
volunteers, auxiliaries and paramedical workers.
4. Large-scale transfer of knowledge, simple skills and technologies to health
volunteers selected by the community and enjoying their confidence.
5. Decentralization of the health care system with the active community
participation; primary health care to be provide through a network of
dispensaries and primary health care centres, secondary health care requiring
basic specialties through different hospitals and tertiary care requiring super-
specialty services through the teaching and apex hospitals.
6. Involvement of voluntary organisations and private practitioners of different
pathies in the mainstream of national health care delivery system.
7. Emphasize and practice domiciliary and field camp approach to reduce
pressure and curative centres.
25
Overview of Hospital 8. Special, well-coordinated services for the mentally ill; physical and social
Care System
rehabilitation of mentally retarded, deaf, dumb, blind, physically disabled,
infirm and aged.
9. Priority to be accorded to those residing in the tribal, hilly and backward
areas and the vulnerable section of the society.
10. Ensuring the emergence of fully integrated bands of workers functioning
within the “Health Team” approach.
11. State must discourage private practice by government doctors.
12. It is necessary that necessary steps be taken to develop the indigenous system
of medicine in accordance to its genius.
13. Problems requiring urgent attention:
a. Nutrition at low cost and acceptable quality.
b. Prevention of food adulteration and quality of drugs.
c. Water supply and sanitation.
d. Environmental protection.
e. Immunization at cent per cent coverage.
f. Maternal and child health with efficient delivery, special focus on less
privileged.
g. School health programmes.
h. Occupational health services.
14. Establishment of an effective health information system throughout the
country.
15. Production of essential and lifesaving drugs under generic name to reduce
the costs for poorer section of society.
16. It would be necessary to devise well considered health insurance schemes on
statewide basis.
17. Review of existing legislations and work towards unified, comprehensive
legislation.
18. Basic research efforts should devote high priority to the discovery and
development of more effective treatment and preventive procedures in regard
to communicable diseases and tropical diseases.
19. It is necessary to set-up the standing mechanism, at the centre and in the
States for securing inter-sectoral coordination in health, agriculture and food,
drugs and pharmaceuticals, water supply and drainage, housing, education,
social welfare and rural development.
20. It would be of crucial importance to monitor and periodically review, the
success of efforts made and results achieved.
26
1.6.2 National Health Policy-2002 Evolution and Classification
of Hospital
To address concerns regarding the non-attainment of a large number of goals set
out in National Health Policy 1983, as well as the changed circumstances relating
to the health sector of the country it became necessary to review the field, and to
frame the revised National Health Policy. This revision was drafted with a view
to set out a new policy framework for the accelerated achievement of public
health goals in the socioeconomic circumstances prevailing in the country.
The main objective of NHP-2002 was to achieve an acceptable standard of good
health amongst the general population of the country through universal provision
of comprehensive primary health care services. The approach was to decentralized
public health system and establish new infrastructure in new areas, and to
strengthen infrastructures in existing facilities. Emphasis was laid on rational
use of drugs in allopathic system and access to tried and tested system of traditional
medicine. The contribution of the private sector for provision of services was
enhanced specially for the population group who can afford to pay for services.
The policy endeavors to achieve following time bound goals between 2002-2015.

1.6.3 National Health Policy -2017

The National Health Policy of 1983 and the National Health Policy of 2002 have
served well in guiding the approach for the health sector in the Five-Year Plans.
But 14 years since the last health policy, the context has changed in four major
ways:
1) The health priorities were changing. Although maternal and child mortality
have rapidly declined, but there was growing burden on account of
noncommunicable diseases and some infectious diseases.
2) Emergence of a robust health care industry estimated to be growing at double
digit.
3) Growing incidences of catastrophic expenditure due to health care costs,
which are presently estimated to be one of the major contributors to poverty.
4) A rising economic growth enabled enhanced fiscal capacity. Therefore, a
new health policy responsive to these contextual changes was required.
The primary aim of the National Health Policy, 2017, is to strengthen and prioritize
the role of the Government in shaping health systems in all its dimensions-
investments in health, organization of healthcare services, prevention of diseases
and promotion of good health through cross sectoral actions, access to
technologies, developing human resources, encouraging medical pluralism,
building knowledge base, developing better financial protection strategies,
strengthening regulation and health assurance.
The policy envisages as its goal the attainment of the highest possible level of
health and wellbeing for all at all ages, through a preventive and promotive health
care orientation in all developmental policies, and universal access to good quality
health care services without anyone having to face financial hardship as a
consequence. This would be achieved through increasing access, improving
quality and lowering the cost of healthcare delivery.
27
Overview of Hospital Hence the main Objectives are to improve health status through concerted policy
Care System
action in all sectors and expand preventive, promotive, curative, palliative and
rehabilitative services provided through the public health sector with focus on
quality.

1.7 ROLE OF HOSPITALS IN HEALTH CARE

DELIVERY SYSTEM
Hospitals play a very important and vital role in providing overall health care
delivery to the community. Even to the extent, it can give a leading role for
providing primary health care in a given area. The role of hospital in health care
delivery system could be better understood by knowing the health systems
operating in that area. It is based on the following factors:
 The approximate population that is to be served by that hospital in a defined
geographical area.
 The number and type of other hospitals available in the area.
 The type of ownership of the hospitals and the interaction between them.
 The level of development of hospital services in relation to community health
needs and comprehensiveness of the services.
 The level of adequacy of referral arrangements.
The situation in our country is such, that so far development of other levels of
health care sub-systems are weaker than the hospitals and coordination among
the levels are not one of the best. As a result, not only the hospitals are too
dominant but also too little attention is paid to the links between hospitals and
primary and secondary level of health care and its workers, working in the outreach
areas. The institutions still lack co-ordination and clearly defined role boundaries.
The situation is further complicated because most of the hospitals in Government
sectors are facing the most severe resource crunches and manpower problems.
Whereas the hospitals in private sectors though by and large are not having any
such problems to a great extent, still they are not committed for providing primary
health care. Hence, the question, for the Government hospitals, who are the main
providers for primary health care, is not how they take newer roles but rather
how they can contain the cost and quality of services and survive in their present
crisis.

Check Your Progress 4

1) Enumerate the five major functions of the hospitals.
2) List the role of Hospitals in Primary Health Care.

1.8 LET US SUM UP

In this unit you have learnt about the evolution and classification of the hospitals.
Right from the Vedic era and era of Emperor Ashoka how the hospitals have
slowly and steadily developed to this era of modern medicine. Also you have
28
seen how many types of hospitals are there and their classification according to Evolution and Classification
of Hospital
various ways. After more than 50 years of Independence, with lot of pride we can
claim that this country has made tremendous development in the field of Medical
Care. This development also is possible for the policy decision taken by the
Government regarding privatization of the Secondary and Tertiary level of health
care which is primarily taken care by the Hospitals only. With the combined
effect and efforts of all these, India is becoming one of the top most country in
the world, where the best quality of hospital services will be available.
After independence, the medical care through the hospitals was mainly in the
government sector i.e., through Central Government, State Governments or in
Public Sectors. Only few hospitals were available in Non-Government Sectors
(mostly in voluntary organisations). Also the maintenance of the super specialized/
tertiary level hospitals started becoming very costly, that too when the services
are to be provided free of cost. Hence, the government took a decision (National
Health Policy, 1983) that by and large the government will not be having any
new hospital until otherwise it is absolutely necessary. Rather the private sector
and the voluntary organisations will be encouraged and given incentives to set
up new hospitals. Government as and when required would buy the services
from these hospitals. As a result of this decision after 1986 very few major hospitals
commissioned in the government sector whereas lot of hospitals are there in the
Nongovernment sector during this period, As a result of this, during the initial
part of this century the number of hospitals were more in Non-government sector
(almost double the number) than in the government sector.

1.9 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1
1) “HOSPITUM”
2) Medical, Social
3) i) T ii) F iii) F
Check Your Progress 2
1) In the era of Emperor Ashoka, i.e. 273-232 BC.
2) Basically the Ayurvedic System of Medicine along with Siddha and Unanr.
3) In the 16th century through European missionaries.
4) Recommended Ratio is I bed11000 population.Curlent ratio is 0.67
bed11000 population.
5) In 1664 at Madras.
Check Your Progress 3
1) General Hospital, Rural Hospital, Specialized Hospital, Teaching Hospital,
Isolation Hospital.
2) Central Government, State Governments, Local Bodies, Private, Autonornous
Body, Voluntary organisation. 29
Overview of Hospital 3) Allopathic, Homoeopathic, Ayurvedic, Naturopathic, Unani and Siddha.
Care System
4) Large, medium and small.
5) General Hospitals and specialized Hospitals.
Check Your Progress 4
1) Curative, preventive and promotion, education and research, professional
support, surveillance centre.
2) Health Education, Specialist support, Diagnostic support, Logistic support,
Referral support, Surveillance centre.

30
 Evolution and Classification
UNIT 2 HOSPITAL ORGANISATION of Hospital

Structure

2.0 Objectives
2.1 Introduction
2.2 Hospital as an Organisation
2.3 Evolution of Hospital Administration
2.4 How a Hospital Works?
2.5 Medical Staff and Hospital Organisation
2.6 Legal Aspects for Hospital
2.7 Professional Service Department in Hospital Organisation
2.8 Let Us Sum Up
2.9 Answers to Check Your Progress
2.10 Further Reading

2.0 OBJECTIVES
After going through this unit, you should be able to:
 describe briefly hospital as an organisation;
 explain evolution of hospital administration;
 discuss functioning of hospital:
 describe five subsystems of hospital viz. clinical, nursing, diagnostic,
supporting and auxiliary services; and
 analyse hospital as matrix organisation.

2.1 INTRODUCTION
In this unit you will learn about hospital organisation. Hospital is made of
subsystems of clinical departments, nursing services, diagnostic services, support
services and auxiliary services. The best way to organize hospital is by matrix
organisation.
In this unit you will also learn about hospital organisation, as to how it is organised
by departmentation or as matrix. The hospital is made up of a series of departments,
which work together in a system to render medical, nursing and support services.

2.2 HOSPITAL AS AN ORGANISATION

You should try to think about hospital as a social organisation, as it is rational
combination of the activities of a number of people for achievement of a common
purpose or goal by division of labour and function and through a hierarchy of
authority and responsibility.
31
Overview of Hospital Organizing is a process of grouping the necessary responsibilities and activities
Care System
into workable units determining laying of authorities and communication and
developing patterns of coordination, this would involve systemizing of all
technical and administrative activities so as to effect satisfaction to customers,
employers and agencies that make it possible to organize. The organisational
structure would depend on size of hospital.

Fig. 2.1: Matrix Organisation

You would perceive the top management is to direct and coordinate the activities
of heterogeneous group of other subordinates managing various hospital services.
Each of them exercise control over a unit. These departmental managers include
at the upper end of the management scale the “line” managers of medical and
nursing units like chief of medical/ surgical divisions, ward matrons, in charge
of operation theatre etc. None of these may consider themselves as managers and
they are also not formally trained for any managerial function.
The organisation process should culminate into a common goal towards which
collective efforts are directed and the goal is spelt out in detail.

32
 ——— Direct Reporting
——— Advisory Relationship
Fig. 2.2: Organisational Chart

33
Hospital Organisation
Overview of Hospital There is a need for clear authority-responsibility relationship that power and
Care System
authority factor need to be reconciled so that individual organisations are
productive and goal directed and there is clarity of organisational relationship,
to reduce conflict that the unity of command must prevail and that authority
must be delegated. You would also see that traditionally most hospitals have
been structured according to a classical theory of organisation. The hospital
organisation may be considered as it may have a structure making a pyramid
organisation but functionally it would best fit into the matrix organization.
This can be explained to students better by a diagrammatic representation of
matrix organization.
The hospital organisation can be defined diagrammatically for better understanding
of the students, however various hospitals depending upon their philosophy would
have different organisational structure to provide patient care, the very purpose
for which hospitals are created. One such organisational chart is shown in Fig.
2.2 for your understanding.

2.3 EVOLUTION OF HOSPITAL

ADMINISTRATION
The profession of hospital administration is unique because hospitals are complete
organisation where the highly qualified professionals are working in a” life and
death” activity, and to manage such organisation the professionals require special
skill; hence hospital administration evolved as a discipline over a period of time
where very few formally trained hospital administrators are available in the
developing countries, while most of the hospitals are being managed by managers
who had on the job training and managing by the principle of traditional approach.
Though hospitals have administrative and service functions that are common to
other commercial enterprises, but it requires integrating with highly technical
and clinical services with administrative and service departments like laundry
and hospital engineering services functioning alongside highly technical, nursing

34
and medical care activities. This variety and complimentary are what make hospital Hospital Organisation

administration such a demanding profession.

In earlier days hospital administrators were selected from the rank of nursing
service and registered nurse had been serving as hospital’s head administrator. In
Church hospital administrator was frequently selected from the rank of religion
order.
In mid1930 first formal university course for hospital administration was
developed. The American College of Hospital Administration (ACHA) is an
organisation that has influenced advancement of the profession of hospital
administration. After World War 1 -1 the field of hospital administration gained
in status as the need for formally trained hospital administrators increased,
however, the situation in developing countries including India is grim as
hospital administration as a profession is still in infancy due to non-availability
of trained hospital administrator and pressure from clinicians to hold seat of
“authority”.
In 1939 American College of Hospital. Administration designed a code of ethics
for hospitals and health care executives, which defines as how health care
executives should function within highest standard of ethical performance. The
code has since undergone several revisions in order to keep pace with change in
the profession.
The clinician and practicing physicians are taking greater role in hospital
management and decision making process because it effects their professional
lives and these clinicians are ever taking management roles as hospital’s full
time medical director.
The main task of hospital administrator is to coordinate hospital’s resources in
order to fulfill institution’s medical care objective in the most efficient and
effective way possible. He should manage personnel, materials, equipment and
finances and is responsible for all function including medical staff functions,
nursing, technical and general service activities.
The hospital administrators of 1940s and 1950s were primarily concerned with
institutions’ internal operation and those activities directly supporting care of
hospital’s patients. The hospital industry changed dramatically subsequently since
many Governmental regulations came into existence. The hospital administrator
has now two roles to perform, firstly managing those activities that went on in a
hospital and secondly to understand and participate in community activities and
assess the needs of community as these influences hospital’s functioning. The
hospital administrator of today is expected to show leadership within hospital
and outside institution’s walls. The major role of hospital administrator is also
public relations and educating community about hospital matters to make hospital
more acceptable by community.

2.4 HOW A HOSPITAL WORKS?

You should understand that hospital functions as ‘matrix organisation’. A matrix
organisation is a structure in which there is more than one line of reporting 35
Overview of Hospital managers. The experts in hospital field have recognized that complex task and
Care System
highly skilled professional workers call for collegial participatory structure while
semi-skilled and unskilled to do repetitive nature work requires hierarchical
formalized structure. Thus there has to be matched physician at one end and
services handled by lower expertise personnel like laundry, dietary services and
housekeeping on the other end of spectrum while nurses and technical fall in
between these two categories. Thus there are two schools of thought, first one is
to run hospital on hierarchical basis and second to run it on cutting the vertical
line horizontally and making hospital a matrix organisation. Thus matrix is a
problem solving management concept where conventional philosophy or system
cannot effectively function in a hospital system. Thus matrix can be considered
as contingency or situational theory of management. This process integrates them
into temporary group with the objective of solving a complex problem that formal
organisation and routine methods cannot solve.

The clinicians thus consume hospital services and resources for their department
from hospital system and this forms lateral horizontal coordination across various
services.

The hospital is organised under governing body and functions under a hospital
administrator. The hospital has broadly five main components firstly clinical
services where all clinicians under various departments provide medical care to
the patients, secondly nursing services where all nursing personnel provide nursing
care to patients, thirdly professional or diagnostic services like laboratory and
radiology services, fourthly ancillary services like laundry, dietary and
housekeeping services and fifthly auxiliary services like public relation
department, welfare service, religious services and hospital inn etc. The students
should’ study hospital working under these five main components and categories
various departments under these sub systems, which are covered under Courses
IV and V to follow.

The hospital should organize itself with unity of command, proper span of control,
delegation of authority, coordination, line and staff relationship and function as
matrix organisation. These aspects are already covered under Course I.

You should understand that there is no one best way to organize a hospital.
Traditionally hospitals are organised in a classical organisation mode which served
them well and still does to great extent. The modern day hospitals are always
seeking better ways to manage. It is clear that the hospitals, that will succeed will
do so by adapting to change.

Check Your Progress 1

1) Enumerate two of the important roles of Hospital Administration.

2) What are the five main components of Hospital?

3) When and where the code of ethics for Hospital Administration was
designed for first time.

36
 Hospital Organisation
2. 5 MEDICAL STAFF AND HOSPITAL
ORGANISATION
The greatest impact the medical staff has on hospital is its role in the quality of
care provided by the hospital. The responsibility of governing body and hospital
administrator is to monitor quality of medical care in the hospital provided by
medical professionals.

The medical profession is highly trained and motivated professional group but
these clinicians or medical staffs vary greatly in their approach to care. In present
era of knowledge explosion there are many super and sub specialties having very
individualistic approach. The task of “Coordinating” the collective efforts of
medical staff is a challenging one for the administration.

The medical staff functions as per rules, regulations, policies and guidelines laid
down by the hospital board and administration. In India unfortunately we are not
yet able to develop standards and guidelines for the hospitals like the ones
developed, by joint commission of accreditation of hospitals in USA with the
result each Indian hospital in his own wisdom had developed its own guidelines
and standards and there is no monitoring body for assessing quality care of the
hospital and accrediting hospitals.

The medical and clinical staff can be managed through management principles
of Total Quality Management. They could be governed by developing its own
rules, regulations and policies through various committee methods like organizing
utilization committee, medical review, Infection control, medical record, tissue
committee and various such committees where clinicians are told to assess their
own quality of care to the patients and these committee reports are perused
periodically by governing board and hospital administration. The details of these
committees need to be studied by the students from various text books of hospital
administration.

The monitoring of Quality Assurance is a necessary function of medical staff.

The students should read details of medical audit, Quality assurance, TOM and
accreditation of hospitals for better understanding of the subject.

The medical director is a member of hospital management board, he is not

answerable to medical staff but to hospital administrator even though they work
with clinical problem and medical staff issues. The medical director’s
responsibility is utilization review, quality assurance and aiding hospital
management in understanding medical staff policies. In fact, new buzz word is
now ‘Total Resource Planning’ of hospital and students should read about
principles of the management philosophy.

The aim of hospital director and medical staff in organizing hospital is providing
quality care to the patients.

37
Overview of Hospital
Care System 2.6 LEGAL ASPECTS FOR HOSPITAL
Law is defined as a body of rules and regulations which, people have established
in order to live with each other in peace and harmony. Hence, Law is an obligation
on the part of society imposed by the competent authority, and noncompliance
may lead to punishment in the form of monetary or imprisonment or both.
With exceptions laid down by specific enactments of the Parliament (e.g. All
India Institute of Medical Sciences Act, 1956 etc.) there are no specific laws
relating to hospitals and their staff and equipment etc. There have been, however,
some reports submitted by committees constituted to go into staff and
infrastructure requirements for different size hospitals. The Bajaj Committee
Report by Dr. I. D. Bajaj the then Director General of Health Services is one of
them. The Punjab Medical Manual 1931 prescribes in detail, plan for hospitals
as well as rules regarding appointment, duty, and allowances of various categories
of staff. As there is no single organisation like an All India Medical Service, it is
expected that hospitals and their staff follow the rules as laid down in the respective
States or organisations (e.g. ESIC, railways, armed forces etc.)
Over the years the process of establishment of healthcare system in India,
necessitated creation of legislative framework for practitioners of medicine. As
the number of doctors qualified in Indian medical colleges increased, creation of
laws for them became necessary. The medical council of India, a national level
statutory body for the doctors of modern medicine, was constituted after the
enactment of Indian Medical Council Act 1933. The First legal recognition and
registration for the Indian systems of medicine came when the Bombay Medical
Practitioner’ Act was passed in 1938. This was followed by two more similar
acts i.e. Delhi Nursing Home Act and West Bengal.
As health is a state subject, hence these acts were mostly applicable to the
respective states only. Consequently, for whole country for the first time any
such act came into existence was Clinical Establishment Act.
The Clinical Establishments (Registration and Regulation) Act, 2010 has been
enacted by the Central Government to provide for registration and regulation of
all clinical establishments in the country with a view to prescribe the minimum
standards of facilities and services provided by them. The Act has taken effect in
the four States namely, Arunachal Pradesh, Himachal Pradesh, Mizoram, Sikkim,
and all Union Territories except the NCT of Delhi since 1st March, 2012 vide
Gazette notification dated 28th February, 2012. The States of Uttar Pradesh,
Uttarakhand, Rajasthan, Bihar, Jharkhand, Assam and Haryana have adopted the
Act under clause (1) of article 252 of the Constitution.
The Ministry has notified the National Council for Clinical Establishments and
the Clinical Establishments (Central Government) Rules, 2012 under this Act
vide Gazette notifications dated 19th March, 2012 and 23rd May, 2012
respectively.
The Act is applicable to all types (both therapeutic and diagnostic types) of Clinical
Establishments from the public and private sectors, belonging to all recognized
38
systems of medicine, including single doctor clinics. The only exception is Clinical Hospital Organisation

Establishments run by the Armed forces.

By and large, laws governing the commissioning of hospital should ensure that
the hospital facilities are created after due process of registration, along with to
ensure the facilities created are safe for the public using them, having at least
the minimum essential infrastructure for the type and volume of workload
anticipated and are subject to periodic inspections to ensure compliance. There
are other laws pertaining to govern the qualification and conduct of
professionals, sale, storage of drugs and safe medication, management of
patients with various patient safety norms, environmental safety, employment
and management human resource, various medicolegal aspects applicable to
hospital and overall patient care, patient attendants, general public and staff
within the hospital premises and community at large. There are laws governing
professional training and research, business aspects, licenses/certifications
required for hospitals, etc.

Hence a hospital administrator should be aware about all these laws,

regulations, policies, procedures, reports and returns and keep abreast with
the latest amendments to be on the safe side of law and provide quality care
to the patients.

2.7 PROFESSIONAL SERVICE DEPARTMENT IN

HOSPITAL ORGANISATION
The professional service departments are those departments which assist physician
and medical team in diagnosing and treating the patient like Laboratory services,
Radiology department, Physiotherapy department and Cardiac Cath lab. However,
it is Radiology and Laboratory services which invariably exist in every hospital
hence students should study in detail and visit these departments in hospitals to
have better understanding. These departments are revenue generating departments
in private hospitals and are more complex than other hospital departments because
they perform a variety of services that make great use of sophisticated equipment
and technology and highly trained technical staff.

39
Overview of Hospital There has also been a lot of technological advancement in these departments in
Care System
last two decades which student would like to know. There has been advancement
in imagining by adding ultrasound, CT Scan and MRI and in laboratory services
by use of semi and auto analyzers and use of various kits. One could now diagnose
with precision by using these diagnostic aids.
Laboratory services are part of pathology department which has shown tremendous
growth and has great impact on patient care. The clinical laboratory services
include bacteriology and blood banking. In 1950 virology, cytology and fluorescent
studies in the hospitals were added. The primary purpose of present day hospital
clinical laboratory is to assist physicians and other members of hospital’s health
team in diagnosis, prevention and treatment of diseases and illness by performing
tests. This department has a major impact on QA programmes in a hospital. The
laboratory reports are critical to come to a diagnosis of “ the patient and thus to
provide quality treatment in hospital, QA is very necessary. The WHO has QA
programme for laboratory services and in India accreditations of laboratory
services have been organised in a humble way.
Thus the mission of the hospital laboratory includes:
a) Provision of comprehensive & accurate analytical test results.
b) Collaborative consultation with the clinicians regarding the most useful
application of scientific procedures to patient care.
c) Training of professional and technical staff.
d) Research.
e) Adaptation of laboratory medicine of useful advances in basic science.
Functions and Scope
The primary functions of hospital laboratory service are to provide :
a. Facilities for the application of scientific techniques for diagnosis and
control of diseases
b. Indices for prognostic evaluation
c. Scientific data, including postmortem studies to evaluate clinical and
therapeutic procedures
d. Laboratory facilities for medical education and research
You while studying any department should think of space and design of
department, its function, staff requirement, organisation, operation and functioning
of the department, record generation, policies and procedure, equipment and
material planning and its maintenance, quality assurance and total resource
planning and assess department’s capabilities and limitation through these
indicators.
The radiology department made its beginning with invents of x-ray by professor
of Physics Dr. W. Roentgen on 08 Nov., 1895 and since then there is no looking
back for radiology department and entering into era of sonography, computerized
40
tomography (CT) and magnetic resonance imaging (MRI).Since early 1960s, Hospital Organisation

significant progress has been made in the conversion of analog images of human
tissue and organs into digital formats. Such digital handling of images has had
a dramatic impact on the ability of the modern day radiology to manipulate and
to analyse radiographic studies for clinical and research purposes. The shift to
the digital formats has resulted in the introduction of computer technology in
medical diagnostic and therapeutic purpose. The areas include CT, digital
subtraction angiography (DSA), MRI, PET, Nuclear Medicine, Ultrasound and
so on.

Many of the procedures as in pathology department are performed on outpatient

and from emergency department. The department depending upon various
facilities available is divided into diagnostic, therapeutic, radiology and nuclear
medicine. In bigger hospitals all these three departments make independent entity
while in smaller hospitals same department does all three functions. You students
should see this difference by visiting radiology department of small and big
hospitals.

FUNCTIONS

The primary function of a traditional radiology department is the provision of

radiologic services of adequate quality and quantity to hospitalized patients,
secondary functions include clinic and other outpatient services, teaching and
research.

The modern radiologic department which is popularly known as imaging

department functions as a centre for the provisioning of patient care as well as
teaching medical, dental, nursing and allied personnel. It is also an important
link in the research programme of any medical institution.

Check Your Progress 2

1) Name the important committees required for total quality management in

hospitals.

2) Which department of the hospital has a major impact on QA programme?

2.8 LET US SUM UP

In this unit you have-learnt hospital as an organisation, its peculiarities, problems
and ways and means to solve by management principles and understand hospital
as a “matrix organisation”.
The evolution of hospital administration and to understand the variety and
complexity is what makes the hospital administration such a demanding
profession.
You have learnt that hospital has five such components viz. clinical, nursing,
diagnostic, ancillary and auxiliary.
You have been sensitized with various management principles applicable in the
hospital field to provide cost effective medical care.
41
Overview of Hospital
Care System 2.9 ANSWERS TO CHECK YOPUR PROGRESS
Check Your Progress 1
1) a) Managing those activities that went on in a hospital.
b) To understand and participate in community activities and assess needs
of community as these influence hospitals, functioning.
2) Five main components:
a) Clinical Services
b) Nursing Services
c) Professional or Diagnostic Services
d) Ancillary Service
e) Auxiliary Services
f) In 1939 American College of Hospital Administration designed a code
of ethics for - hospital and health care executives.
Check Your Progress 2
a) Various committees are: utilization committee, medical review, infection
control, medical record, tissue committee and various such committees where
clinicians are told to assess their own quality of care to the patients.
b) Department of laboratory medicine or laboratory services.

42
 Role of Hospitals
UNIT 3 ROLE OF HOSPITALS
Structure

3.0 Objectives
3.1 Introduction
3.2 Evolution of Role of Hospitals
3.3 Functions of Hospitals
3.3.1 Taking Care of Sick and Injured
3.3.2 Taking Preventive Care and Health Promotion of Community
3.3.3 Surveillance Centre
3.3.4 Continuing Care of Patients
3.3.5 Rehabilitation
3.3.6 Education and Training of Staff
3.3.7 Research

3.4 Role of Hospitals and Peculiarities

3.5 Hospital as a System
3.6 Hospital as Community Institution
3.7 Changing Role of Hospitals
3.8 Challenges and Strategies
3.8.1 The areas of concern
3.8.2 Solutions and Innovations

3.9 Let Us Sum Up

3.10 Answers to Check Your Progress
3.11 Further Readings

3.0 OBJECTIVES
After studying this unit, you will be able to:

 enumerate the various functions of hospitals;

 discuss role and peculiarities of hospitals and also challenging role to keep
pace with rapid updating of technology and science;

 describe challenges hospital has to face; and

 deal with problems and select strategy for optimum functioning.

3.1 INTRODUCTION
This unit aims to familiarize you with the role and functions of hospitals within
the community and futuristic challenges and changing role of hospitals.
43
Overview of Hospital In the previous units of this block you have studied the process of evolution of
Care System
hospitals, their classification, how hospitals are organized and functions as a
system. In this unit you will learn about the role and functions of hospitals and
how a hospital is related to the community it serves. You will also learn the
peculiarities of hospitals which dictate the management needs, and the problems
and challenges required to be handled by hospital administration.

3.2 EVOLUTION OF ROLE OF HOSPITALS

It is mentioned that early Hospitals in India were built by King Asoka (273-232
B.C.). The attendants were ordered to:
 Give gentle care to sick
 Furnish them with fruits and vegetables
 Prepare medicines
 Give massage
 Keep their own person clean
 Maintain confidentiality of patient.

The story of the birth of hospitals is an indication of advancement of civilisation

from individual to family and then to community. The word Hospital came
from a common term (for both Hotel and Hospital) i.e. Hospes (Latin) which
means a place to rest. The hospital originated as a result of sympathy for sick
and suffering.
The modern system of medicine was introduced in India in 16th Century. In
1943 Bed population ratio was 1.3 per I000 and it was decided to increase this
ratio up to 5.6 per I000 in 25years. Until 1960 there were 12000 Hospitals and
185000 beds in India and Bed Population ratio in 1960 was 0.4 per 1000 population
only.
Hospital of today is the evolutionary product of long struggle. It is expression of
man’s right to be well and it is the formal recognition by the community or social
structure of the country of its responsibility for providing the means of keeping
him well. You know Health as defined by WHO is “a state of physical, mental
and social well-being and not merely absence of disease or infirmity”. The task
of hospital is to restore health of community. Therefore, Hospital is defined as
“integral part of social and medical organisation the function of which is to provide
complete health care viz. preventive, promotive, curative and rehabilitative and
hospital is also a centre for training and research of medical and paramedical
staff”.
Hospital is also defined as an institution where “for the patient it is a place to
receive medical care; to the physician it is a workshop in which he/she practices
his profession: to medical and/or nursing student it is an educational
institution.Patient is at the centre of gravity in entire working of hospital as
depicted in the figure3.1
44
 Role of Hospitals

Fig. 3.1: Position of Patient in the working of a Hospital

Hospital is very complex organisation wherein patient is at the centre of gravity

of entire operations. Hospitals are focal point of delivery of health care services
to entire community irrespective of age, sex, cast, creed or colour. The diversity
of staff contributing towards patient care from highly skilled physicians, nurses,
technicians, administration and unskilled staff like general duty attendants (GDA).
Hospital has continuous operation (24 hours working) without any time off makes
it more complex in nature. Hospitals deal with life and death and surprisingly in
many areas of hospital operations there is dual line of authority.

Check Your Progress 1

Fill in the Blanks:
a) .............................. is the centre of gravity in entire working of hospital.
b) In India in 1960 Bed Population ratio was.......................

3.3 FUNCTIONS OF HOSPITALS

Hospital has broad responsibility of maintaining and restoring health of the
Community. Therefore, functions of modern hospitals are:

3.3.1 To Take Care of Sick and Injured

To take care of any patient who is sick and injured is most primary function of
the hospital. All other functions are subordinate and are recognized as part of the
responsibility of the hospital because they contribute indirectly to the care of the
sick. 45
Overview of Hospital The first requisite to give him proper accommodation in the hospital.
Care System
Accommodation to the patient can be given according to:
 Physical condition of patient
 Social and financial status
 Availability
You are aware that patient needs to be admitted as par the principles of progressive
patient care. It means “right patient on right bed with right services around him”.
In other words, patients are given accommodation according to the degree of
illness and need. As far as condition of the patient is concerned may be seriously
ill whose care has to be taken in Intensive Care Unit, where patient who is critically
ill with potentially reversible lesions and who are unable to communicate their
needs and who require extensive nursing care and needs constant observation
irrespective of age, sex and economical status are admitted.
From the second stand point of accommodating patients as per social and economic
status hospital has special, semi special rooms and General wards for admission.
 Hospital should provide proper facilities for diagnosis and treatment with
supportive services of radiology, laboratory, and logistics.
 To provide efficient medical care through expert doctors, nurses and
paramedical staff.
 Hospital needs to provide food services to patients. The diet of patient should
be nutritious and have appropriate caloric value as per his disease
requirements.

3.3.2 To Take Preventive Care and Health Promotion of

Community
Other than the curative services, the hospitals required to play a very important
role in promotion and prevention from diseases. As the preventive medicine for
many communicable diseases, hospitals are involved in various activities like,
immunisation, MCH and family planning activities. Other than these, hospitals
can be very effectively utilised for health education activities, as patients and
their relatives are in right frame of mind to know more about the disease, which
the patient is suffering from. Hence any health education activity imparted will
be better accepted and practised.

3.3.3 Surveillance Centre

Hospitals may be the most important surveillance centre for non-communicable
diseases other than communicable diseases as in a health care delivery system
active surveillance is very minimal for non-communicable diseases.
Also OPD of the hospitals can play a very crucial role in early detection of some
disease out-breaks along with its geographical situation and population at risk.

3.3.4 Continuing Care of Patients

Patients are taken care after surgery till he is completely cured. It is done as a
46 follow up measure and rehabilitation programme. There are certain diseases which
are chronic in nature and need continuous follow up advise on repeated schedule Role of Hospitals

of drugs, physiotherapy, and personalised care.

3.3.5 Rehabilitation
Hospitals can play a very important role in rehabilitation of the patients particularly
who had some physical deformities. This is done through the development of
physiotherapy unit and occupation therapy unit.

3.3.6 Education and Training of Staff

Hospital has to organise training programmes for various cadres like doctors -
for their clinical/ non-clinical subjects, for nurses, for paramedical (technicians)
like x-ray technicians, ECG technicians and also for unskilled workers for
cleanliness, maintenance, sterilization etc. other than the basic training courses
for medical and nursing staff.

3.3.7 Research
In hospital research is carried out on early diagnosis, treatment of patients.
Research is carried out in relation by physical, psychological and social aspects
of health and disease and also in technical and administrative aspect of hospital
practices.

Check Your Progress 2

Which of the following is True/False?

a) Hospitals are not supposed to render preventive and promotive

services. (T/F)

b) Research is one of the very important functions of hospitals. (T/F)

c) Hospitals can be utilised as a very useful surveillance centre. (T/F)

d) Hospitals should not be used as a training centre for

medical and paramedical staff. (T/F)

3.4 ROLE OF HOSPITALS AND PECULIARITIES

Purpose

The purpose of Hospital Administration is provisioning of good patient care with

efficiency and economy, within the resources available.

The Special Needs or the Peculiarity of a Hospital

The hospital as social institution facilitates interaction of a wide spectrum of the

society from varied cultural and socio-economic stratum. The hospital is a media,
through which the scientific technological innovation of Medical Sciences is put
into operation and practised for healthful living of the community.

47
Overview of Hospital The peculiarities of a hospital as an organisation are:
Care System
a) The product of the hospital is ‘service’ which cannot be qualified in any
economic terms and no objective criteria can be laid down to evaluate
the standard of services.

b) The service in the hospital is always personalised, professional and

directly rendered by the medical, nursing and other specialised personnel
according to the needs and requirement of each case or client. As such
the hospital service cannot be mechanised standardized or pre-planned
to meet the specific need. The hospital service is a term work rather than
an individual service.

c) The hospital service is-normally emergent in nature and no two situations

are similar needing the same treatment. So the Hospital Administration
cannot always be pre planned in micro level implementation, with
straightjacket formula. It is more often in management by crisis than
management by objective.

d) The wide spectrum of people involved in the hospital activity ranges

from the highly skilled professional to the man who may not have visited
a school. Therefore, the management of this varied group of people calls
for a balanced psychosocial approach.

e) The dual control by way of professional authority and the executive

authority in the Hospital invariably leads to management conflict which
is a peculiar situation every hospital administrator has to face in the day
to day operation.

f) Of late the hospital being treated as industry for profit as well for
maximization of the output with minimal input has led to application of
management tools and techniques for its administration.

In view of this peculiar nature the hospital administration is a multidisciplinary

approach. It is an art of application of the principles of public administration,
behavioural science and the modern management skill, in the milieu of scientific
medicine to subserve the objectives of the hospitals.

Public Administration For General Administration

Behavioural Science Community and the people in the

hospital

Management Science Methodological improvement

Clinical medicine and community Hospital infection specialized service

health and nd epidemiology

Biostatistics Planning and Forecasting

48
 Role of Hospitals

Fig 3.2: Patient Centered Activities and Services Offered by the Hospital

3.5 HOSPITAL AS A SYSTEM

From a management point of view, the Hospital can be treated as an organized
whole and termed as an open system. This hospital system can be grouped into
four distinct sub-systems:
a) Clinical and Nursing Service Primary Services
b) Supportive Services
c) General Administration and Business Services
d) Utility Services
Clinical and Nursing Supportive Services General
Services Administration
Including Business
and Utility Services

1) Out-patient services 1) Radiological services 1) Personnel Management

2) In-patient services 2) Laboratory Services 2) Financial Management

3) Emergency and 3) Central Sterile Supply 3) House Keeping

casualty Services Services
49
Overview of Hospital
Care System 4) Operation Theatre 4) Laundry Services 4) Material Management

5) Blood Bank Services 5) Dietary Services

6) Mortuary Services 6) Hospital Engineering

Services

7) Rehabilitation Services 7) Transport

(Physical Medicine)

8) Medical Records 8) Public Relations.,

9) Medical Social Worker 9) Communications

10) Pharmacy Services 10) Fire and Security

Thus, to sum up the hospital administration for the patient care services has
become complex and multidimensional. It consists of coordinated activities
provided by a variety of categories of health personnel, utilizing a variety of
precision equipment and skill and is spread over a large physical area of activity.
The Hospital Administration is responsible for synthesis of ‘whole’ organisation
consisting of a wide skill of men and variety of materials into a functionally
effective machine.
The product of this machine is the ‘service’ or the ‘medical care’ provided by a
hospital. This product is intangible and dependent on so many people acting
individually and collectively and does not lend itself to easily definable standards
or to simple units of measurement. No such ready indices are available, which
can be universally applied to measure directly the quality of hospital care.

Check Your Progress 3

Which of the following is True/False?
a) Product of the Hospital service cannot be quantified in any
economic term. (T/F)
b) Hospital services are usually of routine in nature. (T/F)
c) Wide spectrum of people involved in hospital activity ranges. (T/F)
d) Dual control by way of professional authority and executive
authority in hospital makes management easier. (T/F)

3.6 HOSPITAL AS COMMUNITY INSTITUTION

The major part of health care facilities is delivered through hospitals. With
changing era modern technology is also changing at a fast speed. Hospitals are
delivering comprehensive health care i.e. Preventive, Promotive, Curative,
Rehabilitative, Services to patient along with bio-medical research. Also education
and training to various category of staff e.g. medical students, nursing, paramedical
etc. Nowadays hospitals are not functioning in isolation but changing as
community Institution. It is seen that participation of community for O.P.D. indoor
treatment, immunization, preventive health checkups, early detection of diseases,
rehabilitative programmes is ever increasing. In many places hospitals are built
50 within a defined geographical area but do not belong to or catering local population
of that area. Many a times community is not consulted hence they become foreign Role of Hospitals
bodies. Facilities not meeting priority needs may lead to under utilization of
hospital. You are aware that large hospitals are overcrowded with minor or
desperate cases and Rural Health Posts are bypassed.
In such cases Hospitals cannot operate because:
 Lack of Personnel
 Financial constraints
 Breakdown of Mechanical and Electrical, biomedical equipment
 Lack of Maintenance and repair facilities.

Fig. 3.3 : Matrix of Health Environment and Community

It is found that as the expectations of community are increasing with the

‘development of medical technology, the demand is also increasing rapidly. It is
not able to meet increasing demand at the same time maintain quality of patient
care as staff becomes overworked and technical services overwhelmed. Reliability
of health care facilities is of utmost importance. There must -be a proper
communication between hospital and socio-economic institutions like public
works, industry, community development groups; agriculture etc. Population 51
Overview of Hospital dynamics and community environment is influencing in working of hospital as
Care System
community institution.

Check Your Progress 4

1) What are the two main reasons for the overcrowding of hospitals.
2) Fill in the blanks:
a) Local participation of community for optimum utilization of hospital
facilities is....................................
b) There must be proper communication between hospitals and
.......................................

3.7 CHANGING ROLE OF HOSPITALS

Changing and advancing technology with commitment to professional
developments has brought great changes in the organisational structure of the
hospitals. To keep pace with the changing environment and purpose, the role
assigned to hospital administrator has changed considerably
Hence, the hospital administrator’s role in the future will include:
 Understanding the health system operating in the country.
 Awareness of the fact that decisions on planning and programming will be
taken outside the four walls of the hospital. Types of services to be provided
will depend on the community and regional councils.
 Greater involvement of the public and professional experts in the hospital
affairs.
 Dealing with conflicting demands of the hospital board staff, clientele, and
community.
 Need for practical resilience.
Today the modern hospital administrator has to strike a balance between inside
management activities and outside communicator. Maintaining a positive
relationship and effective communication with hospitals clinicians is an internal
duty. The administrator has to provide feedback to the management board so that
they can be assured that the hospital activities are consistent with the hospital
mission.
Administrators are always under pressure to keep pace with changing times. They
must develop new skills and apply old skills to new situations. The administrator
also has a major role in educating the community about hospital matters, this
role is particularly important as consumers clamor about rising hospital costs.
The most effective administrators are visionaries. For modern hospital
administrators time and activities have changed greatly. Marketing public relations,
medical staff relations and strategic planning are some of the key activities in
which they are now involved.
52
Some areas in which hospital effectiveness is being questioned and the influence Role of Hospitals
of administrator in these areas include:
1) Costs and financing of operations
2) Sharing of power for decision making
3) Organisational structure
4) Manpower utilization
5) Patient care
Manpower Utilization
Through job analysis, the skills, jobs and the knowledge required to perform
existing tasks can be identified. This can result in a clustering of tasks into related
skill and knowledge activities. Job pathways can then be designed so that changes
in output and technology can be handled by re-arranging job structures and
selecting appropriate job specifications for assignment of new or different
functions.
Patient Care
The responsiveness of hospital employees can be increased by establishment of
units in which patient complaints are recorded and chronic offenders identified
by confronting employees and their supervisors with written transcripts concerning
unresponsiveness or by confronting them with complainants and their
representatives, the administrator may influence the behavior of the employees.
Continued motivation and training of employees will have favorable influence
on their role performance.
Costs and Financing Operations
The administrator’s influence on cost control is, at least potentially, most
importantly exercised in the budgeting process. The administrator has greater
influence over expenditures for new programmes and facilities. Substantial cost
savings or increased efficiency, however, can probably be realized through real
location of existing budgets, and better correlation of budgets to unit performance
and not merely to historical cost levels. Performance budgeting assumes some
quantifiable output at some given level of quality.
Cost control is seen as a legitimate administrative function by medical staff. As a
representative of the organisation as a whole, the administrator is seen a likely
mediator between conflicting demands and interests.
Sharing of Power
The problems of the administrator increases with the number of bargaining units
and the number of the unions in any one hospital. Negotiating with unions on an
inter hospital basis may result in individual hospitals securing the most expert
representatives and is not being ‘whipsawed” by unions.
Organisational Structure
Structure refers to the organisation of tasks or task groups in units, of units in the
organisation as a whole. The administrator can influence the development and
implementation of formal programme of coordination. 53
Overview of Hospital Because of increased specialization, changing technology, and increased
Care System
expectation of consumers and employees the hospitals require increased
coordination and organisational adaptability. The administrator’s expertise is that
of a integrator structuring the perceptions among producers, and between
producers and consumers, so that chain can be effected without destroying
organisational integration. The administrator requires authority appropriate to
this responsibility.

Check Your Progress 5

1) Discuss how hospital role is changing.
2) Describe changing role of hospital administrator

3.8 CHALLENGES AND STRATEGIES

3.8.1 The Areas of Concern
With the rapid advent of technology, hospital has become a highly scientific and
complex medical institution as against age-old concept of a poor house where
people left their incurable and dying patients. Modernization also causing spiraling
increase in overall delivery cost.
On the other hand, the community is demanding more and better care at minimum
cost in the hospital. A patient will no more tolerate the indifferent and impersonal
treatment offered in our hospitals. An outpatient cannot tolerate forever, long
waiting in queues for registration, consultation, X-ray, laboratory examination,
or for a few tablets in the pharmacy-counter.
A patient now not only demands professional care of sufficiently high standards;
he also seeks more elaborate comforts and cleaner surroundings. An out-of-order
equipment or non-availability of essential drugs and supplies is also resented
upon by hospital patients. A trace of rude behavior on the part of hospital staff
may set off a chain of complaints and allegations. This is a challenge from the
consumers of medical care.
Again, there are many problems within the hospital connected with management
of human and material resources. A hospital social system constitutes a network
of interpersonal relationship with varying degree of complexity. There are a great
number of variables and any attempt to alter any one of them is likely to start a
sort of chain reaction. Orders and policies, no matter how plainly stated, will be
subject to interpretation in the light of psychological set of those who transmit
them or carry them out, the environment in which they find themselves, and the
conflicting pressures which they are subject to. Further, the interaction of the
patient with other patients and their relations, as well as with hospital staff gets
structured into a network of interpersonal relationship, constituting thereby, the
human relation as an important element within the hospital social system. In
order to deal with these social and technological forces it is necessary to use
sound business judgment, based on knowledge of human behavior and experience
of actual operating systems.
The organisation and management of material resources in a hospital still presents
54 a greater problem. Certain services are generated in all the service areas of hospital
through provision of certain facilities in terms of physical facilities, manpower, Role of Hospitals
equipment, furniture, suppliers, such as medicines, food staff, chemicals and so
on. It has been common experience that a lot of costly equipment are purchased
for use in hospitals without prior assessment of their expected output, availability
of technical competence and facilities for maintenance and repair. Utilization of
these facilities in an optimum manner, has been presenting another challenge to
the management of hospitals.
All these issues can be effectively addressed, if the administrative machinery is
proactive. Here again, there are certain drawbacks in our administrative process
itself which fails to achieve the ultimate objective. The major concern of
administration is with the art of getting things done. A decision which does not
result in action is meaningless, and yet, more and more attention in administration
today is devoted to the problems and processes of planning and decision making,
and less and let attention given to effective follow through. Consequently, those
charged with follow through action find themselves unguided, unled and confused,
and, therefore, fail to achieve the desired level of results.
Thus, the weakness in the administrative structures and systems in a hospital add
to the management problems. In a modern hospital a team of doctors, nursing
staff, para-medical personnel, social workers, catering officers, engineers and
administrative staff having specialized training in various branches are working
together to achieve the final objectives of the total hospital system. Many problems
are no longer confined to a single hospital department. A choice of catering system
may involve a catering officer, the engineer, the bacteriologist, the work study
and the cost accountant. Therefore, in order to appreciate the dimension of a
problem it is necessary to examine, analyse and evaluate the system involved in
its totality.

3.8.2 Solutions and Innovations

The expectation from the modern hospitals is to have best of the Quality Health
Care Services with minimal operational cost. Efficiency of medical care applies
to the work of the service as a whole not the end itself but the way the end was
achieved. It is rather concerned with the systematic efficiency of various facilities
which put together contributes towards “quality of medical care” offered by
hospital. “Adequacy” on the other hand, is concerned with the results achieved,
in relation to the stated objectives. The outcome of health centre operation, which
is service (medical care) can be evaluated in terms of:
a) The amount of work done - is it optimal, minimal or maximal;
b) The quality of work performed -how good is the service;
c) The cost of care of the patient and the cost of hospital operation;
d) The extent to which the patient is satisfied with the type of attention he
had received.
The administrative problems mostly faced by a hospital are that of a factory, a
hotel, as well as a college and social service. Administration of such a complex
organisation is just not an art it has become a science which has to be learnt both
by active formal study and experience. With forma1 training a good doctor can
55
Overview of Hospital be very good administrator. Therefore, knowledge of basic principles and
Care System
techniques of management can have a tremendous impact upon its practice,
clarifying and improving it.
During the recent years there has been a greater emphasis on organisational
development, organizational systems and procedures. Underlying this new
approach is the idea that the internal functioning organizations must be consistent
with the demand of organisation task, technology, people, structure, and the power
regulating the course of action. Basically, this approach seems to be leading to
the development of a ‘contingency’ theory of organisation.
Our aim in management of health centre is optimum utilization of inputs for
better output at minimum cost to the maximum satisfaction of consumers of
facilities. How can we achieve this? This calls for introduction of “quality
management system” in hospital, which includes study of organisational structure,
responsibilities, and procedures activities, capabilities and resources that together
aim to ensure that products, processes or services will satisfy stated or implied
needs of the organisation. This in turn needs development of norms and standards
of quality and quantity of medical care services. For planning purposes, it is
necessary to, establish the following norms:
a) The requirement of the community for medical care, covering out-patient
care, supervision of follow up centers (the number of attendance per
person per year),and hospital care (the percentage of patients
hospitalized).
b) Norms for attendance for treatment, the percentage of emergency
admission, hospitalization rate per person, number of patients treated
per bed in a year.
c) Productivity norms, such as, the workload per hour of physicians in
establishments of various types, the ratio of pathological requests per
discharge, the specialist consultation rates, requests for X-ray
examinations per patient or outpatient and so on:
d) Norms of requirement of drugs and consumables.
In contrast “standards” are fixed arbitrarily. It covers indices relating to the
resources required to meet the needs specified by the norms, i.e. indices relating
to the availability of facilities for medical care, such as, standards of staffing,
provision of beds and equipment. We may however, develop standards for average
length of stay of patients, average bed occupancy, financial standards for various
budgetary grants and so on. Therefore, for effective total quality management it
is essential to develop norms and standards, an efficient management information
system and a system of quality assurance in medical care.
Hence newer areas where more and more focus is given are:
1. Use of latest Technology
2. Maintenance of Quality
3. Patient Safety
56
Not only the modern hospitals are no more hesitating in incurring money on Role of Hospitals

developing quality standards for themselves but using adequate resources for
its maintenance. More emphasis is given on patient safety measures. Doing
regular rounds of Clinical Auditing to identify the gaps and looking for measures
to improve it. Even civic authorities are very much concern and aware about
all these. As a result, they are bringing in various acts from time to time, to
ensure that all hospitals and health care facilities are abiding by the basic
requirement, keeping in view, larger benefits and safety of the patients and
community.

Check Your Progress 6

Which of the following is True/False?
a) Hospitals can sustain economically with updation of
technology. (T/F)
b) Community is demanding more and better care at minimum
cost. (T/F)
c) Organisation and management of material resources in a
hospital is no more a problem. (T/F)
d) Main aim of Hospital and Health Management is optimum
utilization of inputs for better output at minimum cost to the
maximum satisfaction of consumers. (T/F)

3.9 LET US SUM UP

In this unit you have learnt about evolution of various roles of a hospital. You
have also learnt about the various functions of hospital. Further you learnt about
the changing role of hospital in present day scenario including hospital as a system
and as community institution. Towards the end you have learnt about the
challenges being faced by the hospitals to keep pace with updation of technology,
resource and ever increasing expectations of the community.

3.10 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1
a) Patient
b) 0.4 beds/ I000 population
Check Your Progress 2
a) True
b) True
c) True
d) False
57
Overview of Hospital Check Your Progress 3
Care System
a) True
b) False
c) True
d) False
Check Your Progress 4
1) Hospitals are overcrowded with minor cases or cases which are desperate.
2) a) Increasing
b) Socio economic Institutions
Check Your Progress 5
1) Changing and advancing technology with commitment to professional
developments has brought great changes in the organisational structure of
the hospitals.
2) a) Understanding the health system operating in the country.
b) Awareness of the fact that decisions on planning and programming will
be taken outside the four walls of the hospital. Types of services to be
provided will depend on the community and regional councils.
c) Greater involvement of the public and professional experts in the hospital
affairs.
d) Dealing with conflicting demands of the hospital board staff, clientele,
and community.
e) Need for practical resilience.
Check Your Progress 6
1) a) False
b) True
c) False
d) True.

3.11 FURTHER READINGS

Rakish, J. S. (1985), Managing Health Services Organizations, U.S.A.
Srinivasan, S. (1982), Management Process in Health Care, New Delhi.
Thompson, John D. (1977), Applied Health Services Research, Canada.

58
 Role of Hospital
UNIT 4 ROLE OF HOSPITAL Administration

ADMINISTRATION
Structure

4.0 Objectives
4.1 1ntroduction
4.2 Job Description
4.2.1 Duties and Responsibilities of Officers of Hospital Administration
4.2.2 Duties and Responsibilities of Medical Staff and Heads of Departments
4.2.2 Duties and Responsibilities of Nursing Staff
4.2.3 Procedure guidelines and standing orders
4.3 Role Towards Patients
4.3.1 Profile of a Hospital Patient
4.3.2 Creation of a Friendly Environment
4.3.3 Patient’s Physical Needs
4.3.4 Patient’s Emotional Needs
4.3.5 Patient’s Clinical Needs
4.3.6 Patient’s Satisfaction
4.3.7 Patient Education
4.4 Role Towards Organisation
4.4.1 Strategic Planning and Management of the Hospital
4.4.2 Relating the Hospital to the External Environment
4.4.3 Operational Management of the Hospital
4.4.4 Managing Hospital Staff
4.4.5 Managing Hospital Materials
4.4.6 Managing Hospital Finance
4.4.7 Managing Hospital Information
4.4.8 Maintaining Relationship with the Medical Staff
4.4.9 Maintaining Relationship with the Public
4.4.10 Risk Management of the Hospital
4.4.11 Managing Ethics and Code of Conduct
4.4.12 Managing Legal and Statutory Responsibilities
4.4.13 Managing Marketing Responsibilities
4.4.14 Quality Management of the Hospital Services
4.5 Role Towards Community
4.5.1 Obtaining Community Participation
4.5.2 Integrating the Hospital with other Health Care Institutions
4.5.3 Supporting Primary Care
4.5.4 Providing Extramural Services
4.6 Attributes, Quality and Skills of a Hospital Administrator
4.7 Let Us Sum Up
4.8 Answers to Check Your Progress 59
Overview of Hospital
Care System 4.0 OBJECTIVES
After going through this unit, you should be able to:
 describe the complexities and ambit of the roles of hospital administrator;
 list the various functions that a hospital administration performs in relation
to the community
 define the role of the hospital administrator that he performs for the hospital;
 explain the responsibilities of a hospital administrator towards the patients;
and
 identify the attributes, qualities and skills required for a hospital administrator.

4.1 INTRODUCTION
In the previous units of this block you have learnt about the evolution and
classification of the hospitals, hospital organization and the role of hospitals. In
this unit you shall learn ‘ about the role of hospital administrator. If you have
visited any hospital either as a patient or as a visitor you might have come across
the various functionaries like the doctors, the nurses, the various paramedical
personnel, housekeeping staff and the like going about their assigned work in a
hurried and professional manner. But rarely if ever, you might have met a hospital
administrator unless, of course, you specifically made it a point to meet him
either to solve some of your problems or to seek certain information.

The hospital administrator basically works at the background to make things

happen and to ensure that the hospital runs effectively and efficiently. At this
point you must not go away with the impression that there is only one person as
the hospital administrator managing the entire hospital all alone. In fact in a
typical moderately large hospital there is a top administrator who is assisted by
several assistants functioning at different levels in the hospital organization. The
role of the hospital administrator will vary depending upon the nature and
complexity of the hospital. In this unit you will learn about the functions of a
hospital administrator obtainable in most of the hospitals.
For a better understanding of these functions we shall subdivide the roles of a
hospital administrator as role towards the patients, role towards the organization,
role towards the community and finally the attributes, quality and skill
60 requirements of a hospital administrator.
 Role of Hospital
4.2 JOB DESCRIPTION: Administration

Job description should normally indicate the title of the job, relation to other
staff, working hours, contents of the job, and special job instructions. The manual
should preferably be in loose-leaf form so that revisions as and when required
could be made reviewed and revised accordingly once a year or once a quarter or
whenever a major change is effected in the hospital. If there is any major policy
change or structured change in the organization there should also be immediate
change in these manual in the form of new job descriptions or position whose
responsibilities and authority have been changed. So a loose-leaf manual will be
handy for deleting the obsolete material and incorporate new pages.

Staffing Marketing

Public Finance &

Relations Responsibi lities Accounting
of a Healthcare
Management
Patient professional Hospital
Satisfaction Operations
Management

Human
Planning &
Resource
Policy Making
Management

Availability of the manual should always be ensured to all unit heads and
departments for overall coordination. It is also to be seen that each one of the
workers, whose jobs are included in the manual, should have a copy of the manual
for his or her understanding and compliance.
Few model job descriptions of some important functionaries in a general Indian
hospital are discussed in this section.

4.2.1 Duties And Responsibilities Of Officers Of Hospital Ad

ministration
The duties of the Medical Superintendent, Deputy Medical Superintendent.,
Assistant Medical Superintendent, Administrative Officer, Welfare Officer,
Nursing Superintendent and Dietician are as follows:
i) Medical Superintendent or Chief Of The Hospital Services
1. Planning, medical supervision and coordination
2. Medical consultation/operations/ward work (for the clinicians who continue
patient care activities)
61
Overview of Hospital 3. Teaching (not exceeding three hours a week to be arranged preferably in one
Care System
or two sessions)
4. Financial and administrative functions - administrative work which should
be performed specifically by the chief of the Hospital, under the rules and
cannot be delegated to lower levels, the matters of general principles and
policy in hospital administration, sanction of all kinds of leave to gazetted
staff; appeals of Class-C and Class-D staff against decisions at lower levels
(appropriate authority).
5. Appointment and discipline authority for class-D staff
ii) Additional Medical Superintendent or Dy. Medical Supdt.
One or two depending on the size of the hospital
1. Day to day routine medical administration of the hospital subject to the control
and general supervision of the Medical Superintendent.
2. Administrator in-charge of
a) Emergency Department
b) Outpatient Department
c) Inpatient Department
3. Medical examination (overall in charge of medical examination cell)
4. Hospital infection control services
5. Sanction of free treatment of indigent patients and routine administrative
matters like public relation
6. Matters concerning treatment of patients, enquiries and their complaints and
related parliamentary questions
7. Medical records for medico-legal cases and court summons relating to them.
8. Matters relating to residents doctors and nurses hostel
9. Supervise the ‘Assistant Medical Superintendent’ on their functioning of
support service areas.
10. Call duty after office hours
11. Any other duty that may be specified by the Medical Superintendent from
time to time.
12. Transport - Controlling, maintenance and repair of staff cars, station wagons,
load carrying vehicles and other vehicles of the hospital - Detailing of
ambulance staff cars, station wagons and load carrying vehicles.
iii) Medical Officer/Assistant Medical Superintendent
1. Sanitation
2. Medical stores responsibilities

62 3. Surprise stock verification of stores and cash

4. Transport and ambulance fund Role of Hospital
Administration
5. Support service areas like blood bank, laboratory, Dietary, Central Sterile
Supply, Hospital sanitation, Medical social work, linen and laundry
service.

6. Security and fire fighting

7. Maintenance of plant and equipment

8. Communication

9. Call duty after office hours

10. Any other duty that may be specified by the Medical Supdt. from time to
time.

11. Maintenance of hospital buildings and liaison with CPWD

iv) Manager (Admn. & Pers.) (Administrative officer in a govt. set up)

1. In charge of logistics and establishment

2. Maintenance of personnel files of all employees

3. In charge of time keeping machine and leave records of all employees

4. Issuing of show cause notices on their disciplinary processes against class-II

and class-III and IV employees

5. Member of enquiry committees, when required

6. In charge of advertisement for fresh appointments

7. Assisting Dy. Medical Superintendent and CEO in planning and development

of the hospital and image building by organizing various neighborhood camps,
participating in government health programmes, empanelling Public Sector
Undertakings and other organizations

8. In charge and coordinator of all legal matters

9. Survey and operational research work

10. Fixation of pay of Class-III and IV staff and sanctioning their leave

11. In charge of vigilance

12. Pursuing and collection from debtors

13. Payment to vendors in time

14. Payment of salary, gratuity, advances when approved in time

15. Technical advice in costing

16. Conducting internal/external audit in consultation with the CEO

17. Joint custodian of cash along with accounts officer

63
Overview of Hospital 4.2.2 Duties and Responsibilities of Medical Staff Heads Of De
Care System
partments
1. To deploy and utilize staff and equipments etc., and to delegate functions.
2. To sanction casual and restricted leave of the non- gazetted staff working in
their departments in accordance with the existing rules and order for which
they will keep proper record.
3. Departmental correspondence as well as leave applications of the staff
(excluding casual leave) and including their own casual leave applications
will continue to be submitted to the Medical Supdt. While sanctioning casual
leave and submitting other leave applications/proposals in respect of the staff
and their own, it will be ensured that satisfactory alternative arrangements
have been made and these will be recorded on the applications. In case
satisfactory internal arrangements are not possible, the leave applications/
proposals should however be submitted with specific recommendations/
suggestions. Mere forwarding of applications/proposals will be presumed as
NO OBJECTION to the acceptance of the proposal/request etc.

The Heads of Department will, in addition, perform duties as assigned by the

Medical Superintendent from time to time.
i) Heads of Units
1. The heads of units will be responsible for the medical care and attention of
all patients admitted to their units (indoor, emergency wards, etc.) and
coordinate with Additional Medical Supdt. for smooth functioning of the
clinical and patient care areas in their charge.
2. The heads of units must see all patients as soon as possible after admission.
For serious cases, the heads of the units must ensure immediate consultation/
examination as considered necessary and the same should be properly
recorded.
3. During the stay of patients in the wards, the heads of units should exercise
continuous personal attention to all seriously ill cases as also to other cases

64
 and should be available for consultation in cases of need in respect of patients Role of Hospital
Administration
in their units.
4. No patient should ordinarily be discharged from the hospital except on
instruction from head of the unit.
5. It would be the special responsibility of the head of the unit to ensure that the
case sheets of the patients are maintained properly and is chronological order
and a true and faithful record of various events in connection with his
treatment, referrals and progress in the hospital is kept. Completion of all
medical records of the patients under his/her treatment.
6. The head of the unit should ensure consultation with his colleagues in case
of need. The consultant requested would similarly record his observations in
the case sheets. Urgent consultation should be so mentioned and consultations
arranged without delay.
8. In case of surgical operations adequate operation notes regarding the surgical
approach used, findings at the operation and operative procedure done, and
post-operative orders should be written.
9. The heads of the units will be responsible for the proper maintenance and
up-keep of the ward in his area and also ensure submission of timely indents
of the various articles required for the treatment of the patients in the ward.
ii) General Duty Officers
1. The Junior Medical Officer of the unit will work in collaboration with the
Senior Resident of the unit and supervise the day-to-day work of house
surgeon and interns.
2. He will accompany the physician/surgeon in charge for ward rounds.
3. On the day when physician/surgeon in charge is not available for ward rounds,
the Junior Medical Officer will take rounds of his own ward. It would be his
sole responsibility to contact the physician/surgeon and discuss about the
serious cases in the ward and if necessary to show these cases to the physician/
surgeon.
4. He will scrutinize the clinical documents completed by the house staff and
make corrections where necessary.
5. The senior-most GDMO will allocate night duties by rotation to house staff
in consultation with the respective registrars/senior resident of different units
and will ensure that the respective staff is available for duty. The duty roster
will be hung up in the duty rooms on the board indicating the name and unit.
The next on duty will be shown in the same list. In case the duty officer is not
available for urgent reasons, the next on duty will act for him.
6. On day of admission he will be available in the afternoon and evening till
relieved by the Registrar/Senior Resident by 1900 hours. He will ensure that
all patients have received attention and necessary discharges from Accident
and Emergency Department have been affected. He will report to the
physician/surgeon in charge by phone whenever available.
65
Overview of Hospital 7. He will also attend to referred cases till the evening. Thereafter, registrar will
Care System
take the responsibility of referred case.
iii) Registrars (Wherever Applicable) /Sr. Residents:
Responsible for clinical care of the patient as well as local ward administration.
1. Sanitation and cleanliness of wards: The Registrar/ Sr. Resident, will take a
sanitary round with the ward staff before he starts his professional work and
ensure cleanliness of the ward. He will cooperate with the ward staff to
maintain discipline in the ward.
2. The Registrar/Sr. Resident will be directly responsible for supervision of
patient care in his unit with the assistance of junior residents or house-
surgeons.
3. He/she will be contacted by the Junior Resident on duty in case of emergency,
if he thinks necessary, he should consult the physician/surgeon in charge of
the unit or G.D.O. when available.
4. He/she will go through all the case notes written by house surgeon and will
make corrections where necessary
5. Besides taking round in the wards during day time, he/she will daily take
round late in the evening with the house-surgeon on call.
6. On admission days, he will attend to cases referred for medical opinion from
other wards. If necessary, he may contact the physician/surgeon in charge for
necessary advice.
7. In case of death, it is his responsibility to scrutinize that case documentation
is complete in every respect and will write a brief summary of the case,
before it is sent to the Medical Records Section.
8. He will maintain a book to indicate the patients in his care who would need
attention after the night rounds and he will apprise the duty house staff of
such cases.
9. He will maintain a register to indicate that the relatives of seriously ill patients
are informed through the central registration office of the hospital. This is
also applicable in case of patients absconding from the ward and also in case
of death.
10. When house surgeon is not available, he will carry out all the duties of a
house surgeon.
11. Registrars/Sr. Residents will certify death.
iv) House Surgeon
1. He/she will take advice from Registrar or Sr. Resident for guidance and
efficient execution of professional care of his patient.
2. In OPD house staff will refer the case to the Registrar/ Senior Resident or the
G.D.O. with a short history and physical findings of the case written on the
OPD card.
66
3. House staff is primarily responsible for the case allotted to him. Besides, he Role of Hospital
Administration
would have a general idea of all the cases in the ward. As soon as a case is
admitted, patient will be examined by the house surgeon who will complete
the case sheet in all details. He will then show the case to the Registrar/
Senior Resident or G.D.O. He will see that all necessary investigations are
done in time, and entered in the case sheet.
4. In case of acutely ill patients, it is his responsibility to show the case
immediately to the Registrar/Senior Resident or G.D.O. for advice.
5. He/she will enter the daily follow up of the case in case sheet. In case of
seriously ill patients the progress of the case will be recorded every time the
patient is examined.
6. On admission days one house physician will be physically present on duty in
Accident and Emergency Department during OPD timing for attending to
cases admitted there. After the OPD closes, two house surgeons will be present
on duty throughout the day in Accident and Emergency Department. In the
night one house surgeon will be on duty in Accident and Emergency
Department
7. On other days the house surgeon, junior resident on duty should be present
in the doctors duty room.
8. On Sundays and Gazetted holidays all house surgeons junior residents will
come for rounds in the forenoon. In the afternoon and thereafter only one
house surgeon junior resident will be on call duty.
9. Night emergency duty in ward (from 2100 to 0800 next day) - House surgeons
from each unit/sub-unit will be on emergency duty in the night for the
respective units in addition to one resident staying in Accident and Emergency
Department.. The senior resident on night call will apprise himself by direct
contact with the Registrar/Resident about cases that would need special
attention.
10. Laboratory and X-ray registration - Requisite forms for laboratory and X-ray
registration should be filled in the previous evening with full clinical notes
for routine cases. In emergency it should be done immediately. The requests
for investigation should be collected in time to be useful.
v) Post-Graduate Students (Residents)
1. They will attend the OPD on the scheduled OPD days of the unit to which
they are attached.
2. Go through and examine all the cases admitted in their respective units and
attach a review of the case on a separate sheet of paper. During ward rounds
they will discuss the case with the physician/surgeon.
3. They will attend the clinical meetings and present cases for the same.
4. For all purposes they will work in collaboration with the Registrar/Senior
Resident.
5. They will not certify “death” and will not discharge a medico-legal case
without the permission of the ward in charge. Under the technical guidance 67
Overview of Hospital of senior resident or the Registrar. Clinical duties and assignment of the
Care System
patient care duties will be organized as per the teaching schedule of the
department. For all practical purpose they will be responsible for patient
management to the consultant or faculty in charge of the case through his
senior resident.
vi) Interns
1. They will work in collaboration with the house surgeon/ junior resident.
2. They will attend OPD on the admission days of the unit to which they are
attached.
3. In the wards they will be allotted beds. They will examine the patients on the
beds under them and complete their case sheets.
4. They will work in the clinical side-room and do routine blood, urine, stool
and sputum examination of the cases under their care.
5. They will be on emergency duty in Accident and Emergency Department
according to the duty roster prepared by the Department.
6. They will attend special clinics, run by their units on the respective days.
7. Interns will neither prescribe treatment nor certify deaths.

4.2.3 Duties and Responsibilities of Nursing Staff

The duties and responsibilities of the nursing staff is discussed in details in Course
MHH-102, Unit 6 titled ‘ Nursing services Organisation and administration.

4.2.4 Procedure Guidelines and Standing Orders

In order to promote efficiency and effectiveness of all aspect of the Hospital

Services, it is advisable to systematize and standardize the procedures of Hospital
Management within the broad policy frame work of the organisation. The Director/
Medical Superintendent of the Hospital exercises command by issuing various
orders for its operation. In a very small hospital much can be accomplished by
personal contacts but as the hospital increases in size it becomes a necessity to
have larger number of guidelines, procedures and its relationships therefore have
to be defined in explicit terms and should be published as a in-house hospital
document for its compliance.
Nature of the guidelines
Amongst the various types of orders issued from time to time in an organisation
there are some which may be of a permanent nature and some may be for one
68 time use relating to solving some problem of temporary in nature. These orders
or guidelines are usually defined or described to explain certain procedures, Role of Hospital
Administration
authority, responsibilities, position, classification or interdepartmental
relationships. These normally do not change frequently even if there are changes
of the incumbent. Such orders may be the reiteration of policies and regulations
laid down by higher authorities, put into practices, and have become a convention
in organisation. Such orders usually form the most part of a hospital manual or it
can be termed as hospital procedural guide. In order to be effective these orders
should be read and understood by all concerned and there should be a system by
which all individuals particularly who are newly posted to the hospital should
become conversant with.

4.3 ROLE TOWARDS PATIENTS

You have already learnt that a hospital performs promotive, preventive, curative
and rehabilitative functions to a varying extent in relation to the health care delivery
to the community, yet the primary reason for the hospital’s existence is for the
curative care. The patients are the sole reason for a hospital’s establishment. A
hospital, therefore, has to design its entire operational system centering round
the patient. The hospital administration has to ensure that this objective of a
hospital is achieved in its entirety

4.3.1 Profile of a Hospital Patient

A patient is a person and a member of the society in need of medical care. He is
not an object and not a disease entity. When he comes to the hospital he brings
along with him all his emotions, all his need for individuality and his need of
independence. A hospitalized patient is under great stress. The reasons for this
stress are unfamiliarity with the hospital surroundings, loss of independence,
separation from the family, financial. problems, isolation from the people, lack
of information, fear of death and, anxiety with the treatment modalities and the
attitude of care givers.
Though it is expected that a nurse will give equal care to all patients and will not
allow personal liking or disliking interfering with their professional duties but in
actual practice this does not happen always. Patients who grumble or complain
or demand more attention from the nurses usually become unpopular. Patients
with physical defects, obesity, of foreign nationality and those patients who stay
longer are also unpopular with the nurses.
The hospital administrator has a great responsibility to understand and appreciate
these behavioral aspects of patient care and take appropriate measures to negate
these dysfunctional aspects.
The hospital administrator also has to understand the specific needs of certain
special group of patients so that those needs can be met. These groups are patients
in wheel chair, elderly patients, paediatric patients, newborn babies and patients
in intensive care units.

4.3.2 Creation of a Friendly Environment

In the previous sections we have tried to emphasize that a hospital is meant for
the patients. Therefore, it is necessary that hospital administration must endeavour
69
Overview of Hospital to make a patient feel welcome. The hospital surroundings and the environment
Care System
are unfamiliar to the patients. Hospitals usually have imposing buildings, strict
rules and procedures and expected norms of behaviour from the patients. The
formidable and intimidating looking gadgets and usually glum faced non-
communicative functionaries further enhance the alienation of the patients.
Hospital administration has to recognize these and all necessary measures to
make the hospital as friendly to the patients as possible.

4.3.3 Patient’s Physical Needs

A hospitalized patient has very little control over his environment. Moreover, the
disease process might have made him dependent on others for his physical needs.
The needs which must be looked after by the hospital administration include
physical comfort with proper and comfortable beds and environmental control
with proper temperature, humidity and lighting, bathing, feeding, sanitation,
mobility and so on. Control of noise and excessive glare from lighting needs to
be looked into. Besides the physical comforts, needs for privacy and security
also have to be given due importance. The needs of the individual patients vary
and hospital administration should device the system in a manner that these needs
of the individual patients are met.

4.3.4 Patient’s Emotional Needs

A patient is usually under great emotional stress in hospital. Sadness, loneliness,
uncertainty, fear, helplessness, despair all contribute to emotional stress of the
patients. It is the duty of the hospital administration to recognize these aspects
and do whatever is possible to reduce these stresses. All may not be controllable
but at least their effects can be minimized by appropriate measures, policies and
procedures, behavior modification of functionaries, longer visiting hours and
facilities of communication with their near and dear ones.

4.3.5 Patient’s Clinical Needs

The primary reason of hospitalization of a patient is to get treated or to get certain
diagnostic tests performed. The patients will always like to get these things done
at the earliest without any delay. The hospital administration has to design the
system in such a manner that this aspect of patients’ needs is fulfilled. Procedures
for admission, investigation, consultation, treatment and discharge must be
streamlined in order to achieve this objective. Hospital bottlenecks which can
interfere with quick disposal of patients needs to be identified and removed.
Stock out of drugs and supplies needs to be controlled.

4.3.6 Patient’s Satisfaction

You must be remembering that we have emphasized several times earlier that the
very purpose of hospital’s existence is for the patients. If there is no patient there
will be no hospital. Therefore, it is in the interest of the hospital that the
administrator must take all possible measures to obtain the greatest degree of
patient satisfaction. For this purpose the hospital administrator has to identify
various dissatisfies in the total service components delivered to the patient. The
dissatisfies may be in the dietary services, may be in the behavior of nurses or
may be in the environmental condition of the hospital. Removal of the dissatisfies
70
may not immediately improve the satisfaction level of the patients. For this purpose Role of Hospital
Administration
the hospital administrator has to identify the items of services that positively
improve the satisfaction level of the clientele. Patient satisfaction is an important
indicator of quality of care being given to the patients. This is also necessary for
survival and prosperity of the hospital.

4.3.7 Patient Education

The patients are usually lay persons. They are ignorant about the high technicalities
of modern day medical science. They need to be educated regarding various
aspects of the medical care given to them. This is necessary for better patient’s
compliance. Patient can participate better in the treatment process if they know
why and how of the care being given to them. The hospital administration has to
device means to seize all opportunities to educate the patients. For example a
diabetic patient may need education regarding his diet, his way of life, necessity
of regular checkups and so on. A young mother may have to be advised regarding
the desirability and methods of breast-feeding. Hospital administrator has to
provide facilities and take appropriate measures for training and motivation of
hospital functionaries for achieving this objective. The hospital policy manual
and medical staff bylaws also must incorporate these aspects.

Check Your Progress 1

1) List the role of hospital administration towards patients.
2) List three probable causes of patient dissatisfaction
3) What a patient will want in terms of physical needs?
4) List the causes of stress of a hospitalized patent

4.4 ROLE TOWARDS ORGANIZATION

The primary duty of hospital administration is to manage the hospital effectively
and efficiently by utilization of resources placed under its command to achieve
the hospital’s objective. If you study the hospital organisational structure, the
realization will immediately dawn upon you that the hospital is an extremely
complex organization. This complexity arises from the facts that there are a large
number of professional groups functioning in a hospital with diversity of
objectives. These groups take part in patient care, housekeeping, maintenance
services for building and equipment, dietary services, security, electronic data
processing, hotel type of accommodation and varieties of investigations and
procedures on patients. Because of diversity of objectives, there is a potential
fertile ground for conflict. Effective coordination, clear enunciation of policies
and procedures, delineation of functional boundaries and so on are necessary’ by
the hospital administration. Unlike other organization, a hospital deals with life
and death situation and functions continuously round the clock with personnel
whose skill and education levels vary widely. The hospital administration has to
bring in unity among this diversity. A paradox in hospital organisational structure
is its duality of command in its many aspects. This is again a potential conflict
situation that a hospital administrator is frequently called upon to resolve.
71
Overview of Hospital 4.4.1 Strategic Planning and Management of the Hospital
Care System
During the last several years, the provisioning of health care delivery in India, is
gradually shifting from the government sector to the private sector. This was
necessitated by the forces of globalization, rapid technological changes, increasing
customer expectation, demand for high quality care and increasing purchasing
powers of certain sections of the clientele. More and more corporate houses are
joining the fray of hospital business. As a result the competition is becoming
intense and sometimes the survival of the hospital is also at stake.
Thus, in response to this pressure, the hospital administration is becoming
gradually professionalized. Strategic planning and management has become a
necessity to circumvent the effects of the changes in the external environment of
the hospital. Strategy is the explicit, pro-active, long range programme to achieve
the hospital’s objectives and thus accomplishing its mission. The strategic planning
is concerned with laying down the objectives after situational appraisal of both
external and internal environments, programme implementation, allocation of
resources and control.
The top hospital administrative echelon is responsible for the strategic planning
and its implementation in a hospital. The hospital administration has to identify
the weaknesses, opportunities, threats and strengths of the hospital. This will
lead to choice of a strategy, formulation and reformulation of objectives and
orientation of hospital’s resources to achieve them.
The steps that the hospital administration must take for strategic planning and
implementation are as under:
 Formulation of objectives of the hospital
 Defining of present objectives and strategy
 Environmental appraisal to determine strengths and weaknesses of the hospital
finding out opportunities and threats
 Modifying the present strategy to bring it up to the desired level
 Implementation of the strategy
 Monitoring and control

4.4.2 Relating the Hospital to the External Environment

From your learning in the previous section you must have understood the
importance of the influence of the external environment on strategic planning
and management of a hospital. But what is external environment after all?
You may be able to appreciate that no organization can work in a watertight
compartment. It has to depend for many things on outside agencies. The role of
any organization is to obtain inputs from outside, process them and convert them
into an output. The outputs can be either services or goods. The produce of the
hospital is again utilized by the outside elements. The external environment,
then, consists of those elements which directly or indirectly influences the
functioning of the hospital.
72
The elements can be listed as under: Role of Hospital
Administration
 Material supplies

 Manpower supplies

 Supply of finance

 Consumers

 Regulatory agencies

 Political groups

 Other similar organization

 Press and other media

 Environmental Protection Activist Technology change

 Economic environment

 Social and cultural milieu

 Political, legal and ethical environment

 International environment

Some of these elements influence the organization directly and some interact
with the organization in an indirect manner. The hospital administration has to
take all these elements into account for their managerial activities of planning,
organizing, staffing and controlling. Any change in the external environment
will have a direct or indirect bearing on the functioning of the hospital. The
hospital administration might have to formulate their objectives and planning
taking all these factors into account. To be effective, a hospital administrator has
to anticipate the changes in the external environment by monitoring them on a
day-to-day basis. He has to take pro-active action to circumvent negative impact
of these changes and seize the opportunities offered by these changes. The hospital
administrators can use the various forecasting techniques available to anticipate
these changes. If the hospital administrator fails to respond to the changes in the
external environment as they occur, their hospital may lose the ground to their
competitors and may not remain viable.

4.4.3 Operational Management of the Hospital

The hospital administration has to run the hospital on a day to day basis to render
patient care, which is the primary objective of the hospital, with the personnel,
finance, accounts, technical and supportive services. In order to do this the hospital
administration has to create a functional organization that will be effective and
efficient in order to achieve the hospital objective. The structure of the hospital
need not follow any stereotyped fashion but must be responsive to the needs and
demands of the situation. Expectation of the society, concepts, and philosophies,
accepted and time-tested principles must be taken into consideration and adapted
to the prevailing environmental conditions to determine the organisational
73
Overview of Hospital structure of the hospital. The organisational structure must also take into account
Care System
the ethical aspects and standards that is expected of the hospital.
Many of the hospital’s functions are repetitive in nature. The hospital
administration must lay down certain directives to guide the various functionaries
regarding the activities to be carried out by them. When to deal with a situation
an employee must know, what he should do, how he should do it and what lie
ought to do or ought not to do. The hospital administrator has to carry out his day
to day activities efficiently and, effectively managing the hospital by laying down
the policies, procedures and rules. We shall be explaining these terminology as
under:

Policies: Everyone has to make some decisions big or small regarding his areas
of activities. When faced with such a situation no body can sit down to undertake
various steps necessary for a formal decision making. Policies are formulated to
take care of such situations. Policies are general guidelines for decision making.
In an organization policy determines the perimeters within which the employees
have to take their decision. It is the duty of top management to lay down the
organisational policies. Policies contribute to effectiveness of the organization.
It can also help to avoid conflict situation.

Procedures: Procedures are customary way of doing things in an organization. It

guides the future activities. When some kind of functions occur repeatedly, it
tells them how that activity will be performed. Sometimes this is also called
standard operating procedures. It helps new employees to perform a particular
function without much external assistance. This will also avoid variability in
performance of a function and all functionaries can perform a particular job in a
consistent manner. Essentially a procedure lays down the chronological sequence
of an action.

Rules: This lays down the actions that must be done or must not be done in a
given situation. When a rule is applied to a particular situation, there is no Scope
for discretion. Rules are usually very rigid in its interpretation and application.
This absolves a lower level employee from the burden of decision making and
the consequences of a decision provided, of course, the rules are applied correctly
to that particular situation. Rules are part of operational plan made by top level
of hospital administration. It ensures conformity and accountability for the actions
of the subordinate staff. The rules must be framed in a most explicit manner so
that there is no ambiguity in its understanding.

4.4.4 Managing Hospital Staff

You might be impressed when you visit a modern hospital by its imposing
buildings and the plethora of gadgets. But in spite of the highly technical
environment of the hospital, human element still remains the sheet anchor of
success of any hospital. A hospital employs a large number of people of different
categories with widely varying educational and technical background. Some of
them are highly skilled professionals while some others are of moderate education
and without possession of any specific skill. This calls for a very efficient degree
of personnel management.
74
 Role of Hospital
Administration

Personnel management in essence involves the following elements of function

by the hospital administration. You have already read about these in Course 1,
Block 2 in detail. But are being mentioned here in brief for highlighting the role
of hospital administration in there functions.
a) Manpower planning: A hospital in order to grow and function effectively
needs a supply of well-qualified and efficient employees in adequate numbers.
Advance planning and actions are necessary for this purpose.
b) Recruitment: In order to have adequate supply of trained manpower, the
hospital has to acquire these personnel through a process of recruitment. The
hospital may not face any difficulty in recruiting highly trained people if its image
is positive.
c) Selection: The process of selection involves mutual decision making on the
part of the hospital as well as the candidate. This is not always an easy task. The
hospital administration will always want to hire the best people. The process
begins with an ‘ application form from the candidate. Ifthere are a large number
of applicants for a particular job, an initial screening interview may be held to
short list the prospective candidates. Testing follows this. In this process the
hospital administration tries to evaluate the candidates’ skill level to determine
whether these matches with the job specification. This will be followed by
background investigation to check the genuineness of the applicant. Thereafter
in-depth selection interview may be held or may be omitted. If the candidate is
found suitable at this stage then he is subjected to a physical examination and
finally if everything is alright, a job offer is made.
d) Training: The hospital is a knowledge-based organization. A new recruit
needs to be given induction training in which he is introduced to the job. Training
is required to learn new techniques and concepts. Remedial training is most often
necessary. If the employees are found to commit mistakes and the quality of their
output is not up to the desired standard. Some retraining may have to be organized
by the hospital administration, if some of the employees are displaced to another
job so that they can be gainfully employed. For developing and employee and for
his advancement. Training has to be imparted.
e) Performance Appraisal: You will appreciate that in the interest of the
hospital, the, hospital administration will always like to know how well an
employee is performing in his current job. The process of performance appraisal
can determine this. The information obtained through performance appraisal can
be utilized for determining the level of compensation, placement of the employee
to a suitable job or for his advancement, or, in case he is performing poorly, for
75
Overview of Hospital his discharge. Performance appraisal may also indicate the need for training and
Care System
development. The hospital administration must very carefully determine the
procedure of performance appraisal. because quite often it is a starting point of
employee dissatisfaction. The methods used should be, as far as practicable,
objective and without any bias.
f) Grievance Procedure: You shall agree that in any organization employees
will have occasionally some grievances. These usually have a snowballing effect
and may degenerate into a major conflict situation between the management and
the employees. It is, therefore, imperative that the hospital administration must
install an appropriate, functional and active grievance procedure through which
the employees can seek redress of their grievances. Grievance procedure is a
formal method mutually agreed upon by the management and the union. It is a
step-by-step procedure that specifies the persons to whom the grievances can be
referred and also the time limit for solving the referred grievance. It also indicates
the way the grievance should be submitted to different stages of its handling.
g) Discipline: The hospital administration while recruiting people will try their
best to recruit people who will be well disciplined. Yet there will be occasions
when there will be a need to discipline employees. Self-discipline is the best
discipline and it is an attitude of mind. The hospital administration should lay
down rules and regulations that the employees can perceive as just and reasonable.
In such cases the employees will usually follow them unhesitatingly. Though it is
always best to avoid in discipline, yet sometimes it will be unavoidable. The
penalties imposed should be commensurate with the degree of indiscipline. It is
preferable to have increasingly severe awards of punishments each time a person
is successively disciplined. The penalties can take the forms of oral warnings,
written warnings, stoppage of increment in salary, withholding promotion if due,
disciplinary layoff, demotion and finally discharge. The hospital administration
must be very cautious while disciplining an employee. It should be immediate,
with warning, consistent and impersonal.
h) Wage and Salary Administration: Hospital administration must make
special endeavor for wage and salary administration. With a proper salary
administration, the hospital will be able to recruit satisfactory employees. It is a
motivational tool and it can reduce the incidence of personnel grievances. The
hospital administration has to take appropriate measures for salary and wage
administration, as it is the largest item of hospital cost. There are four closely
related items of wage and salary administration. These are, wage and salary survey
which will indicate the general pay level in similar organizations, job evaluation
which will relate wages and jobs within the organization, merit rating in which
new employees start at a base salary and gradually progress to higher scales
through merit rating and, lastly, incentives in which for a normal level of
productivity the employees get a base level of salary and if the productivity is
higher, the employees will get an incentive bonus. In corporate hospitals, most of
the consultants are paid a percentage of the earnings from the patients treated by
them. This is also an incentive scheme that motivates the consultants for higher
productivity.
i) Collective bargaining: Hospital administration has to sit many times at the
negotiating table with the representatives of the workers’ union. Collective
76
bargaining is an important process in industrial relation where the management Role of Hospital
Administration
and the union directly negotiate the terms and conditions of employment or
working environment or any other issues affecting the employees. Collective
bargaining is an important means of maintaining industrial peace. The
management must recognize the rights of the union to negotiate and both the
parties must have trust and confidence for each other. In this regard attitude of
the management and the union towards each other is important.

4.4.5 Managing Hospital Materials

Materials cost almost fifty per cent of hospital budget. There are two types of
cost: cost of materials and cost on materials. It is necessary for the hospital
administration to reduce these costs. The scientific materials management
techniques can address these aspects. Materials management involves as a single
responsibility the systematic flow and control of materials from identification of
need through customer delivery. Objective of materials management in a hospital
is to render better service to the patients and improve profitability by reducing
costs. Stock out of a vital drug may cost the life of a patient. This cost cannot be
measured in monetary terms. The hospital administration, therefore, has an added
responsibility in comparison to other organizations the efficient management of
materials in a hospital. The materials management functions include:
a) Developing specification for materials
b) Materials planning and programming
c) Procuring materials through centralized purchasing
d) Receiving
e) Distribution
f) Inventory control
g) Storage and preservation
h) Transportation
i) Materials handling
j) Disposal of scrap and obsolete materials, equipment and surplus material.
The hospital administration has to lay down various policies and procedures for
purchasing, distribution and disposal. Prevention of theft and loss of material are
important managerial functions. The hospital administration must take measures
to reduce these menaces. Thefts can be in the form of manipulating various records.
Laying down appropriate policies and procedures can reduce these.

4.4.6 Managing Hospital Finance

Hospital financial management is an important area of functioning of hospital
administration. For this purpose various tools and techniques are available to the
hospital administration. The first step in the financial control process is the
programming, Programming is the process of deciding on the nature and size of
the programme that are to be undertaken in order to achieve the hospital’s goal.
The most widely known programming system in non-profit organization is PPBS 77
Overview of Hospital — Planning — Programming — Budgeting System. The tool that can be used to
Care System
evaluate a programme is Benefit/Cost Analysis. The other tools that are used for
financial management are various kinds of budgets — Capital Budget, Cash
Budget, Operating Budget etc.
The financial management control process involves two further activities: control
of operations and measurement of output. In the activity of control of operations,
control is exercised on spending, on adding personnel or spending on material.
The financial control is to see that the organization achieves its stated objectives.
In the output measure, three aspects are seen. These are results measure that is a
measure of output expressed in terms that are related to the hospital’s objectives,
productivity measure and social indicators.
The hospital administrator should be able to understand various financial
statements like a balance sheet, profit and loss account and so on. The hospital
must constantly monitor the financial health of the hospital in order to ensure its
survivability. For this purpose various tools are used which are basically
determination of ratios. Some of these are: Operating margin (price level adjusted)
ratio, Non-operating revenue ratio, Return on equity, Liquidity ratio, Long-term
debt to equity, Total asset turnover, Days in patient account receivable and so on.

4.4.7 Managing Hospital Information

Information is an essential ingredient of decision making. Information is necessary
at various levels to function effectively. Hospital administration has to design an
information system that can deliver quality information which is timely and
accurate. The essential functions to be included in the hospital information system
are Medical functions, Administrative functions and financial functions.
These three broad functional areas can further be subdivided into several levels.
These are:
a) Transaction Processing. Examples are: order entry of drugs, diet, linen,
census, patient billing, inventory control, treatment scheduling for
operation theatre. physiotherapy, special procedures and so on.
b) Control Function. Examples are: medical care evaluation, occupancy
and patient mix, surveillance of hospital infection, cost control
c) Operational Planning. These may include: staff education, patient care
planning, discharge planning, purchase plans, budgeting.
d) Strategic Planning. Examples are: services to be offered, levels and
sophistication of patient care to be planned, hospital image improvement
plan.
In the management of information one of the most important aspect to be looked
into by the hospital administration is the medical records department. This is the
most important source of hospital information.

4.4.8 Maintaining Relationship with the Medical Staff

The hospital administration has to maintain a cordial relationship with the medical
78 staff. The objective of both the groups is that of rendering better patient care. The
medical staff directly delivers the patient care whereas the hospital administration Role of Hospital
Administration
provides the facilities and resources for this purpose. Both the groups must work
within an environment of mutual trust respect and confidence.
However, occasionally, some problem does arise. These are mainly due to
misunderstanding due primarily to poor communication. The hospital
administration has to keep the medical staff informed about the organisational
policies and changes whenever these occur. The situation in which both the groups
function has a potential for conflict. The medical staff is concerned for the patients
and for their own economic interest. The administration is concerned for the
entire hospital, the employees and the economic health of the hospital. However,
the medical staff who understands the reasons for the policy changes will be
more appreciative of the constraints of the hospital administration and will be
more supportive. The hospital administration, therefore, must freely and frankly
communicate with the medical staff, listen to their problems patiently and sincerely
try to solve them. If there is no apparent solution immediately available, then
that fact must be explained to the medical staff. The medical staff regards the
administration as problem solver, as provider of resources, as catalytic agents, as
facilitators and holds them responsible and accountable for any deficiency in
these functions. You will appreciate that as the medical staff is the agency through
which the medical care is delivered a harmonious relationship has to be maintained
with them by the hospital administration.

4.4.9 Maintaining Relationship with the Public

A hospital is a community institution. For its survival it needs support from the
community. It is necessary for the hospital administration to know the needs,
demands and aspiration of the public. Hospital also has to constantly endeavour
to inform the public that what it is doing for them and they should expect from
the hospital. Essentially, management of relationship with the public has four
primary aspects. These are:
a) To know about public desires and aspirations
b) Educating the public about what it should desire
c) Arranging satisfactory contact between public and the hospital and
d) Informing the public about what the hospital is doing
The top hospital administration has to take it upon themselves, the public relation
activities as one of their primary responsibilities. It should be undertaken as a
planned process and as an on going activity.

4.4.10 Risk Management of the Hospital

If you open a newspaper in the morning, quite often you may come across
news item pertaining to hospital. These may be consisting of reports regarding
death of a patient due to negligence on the part of the hospital, damage to the
hospital property due to vandalism by the public, hospital having been asked to
pay huge compensation to a patient by a consumer forum. There may be other
kind of damage to the hospital property by fire or flood or any by other natural
calamity.
79
Overview of Hospital Like any other organization a hospital is also exposed to many kinds of risks. In
Care System
a hospital there is an added element of patients. Due to increased awareness of
the public, the hospitals many times find themselves in an embarrassing situation
due to certain faults in their functioning. Hospital administration, therefore, must
take all measures, firstly, to avoid risk and then to minimize the effects of the
risks. The hospital administration must have a very positive outlook towards the
risk management. This positive attitude will percolate to the supervisory staff
and down to the lower level employees. Security and safety consciousness then
can be ensured.

4.4.11 Managing Ethics and Code of Conduct

Ethical behavior is necessary throughout the medical practice. Though most of
the tenets of ethical practice are outside the preview of law, the guiding principle
is welfare of the patients. It is basically a self-imposed responsibility of the medical
profession. The hospital administration has to maintain an ethical environment
in the hospital so that patient’s interests are served. The hospital administration
has to lay down appropriate rules, regulations, policies and procedures for
everyone to follow. The broad areas that need to be looked into are: Consent of
the patient to disclose information, Right to information of patients, Ethical
relation of a doctor with other doctors and so on. All doctors know the
source of medical ethics originated in the Hippocratic oath. Besides these, ethical
codes govern the experiment and research involving human subjects. Helsinki
declaration, in which most of the nations including India are signatory, lays down
the conditions and procedure to conduct such research.

4.4.12 Managing Legal and Statutory Responsibilities

Since independence various legislations have been enacted by the parliament in
India to govern the functioning of the health care institutions. Even before
independence many such legislations were in force. These legislations cover a
wide range of topics including health, manpower, disease control, family health,
reproduction, mental health, food safety, control, manufacture and safety of drugs,
transplantation of human organ, pollution control and disposal of biomedical
waste. The sources of these controlling legislations are as under:
a) Constitution of India (1950)
b) Indian Penal Code (1860)
c) Medical Council Act (1956)
d) Consumer Protection Act (1 986)
e) Transplantation of Human Organ Act (1 994)
f) Biomedical Wastes (Management & Handling) Rules (1998)
It is mandatory that the hospital function within the boundaries of these acts.
Hospital administration has a duty to lay down the provisions of this legislation
in the policy and procedure manual of the hospital. In addition, hospital
administration has to train the functionaries about tiles laws so that no violation
occurs. Moreover, they have to install a monitoring mechanism to watch for any
probable breach and take remedial measures before they occur.
80
4.4.13 Managing Marketing Responsibilities Role of Hospital
Administration
Marketing means that a party receives something of value from another party in
exchange of something of value. In health services a patient receives medical
care for which he pays a charge. This payment may be paid directly by him or
indirectly by another agency. Today’s hospital function in a competitive
environment. Competition has a positive impact on health care delivery system.
It helps in reducing cost; services will be more efficient and provides some impetus
to improve quality. You might recall that in an earlier section we have discussed
strategic planning and management of hospitals to achieve hospitals mission.
Marketing audit helps the hospital administration in diagnosing the external
environment and then formulating objectives for implementation.
The marketing responsibility though may be entrusted to the marketing department
manned by personnel with marketing background or the responsibility may be
given to an outside consultant, yet the top management has the responsibility for
planning, development and implementation of marketing activities.
Marketing involves the management of four factors essential to the delivery of
health care.
These are:
a) Product: The range, variety, sophistication and level of services to be
offered is the product.
b) Place: How and where the services will be offered - hours, outpatient,
inpatient or domiciliary services.
c) Price: This includes the price paid by the patient either directly or
indirectly or this may include other intangible costs the patients incur.
d) Promotion: This is the mechanism of making the patient aware of the
services offered by the hospital and also involves aspects to create an
interest in him to use the services whenever needed by him or by his
friends.
Thus effective marketing strategy will ensure proper utilization of the hospital’s
facilities and maintain its competitiveness.

4.4.14 Quality Management of the Hospital Services

Hospital administration is duty bound to provide high quality services to their
clientele. This can be achieved through a programme of total quality management
and continuous quality improvement. This is an all-pervading function involving
employees, their training, development, and motivation. Customer focus is the
prime requirement for this quality management programme. Leadership and
commitment of the top hospital management to this cause is essential for this
programme to succeed. The hospital administration has to take an active part in
and be a driving force for the programme. The quality management is a planned
and continuous activity for an organization. The top management must fully
support actively the quality management programme. It should not degenerate
into a lip service and genuine interest, active support and participation by the top
management of the hospital will be necessary.
81
Overview of Hospital
Care System Check Your Progress 2
1) List the seven steps for strategic planning.
2) What are the different aspects that hospital administration looks into for
managing hospital employees.
3) Enumerate the different management responsibilities for operational
management of the hospital.
4) List the four factors that need to be considered for health care marketing.

4.5 ROLE TOWARDS COMMUNITY

If you recall the definition of a hospital as provided by the World Health
Organization lit will be immediately clear to you that a hospital besides being a
medical organization is also asocial institution. A hospital is meant to serve the
health needs of the community in which it is located. A hospital is a part of total
health care delivery system providing comprehensive health care. A large number
of people and their families get directly or indirectly involved with the hospital
physically, emotionally and financially either as a patient, as a supplier of goods
and services or simply may be as visitors. A hospital must be able to fulfill the
needs and aspiration of people. The hospital administration has to fulfill this
obligation and responsibility in shaping the hospital as a truly community hospital
by orienting its services towards that end.

4.5.1 Obtaining Community Participation

In order to fulfill its role effectively full community participation is essential.
Without active support from the community no hospital can survive. The hospital
needs moral and financial support from the community to be able to discharge its
duties properly. The hospital administration has to inform the community about
this need. The hospital administration has to take a positive interest in the
improvement of the community pertaining to health related issues. His support
and leadership towards this cause is quite necessary.

4.5.2 Integrating the Hospital with other Health Care

Institutions
Health of the community cannot be viewed as fragmented efforts being undertaken
by the various agencies. Health care delivery is a continuum-in which hospital
occupies a very prominent and most visible part. In a community there will be
other health care institutions, public health laboratories, private practitioners and
others. A hospital occupies a pivotal position and has a leadership role to perform.
It is the responsibility of the hospital administration to integrate the services of
these isolated agencies and coordinate their efforts for providing a comprehensive
and need based health care with universal coverage, accessibility and affordability.

4.5.3 Supporting Primary Care

Primary care is the method by which health need of the community can be met to
a large extent. Primary care is basically provided mostly by the community based
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health care institutions other than the hospital. But without the active support of Role of Hospital
Administration
the hospital primary care cannot succeed. Hospital is a repository of all state of
the art medical knowledge.
Hospital can provide necessary expertise to the other’ care providing organizations.
Hospital call also guide and direct these institutions regarding the best way to
deliver medical care. The hospital administration, apart from providing the
technical expertise can also support primary care activity of other institutions by
looking after their need of manpower, equipment and supplies.

4.5.4 Providing Extramural Services

We may again recall the role of hospital as enunciated by the World Health
Organization in which the world body while defining the hospital has mentioned
that the services of the hospital reach out to the community in their home
environment. In fulfilling this commitment the hospitals do hold various kinds
of medical camps. Eye camps organized by the hospitals are common examples.
In addition to these medical camps, the hospital can organize domiciliary care,
immunization camps and the like. The hospital must have a positive outlook
towards these extramural services so that necessary resources can be provided
for these ‘purposes.

Check Your Progress 3

1) How hospital administration fulfils its role towards community.
2) What hospital administration can’ do to support primary care.

4.6 ATTRIBUTES, QUALITY AND SKILLS OF

AHOSPITAL ADMINISTRATOR
Role of Hospital Administration

Hospital administration is a challenging profession. By now you must have

appreciated the formidable and diverse functions that a hospital administrator is
called upon to perform. Atypical hospital administrator in India is a medical
graduate with a postgraduate degree in hospital administration. Currently about
six medical institutions are offering doctoral courses, which is at par with any
other postgraduate medical qualification and is recognized by the Medical Council
of India. In addition, many management and other institutions area also offering
postgraduate courses for graduates from all other streams.

The All India Council of Technical Education recognizes these courses. In some
countries, particularly in USA, a hospital administrator is typically a non-medical
person. According to Dr. J. R. Mc Gibony, Hospital Consultant, this was due
primarily to the shortage of doctors. The training involves inclusion of subject
matters like social, behavioral and management sciences, public health, principles
of medical care and application of administrative concepts and skills in health
care organizations. Whatever be the feeder channel for the profession of hospital
administration, certain attributes are necessary for efficient performance of their
ob. 83
Overview of Hospital These are: a successful past record of efficient and effective management, ability
Care System
to direct the subordinates to achieve the organisational objectives, a high degree
of conceptual skills, mental robustness, plenty of tact and ability to withstand
adverse criticism. The most important skills are summarized as under:

a) Leadership skills: A hospital administrator must have leadership skill. He

should be able to influence people to act with zeal and enthusiasm to achieve
organisational goal.
b) Interpersonal skills: Hospital is a labour-intensive organization. .A congenial
environment is conducive of productivity, satisfaction and happiness. A hospital
administrator must have good interpersonal skill to create such an environment.
At the core of interpersonal relationship is communication and empathy.
c) Conflict management skills: In an organization like a hospital where
diversity of objectives is the norms, quite often conflict situation arises. It is
argued that a certain level of conflict is essential for any organization to remain
vibrant, dynamic and responsive. This is functional conflict and call be utilized
by managers to the benefit of the organization. A hospital administrator must be
able to manage conflict well and should not allow it to become dysfunctional.
d) Negotiating skill: A hospital administrator is called upon to negotiate quite
often on various matters pertaining to his organization. Negotiation means a
process in which two or more parties exchange goods or services and to arrive at
a common meeting point. It has to be carried out in an atmosphere of cordiality
and at the end both the parties must have a feeling of winning. In a hospital
negotiation is required to be done with the suppliers of various materials. A
collective bargaining is also a form of negotiation between the management and
the workers union.

Check Your Progress 4

1) What are the attributes to be a successful hospital administrator?
2) List the four important skills for a hospital administrator.

4.7 LET US SUM UP

In this unit you have learnt about the role of a hospital administrator and his
attributes, qualities and skill requirement. You have learnt that in his role towards
patient the hospital administrator should have a better understanding of the
84 patients. He should create a friendly atmosphere where patients feel welcome.
His role towards patient also includes looking after the physical, emotional and Role of Hospital
Administration
clinical needs of the patients. You have also learnt about the role of hospital
administration towards the organization. He has to lead the hospital towards the
future long-term goal of the hospital to serve its mission and ensure its survival
and competitiveness. This is done through strategic management techniques.
In the day-to-day operational management of the hospital, he has to manage the
resources of the hospital to produce a high quality medical care service. The
resource the hospital administrator has to manage includes personnel, materials,
finance and information.
His other routine job includes public relation activities, maintaining relationship
with medical staff, risk management, marketing management and maintaining
an ethical environment. He also has to abide by the various statutory and legal
provisions for functioning of the hospital. Total quality management and
continuous quality improvement calls for a commitment from the top level of
hospital administration on an ongoing basis. You have also learnt that hospital is
a community organization and a hospital administrator has to ensure community
participation that is necessary for moral and financial support of the hospital. In
his role towards community, supporting primary care and provisioning of
extramural services calls for a positive attitude on his part.
Towards the end you have learnt that a hospital administrator has to have attributes
of a highly skilled professional qualification and good past track record. The
major skills required are leadership skill, interpersonal skill, conflict resolution
skill and negotiating skill.

4.8 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1
1) a) Creation of a friendly environment
b) Looking after patients’ physical needs.
c) Looking after patients’ emotional needs
d) Looking after patients’ clinical needs
e) Obtaining patient satisfaction
f) Patient education
2) a) Dietary services
b) Behavior of nurses
c) Environmental condition of the hospital
3) Physical comfort with proper and comfortable beds, environmental control
with temperature, humidity and lighting. Other physical needs include
arrangement for bathing, feeding and sanitation.
4) a) Unfamiliarity with hospital surroundings
b) Loss of independence
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Overview of Hospital c) Separation from family
Care System
d) Financial problems
e) Isolation from the people
f) Lack of information
g) Fear of death and
h) Anxiety with the treatment modalities and attitude of the care givers.
Check Your Progress 2
1) a) Formulation of objectives
b) Defining present objectives and strategy
c) Environmental appraisal to determine strengths and weakness of the
hospital
d) Finding out opportunities and threats
e) Modifying the present strategy to bring it up t he desired level
f) Implementation of the strategy
g) Monitoring and control
2) a) Manpower planning
b) Recruitment
c) Selection
d) Training
e) Performance appraisal
f) Grievance procedure
g) Discipline
h) Salary and wage administration
i) Collective bargaining
3) a) Managing hospital employees
b) Managing hospital’s materials
c) Managing hospital finance
d) Managing hospital information
e) Maintaining relationship with the medical staff
f) Maintaining relationship with public
g) Hospital risk management
h) Managing ethics and code of conduct
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 i) Managing legal and statutory responsibilities Role of Hospital
Administration
j) Managing marketing responsibilities
k) Quality management of the hospital services
4) a) Product
b) Place
c) Price
d) Promotion
Check Your Progress 3
1) The hospital orients its services keeping the community need, demand and
aspiration in mind. A positive interest towards improvement of community
health on the part of the hospital administrator helps achieving community
participation. Integration of services of all the other heath institutions
providing health care of only some aspects of total health care of the
community is essential. The hospital needs to support the primary care
activities. Lastly, the hospital provides various extramural services.
2) The hospital supports primary care activities by providing leadership,
expertise, material and personnel resources.
Check Your Progress 4
1) Hospital administrator should be a man of experience with a post graduate
degree or diploma in hospital administration. The hospital administrator
should possess a high degree of conceptual skill, mental robustness, tact and
ability to withstand frequent adverse criticism.
2) a) Leadership skills
b) Interpersonal skill
c) Conflict resolution skills

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Overview of Hospital
Care System

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