Final 41
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Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
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Apollo Hospitals, Hyderabad.
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INTRODUCTION In the last two decades or so, hospitals around the world have become a dynamic industry, which is expanding and becoming more complex with the passage of time. Technological advances have become the order of the day and with the increased number of sophisticated equipments being used in the day-to-day activities for providing quality healthcare maintenance of these equipments and different plants is posing a big challenge for the hospital authority. This challenge, has given rise to the need of developing a professional team and the maintenance department whose prime responsibility is to ensure smooth functioning of the central plant; generation, storage and distribution of steam, cold and hot water; refrigeration; ventilation; air-conditioning and electricity. Besides adequate capacity, reliability is a major concern , primarily because of the many life saving services provided by the hospital . the activities of the engineering department include highly specialized services which should be determined by the specialist engineers, consultants and architects of the planning and design team. The engineering and maintenance department is charged with the responsibility for ensuring safe and economical operation and maintenance of hospital facilities and expensive equipment. The department should be capable of providing technical and management support to the hospital.
OBJECTIVES To adopt a planned procedure for checking and maintaining all equipments that comes under the list of in-house maintenance as well as external agencies though annual maintenance contract.
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LOCATION AND ACCESSIBILITY The department is located in the cellar at the G2 level. The other departments located in the floor are housekeeping, stores and pharmacy stores. Most of the equipments under the control of this department are located either in the same floor or outside the hospital building. Since the department’s service is not obtained by coming to the department physically the location is not a matter of great concern. But the location of the department of the location cannot be considered safe as in case of any eventuality like accidents the whole building will be in potential danger.
UNITS UNDER THE DEPARTMENT A/C Plant Boilers Central Gas Supply Scheme Water supply Autoclaves Electrical Substation Water Purification Plant Plumbing, electrical works and carpentry
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Apollo Hospitals, Hyderabad.
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Apollo Hospitals, Hyderabad.
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JOB DESCRIPTIONS CHIEF ENGINEER •
Fixing the target for the department
•
Planning, scheduling and controlling jobs to be done by the department and coordinating with other departments in achieving the above goals.
•
Responsible for major renovations like building and expanding the existing area.
•
Looking for negotiations and approving the technical aspect of the new equipment and also responsible for approving installations.
•
Responsible for day-to-day ongoing activities of the department.
•
Responsible for approving the plans of preventive maintenance.
JUNIOR ENGINEER The department has two junior engineers. One is responsible for civil works and the other for mechanical and electrical works. They are responsible for •
Planning and preparing the breakdown estimates
•
Earliest possible execution of jobs.
•
Material indenting and follow up with the purchase department and the related contractor.
SUPERVISORS •
Correspondence, execution and follow up of work plan by engineers with the help of the workers.
•
Supervisor is responsible for the execution of the preventive maintenance schedule.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
BOILER OPERATORS •
Responsible for preventive maintenance, upkeep and routine operation of the boiler plant.
•
Checking proper supply of hot water and steam to required place.
ELECTRICIAN •
Responsible for proper functioning of generators, panel boards in his shift
•
Preventive maintenance of power and lighting distribution boards.
•
Responsible for the prevention of general breakdown.
A/C PLANT OPERATOR •
Responsible for proper functioning of the air conditioning plant and the related equipments like window A/C, AHUs, FCUs, split units, package units and deep freezers.
PLUMBER •
Responsible for proper functioning of pumps, supply of water to all areas of the hospital.
•
Check tank levels for routine fill and quantity of water being supplied from the outside suppliers.
CGSS ATTENDER •
Responsible for ensuring the constant supply of oxygen and nitrous oxide to operation theatres as well as to other areas as and when required.
•
Responsible for placing empty cylinders on time.
LIFT OPERATORS
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Responsible to provide continuous and pleasant service to patients through perfect operation of lifts and to ensure that the lift is in presentable status functionally and aesthetically.
PCC TECHNICIAN •
Responsible for the repairs of air conditioning, mechanical and electrical works and the minor carpentry jobs in patient areas.
FITTER •
Responsible for the general mechanical fitting and fabrication work in the department.
DESK CLERK •
Responsible for registering complaints from the different departments and informing the concerned person through the supervisor and also helping the department in other clerical works.
TYPES OF MAINTENANCE WORKS PREVENTIVE MAINTENANCE: Maintenance works on a piece of equipment on a planned schedule to prevent breakdown is called preventive maintenance. The work consists of inspection, adjustment, and calibration, cleaning, repairs e.t.c. Preventive maintenance is carried out periodically by all sections of the department. The schedules are prepared by the engineers and maintained in each section. There are daily, weekly, monthly, bimonthly, quarterly, OJT Team A, I Batch
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annually conducted preventive maintenance schedules. This depends on the nature of the equipment.
EMERGENCY AND ROUTINE MAINTENANCE: Immediate repair of vital piece equipment is known as emergency maintenance. While maintenance on routine basis, which can be classified under non-urgent repairs such as replacing of tiles, e.t.c, which can wait until scheduling is possible, is called routine maintenance. Complaints pertaining to lighting, air conditioning and plumbing are brought to the notice of the maintenance department and is done through job orders from various departments, which is passed on to the PCC. In case of breakdown of equipment serving a particular department, the time required for the repair of the equipment is intimated to the H.O.D. of the concerned department so that the H.O.D can plan out his work accordingly. If the equipment is under service contract, the supplier is informed of the breakdown and the complaint is entered in the breakdown register. On receipt of the job order, verbal or telephonic complaint the desk clerk or the supervisor incharge makes sure that the maintenance work is done through the concerned department. When the job is completed the job order is handed over to the desk clerk, which is an indicator that the maintenance work has been done. CONTRACT MAINTENANCE: Under this system repair of equipment is done through contract labour and materials under annual maintenance agreements. This can be done either on a routine basis or on a piece of equipment under service contract. Many of the costly equipment come with a warranty for a particular period and after the expiry of the warranty normally a contract for maintenance is entered with the supplier.
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AIR CONDITIONING SYSTEM Air conditioning is required in a hospital to achieve a certain level of temperature, humidity, filtration and circulation. Areas like operating rooms, ICUs, nurseries are some of the areas which require air conditioning. Sophisticated medical equipments are sensitive to temperature and humidity, which if not maintained can affect the performance of the equipment. Air conditioning system ranges from a battery of small self contained window units to complex central air conditioning system. The following are the air conditioning systems under the control of the department: •
Central A/C Plant
•
FCU
•
AHU
•
Package Units
•
Window Units
The basic principle of an A/C is cooling using a refrigerant. Air in the room is taken into the A/C unit and exposed to a refrigerant medium that takes up the heat and then the cool air is returned back to the room. The main components involved in the process are •
Compressor
•
Condenser
•
Refrigerant medium – gas or water
•
Inlet and outlet pipes
•
Ducting system
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CENTRAL A/C PLANT: The central A/C plant has a large capacity compressor that pumps refrigerant gas to the condenser. The refrigerant gas is cooled by the water-cooling system and is condensed to liquid form. The liquid absorbs heat from the water coming from the various units at the cooling tower and again is converted to gas. The gas is then circulated back to the compressor. This is continuous cycle. Temperature at the cooing tower is maintained at Ο
13 C. The chilled water goes back to the FCUs and is pumped to the various rooms and wards. The department has seven compressors with a total capacity of 620 tons.
Blue Star
100T
Kirloskar (2)
80T each
Accel (2)
80T each
Dunham Bush
100T
VAM Thermax
100T
The central A/C plant caters to the need of all single and semi private rooms.
FCUs: Ο
The FCUs maintain room temperature at 23 C. The FCUs has an A/C grill, filter, coil system over which chilled water runs cooling air and releasing it back into the room.
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AHUs: The AHUs handle air in areas where intermixing of air of two different areas needs to be avoided to control hospital-acquired infection. The AHUs have a ducting system that brings air from the respective areas, which pass through filters, and is cooled by blowing the air over water coolants. There are eight AHUs in the second floor terrace, which cater to the need of the Ots and the ICUs. The AHUs caters to
All OTs - OT1 and OT2 have single AHU and all other have one AHU each. CT Scan Nephrology and Burn Unit MD’s office CT post and SICU
PACKAGE UNIT: These units are used in areas where low temperatures have to be maintained than that provided by the central plant. The package unit has two compressors, one located at the required area, which is connected to the other at the second floor terrace through ducting system.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
WINDOW UNITS: Window units are wall mounted and self-contained units that have components in one cabinet. There are around 40 such units. Some of the areas, which the window units serve, are •
Blood bank
•
Casualty
•
Cath Lab
•
EDP
•
Physiotherapy Labs
•
MICU
•
ECG
•
TMT
•
GM Operations
In addition there are split A/Cs which caters to the need of •
All Laboratories
•
MICU
•
Super deluxe rooms
•
Eye block
•
IHC
•
Minor OTs
•
Gamma Camera Room
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Administrative Block
ELECTRICAL SUPPLY SYSTEM Electrical energy is an essential source of power, the pivot which almost every function of the hospital revolves, and the system is increasingly becoming more demanding,
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complex and crucial. This is partly because of the specialized and medical equipments used for diagnosis. Treatment and rehabilitation of patients is partly because of the larger load of power needed in today’s hospitals. In the electrical system the main concern of the design team and the hospital engineer is the power distribution system, which, it is rightly said, is the electrical lifeline of the hospital. There are also other concerns like an adequate and dependable supply.
The substation of the hospital is located behind the main block opposite to the maintenance area. The entire area is covered with 2 – 3 inch layer of gravel to drain off the rainwater in order to prevent electrical short circuits. The area is fenced and has security personnel posted round the clock. The objective of having a substation is to have uninterrupted power supply.
The hospital receives power from AP TRANSCO, Jubilee hills. In case of shortage or interruption Chandrayangutta substation fulfils the requirement. The hospital has two transformers of 1000KV capacity each. The voltage supply to the transformer is brought down to 220 volts. The power enters into two different areas of the hospital through two separate Control panels, one of which is the circuit board from where electricity is distributed to the main areas like the OTs, ICUs, CT post and other areas. The second line provides electricity in case of breakdown. In case of trip downs there is a remote control panel, which is charged by a set of batteries, which automatically restart the panel or the transformer.
The hospital has two generators of Kirloskar and Jyoti make. The load to be placed on the system has to be carefully determined. The load can be transferred from the direct power source either manually or automatically. Jyoti is on manual transfer mode whereas
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Kirloskar is on automatic transfer mode wherein the electricity is restored within seven minutes of power failure.
The consumption is monitored continuously by the technical staff comprising of one electrician, one assistant engineer, and one supervisor. When the load is high the equipment not in use are shut down and all A/Cs and lights not required are shut down.
The safety measure that are followed by the department are Substation is covered with gravel to prevent electrical short circuits The main station flooring is done with rubber. Fire extinguishers are placed at strategic points.
WATER SUPPLY SYSTEM Water is one of the critically important utilities in a hospital, yet its supply is often taken for granted. Much of the hospital’s engineering service is concerned with installing, repairing and maintaining the systems that deliver utilities and services, water being one of them in a functional continuing and safe manner. The hospital requires a copious supply of water. While the nation’s population and demand for water is increasing, the country’s water supply is diminishing. This puts a tremendous pressure on the ability of the administrators and hospital engineers to supply pure and safe water to the hospital. The water flow from Krishna Nagar is first collected at the pump house near Andhra Bank. The pump house receives 2 lakhs gallons of water per day. From the pump house
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water is transferred to the underground tank near the cancer block. The water passes through the process of filtration before being pumped to eight overhead tanks present at the main building having a capacity of 1,50,000 litres. Water supply to the administrative block and research foundation building comes from the cancer block. There are four plumbers who support the junior engineer in maintaining a proper supply of water. Monthly microbiological tests are performed to ascertain the safety of the water. Effluent water from the bathrooms and other used water outlets are pumped into the water effluent plant. The plant contains two chambers where sludge is separated from the water using oxygen. Fiber raisins are added to remove the bacterial content. Purified water from the plant is sent to the tube settlers. The fresh water that comes out after this process is used for gardening, boiler, A/C plant e.t.c. Samples of this water are tested regularly to ascertain the purity.
TRANSPORT SYSTEM There is one patient lift in the cancer block and two in the main building adjacent to the ramps. There is also a service lift near the staircase. The maintenance of these lifts is under contract with Kone company who have installed the lift. The minor problems are looked after by the department and in case of severe problems the contract company is summoned. The company people also do a routine maintenance of the lifts. There is a operator in every shift who mans the lift and reports to the front office manager.
BOILER The two boilers used are oil fired, coil type automatically packed manufactured by Thermax with a capacity of 600 Kg/Hr and only one is used at any particular time whereas the other is standby. The total running time of the boiler is around 11 – 12 hours per day. The boiler is used for the purpose of supplying hot water to patients, sterilization
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in CSSD, cooking, washing and sterilization in F&B and washing in the laundry. The boiler uses 540 litres of water per hour and the efficiency of the steam generated is 80%. Ο
The pressure of the steam generated is 15 kg/cm2 and the temperature is 180 C but the Ο
hot water sent to the patient room has temperature of 40 - 50 C. Water softening is done once in every two days and infection control testing is done every month. The department does all major and minor maintenance. There are four boiler operators one in every shift, they report to the H.O.D. maintenance. CENTRAL GAS SUPPLY SYSTEM The CGSS provides medical gases and vacuum at required points in the hospital viz. OTs, ICUs and patient bedside in the rooms and wards. The plant is located in the G2 level of the hospital.
OXYGEN: The company called Oxyco supplies the major portion of the oxygen required by the hospital. The daily consumption of oxygen is between 8 – 8.5 kg/ hr. An average of two trailers each containing 52 cylinders is consumed daily. Several oxygen cylinders are placed at wards and other strategic points of the hospital to meet any emergency requirement. In addition to the supply by Oxyco the hospital also produces its own oxygen. Oxygen pipes are yellow in colour and are available at the bedside, which supplies liquid oxygen.
NITROUS OXIDE: The average consumption per day is 450 cubic meters. Each cylinder contains 7.1 cubic meters. Pressure is to be maintained at 40 – 60 lbs. 60 portable cylinders for OT and ICU are used. BOC India Limited is the major supplier of nitrous oxide.
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MEDICAL AIR: There are two medical air compressors; one is used whereas the other is standby. The medical air generated is supplied to OTs, Casualty, Nephrology, Burns Unit, Lithoscopy and CT scan area. There are three personnel in the department and only one person is posted in every shift. There is the system of returnable gate pass for all the cylinders. Preventive maintenance is done for the compressor on a monthly basis. Bedside vacuum units are also checked once in a month. Valves, connection points and pressure gauges are checked every week. AUTOCLAVE The hospital has autoclaves in the laboratories and CSSD. In CSSD there is one horizontal high-pressure steam sterilizer and one sterilizer in the Laboratory. The concerned department does weekly microbial tests of efficiency. Maintenance department does bimonthly check of the pressure gauge, valves, nuts and gaskets etc.
PATIENT CARE CELL The PCC is located on the first floor beside guest relations. The daily work schedule of the department is to receive •
Complaint calls and check back on them
•
Daily rounds to all rooms and ICUs
•
Accept job order and attend to them
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There are 2 – 3 members working in three shifts. Every floor has one incharge from PCC. They take only written complaints. The usual complaint form contains the following. Room No Nature of complaint Complaint receiving time Completing time Material used Signature of the technician There is a logbook, separate daily report register, ICU and OT register and material requisition voucher book. IMPORTANT DOCUMENTS MAINTAINED BY THE DEPARTMENT •
Working instruction for various equipments
•
Breakdown register
•
Complaint register
•
Calibration record
•
Preventive maintenance schedule for A/C Plant, plumbing, boiler plant, electrical and oxygen plant
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Daily status report
•
Electrical safety test register
•
Service record
TATA HONEYWELL ENERGY MANAGEMENT
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Apollo Hospital, Hyderabad is the first hospital in India to install state of art energy management and building automation systems in collaboration with Tata Honeywell Limited (THL). The company is in performance contract with the hospital to achieve energy efficient and eco friendly environment. The energy management system developed in collaboration with THL and the contract is drawn out for eight years. The performance contract allows the consumer to increasingly save on energy and build up on infrastructure without out of pocket capital investment at the same time with guaranteed success. BENEFITS: •
Increase in competency and profitability
•
No capital investment
•
Scientific analysis
•
Positive or neutral cash flow
•
Efficient utilization of resources
•
Positive environmental impact
•
Training, monitoring and continuous improvement
OBJECTIVES OF THE CONTRACT: •
To provide an aesthetic and patient friendly atmosphere in the hospital, with enhanced patient care to achieve faster recovery
•
Optimum utilization of resources like water, electricity, fuel etc. to cut down operational cost.
•
Recycling of resources like water and in turn reduce stress on government services.
•
Energy is an important part of infrastructure development. The tie up would help in upgrading the quality and sustainability of the infrastructure.
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With the vast industrial development the term eco friendly deserves utmost importance. The tie up ensures minimum wastage and thereby culminates into eco friendly set up.
PHASEWISE IMPLEMENTATION OF THE PROGRAMME PHASE I: Energy audit with respect to electricity, water, and fuel consumption was performed Consumption and utilization patterns of resources were studied Study of maintenance of utilities and associated cost were ascertained. It was found that the hospital spent 5% of the sales turnover on these resources.
PHASE II: The above information was used to draw out energy management schedules. Revamping programme of certain equipments and facilities were done. Financing of these equipments were done by SBH.
IMPLEMENTATION AREAS: •
Air Conditioning equipments
•
Steam control
•
Optimization and systems
•
Water system conservation and recovery
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Automation
A 100-ton screw chiller, 100-ton Vapor Absorption Machine (VAM) and the water recycling plant were introduced. The screw chiller used for air conditioning consumes 70 – 80% of energy compared to conventional systems. The VAM air conditioning plant operates on excess steam generated by the boiler also conserves energy and hot water residual is again for laundry systems and food warmers in the kitchen and dining halls.
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PHASE III
The automated system, which could control temperature of the various AHUs was installed. Various equipments like CT scan, MRI etc. are required to be maintained at particular level of temperature, which was made easier by making the system computerized. This improves the quality and the life of the equipment.
PHASE IV The staffs of the hospital were trained to run the system. The programme focuses on continuous maintenance of the new and existing equipments and training of the maintenance staffs.
BENEFITS TILL DATE: Power consumption has been reduced in all the AHUs mainly by installing monitors, which continuously logs readings facilitating online monitoring Within the first three months of its operation the hospital managed to save Rs. 17 lakhs. The power consumption, which was 15000 units per day, has been brought down to 12000 units per day. Out of the total power consumed by the hospital 60% is for A/C Plant, 20% on lighting, 10% on bio medical and 10% on accessories. The savings on power was made possible only from A/C plant as the other areas are not under the contract of THL.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
The hospital needs 1,50,000 litres of water per day. A sewage water cycling plant was installed to treat the wastewater from the hospital. This water is used for gardening, cooling tower and flushing. This provides saving of the money to be paid to the corporation and helps attain selfsufficiency.
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INTRODUCTION: Hospital acquired infections is a serious problems the health care industry is facing today. The approach to the combat this problem is effective method of disinfections and sterilization and in our hospital it is centrally done at the Central Sterilization &Supply Department, it is an integral and vital part of present day hospitals. LOCATION: It is located on the third floor adjacent to the Conference hall and opposite to the lift , the flow of people are less in this area as compared to the other floors, there is separate lift for dispatch of sterilize material to different departments. The lift opens in the OT AIMS: CSSD is a vital department of the hospital and is responsible for receiving, storing, processing, sterilizing distribution of medical supplies and instrument to all departments of the hospital. The department is based on GCP and run appropriate controls to ensure sterile supply of each article thus help in reduction of incidence of hospital cross infection. OBJECTIVES: The Objectives of the CSSD are: 1. To provide supplies of sterile instrument, linen packs and other sterile items used in patient care. 2. To ensure each cycle has passed the load quality check before dispatch. 3. To maintain records of sterilization process. 4. To monitor and enforce appropriate control necessary to prevent cross infection according to infection control policy. 5.To maintain an inventory of supplies and equipments. 6. Regular update on development in the field. 7.To provide a safe environment for the patient and staff. ACTIVITIES OF THE DEPARTMENT The primary activities of the department are:
Receiving the solid material Cleaning Inspecting equipment, instruments and linen Wrapping for sterilization Sterilization Storing Distribution WORK FLOW: The flow is unidirectional and the personnel must follow the rules strictly. There should be a one person in the sterile dispatch area and this person must not circulate In un-sterile area.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
STAFF & SHIFTS: There are total of 10 members in the CSSD. 3 Shifts from 8 a.m. to 4 p.m. 12 p.m. to 8 p.m. 8 p.m. to 8 a.m.
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PR
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O
EQUIPMENTS USED IN CSSD:
One ETO (ethylene oxide) machine for plastics reuse materials like catheters, ambubags, bed pans, its capacity is 10 bags per load, There are total three auto claves in which two are manual and one is rectal autoclave it is automatic ,used for linen, all surgical instruments, trays, gowns, Temperatures maintained to sterilize the equipments are:
Linens and articles at 20 pound pressure at 30 minutes or 30 pounds pressure at 20 minutes at 120 degrees centigrade temperature. Rubber goods and all glass materials at 10 pound pressure in 15 minutes or 20 pounds pressure in10 minutes at 121 degrees centigrade temperature. The materials which melts at high temperature under steam sterilization they can be sterilized under gas sterilization covered polythene sheet at 56ocentigrade temp for 16 hours by using ethylene oxide gas. The expiry date for autoclave items are 3 days or 72 hours.
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The expiry date for ETO items are 6 months.
MONITORING PROTOCOL:
Scope : These guidelines covers the monitoring system for evaluation and validation of the following : Sterilization process including steam, ETO.
Equipment control : Maintenance department must carry out thermocouple test, leak test ,and air detection test periodically
Load control: Done by PCD- PROCESS CHALLENGE INDICATOR DEVICE –every load must have this test passed. Apart from this Biological indicator must be run once every week, incubated and results recorded. These controls help ensure the sterilizing system is working fine, and the specific load is free of any spores . There are different PCD for ETO and steam sterilization.
Exposure and pack control:
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chemical indicator tapes. These controls help issuing officer and user identify a sterile pack and ensure that only sterile item enters a sterile area. CODING FOLLOWED: Color coding is followed in the CSSD according to the department for consistency those are : Color Department Blue Ortho OT Green /White General Surgery Light blue Ophthalmology Maroon Wards and Departments Violet Pediatrics ward Brown Neuro OT A tape attached to each and every kit to indicate load, temperature, date and sterilization. This tape will be in blue color before sterilization and it turns to light green when it is sterilized, to ensure the sterilization. In case of urgency, concern dept.should be mentioned on the kit. QUALIFICATIONS: A diploma or degree in nursing and suitable combinations of education and experience may be considered. A minimum of five years clinical experience working in an acute care environment. Previous experience working in a sterile processing department or operating room is preferred. JOB RESPONSIBLITIES :
Picks up and delivers equipments from all areas of the hospital. Disassembles, clean and checks for proper function of equipments, such as suction machines, feeding pumps, I.V. infusion pumps, etc., Perform minor repairs on equipments, replace worn hoses and installs spare parts as needed. Installs equipment, such as side rails trapeze assembly and Stryker frames, at bedsides as needed. May provide some functional guardians to personnel operating equipments on units. Operates gas and steam sterilizer following authorized procedures Stocks shelves with clean and sterile supplies. Washes and disinfection items, such as bedpans, scissors gloves syringes and tubing with prepared antiseptics solutions and detergents. Dries, wraps ,bags and seal items in preparation for sterilization . Cleans and disinfects the work area. RECORD KEEPING : Scope:
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These guidelines shall cover the record required to be maintained by CSSD with respect to processing equipments,instruments and personnel working in CSSD. Processing equipments : Steam sterilizers: The following records shall be maintained for the sterilizer.
Record of thermograph for each cycle.
brecord of every load PCD.
Chemical indicator.
Weekly biological indicator results.Crush vial(containing bacillus stearothermophilus)after cycle and incubate at 56o C for 48 hours and looked for colour changes.
All records should be kept for 2 years. ETO Sterilizers: The following record per cycle per day for sterilizer shall be maintained.
Chemical indicator.
Spore test or biological indicator results.via (contains Bacillus subtilis subspecies niger)is crushed after the cycle and incubated at 37o C for 48 hours. There should be colour change.
All records should be kept for 2 years. Instruments : Packs trays shall be identified by : Date of sterilization, date of expiry, pack name, operator name, and method of sterilization
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Apollo Hospitals, Hyderabad.
BILLING DEPARTMENT
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INTRODUCTION: The billing department represents the efficiency of the hospital in providing quality patient care, through revenue collection of various services , rendered by the hospital to the patient
The billing department is divided into following areas as per the services provided: 1) OP billing 2) IP billing 3) Corporate cell
OBJECTIVES: •
The primary objective of the department is to collect the revenue through OP/IP/Corporate billing.
•
Direct patient interaction and clearance of doubts of patients regarding the final bill, charges ,discount etc as per the queries.
•
Keeps proper documentation of the revenue generated and hence gives the information to the management regarding the efficiency and feasibility of the department .
•
Settlement of the doctors fees.
LOCATION: This department is located in the ground floor close proximity to the front office and have a direct accessibility for the patient .
OP Billing: This department is located on the left side of the front office and on the right side of the main entrance.
IP Billing : This Area is located Just behind the Op billing area in the ground floor near the front office.
Corporate Billing : This cell is located in the ground floor behind the main reception but the original corporate /credit bill is generated in the billing section which is located inside the MHC .
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Credit Cell: This is located in the administrative building as it has no direct patient interaction. ACCESSIBILITY: •
Both the IP and OP billing area are directly accessible to the patient and in close proximity to the front office and hence a suitable location for efficient traffic flow.
•
The corporate billing which does not has a direct patient relation but has a functional relation with IP and OP billing is located in the less important area but is easily related to the IP and OP billing.
DESIGN OP Billing: •
There is only a single OP billing for all the services as lab,diagnostics,pathological test,etc.
•
The OP billing doesn’t have a separate waiting area or sitting arrangement but as located close to the main reception the waiting area can be used for the OP billing waiting purpose.
IP Billing: •
The IP billing as located in a separate cabin has a good waiting area but insufficient during peak time.
•
It is divided into four major sections according to the patient requirement as cash, credit, bill making, counseling.
•
There is separate cabin inside the IP billing department for the Billing in charge.
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Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
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Apollo Hospitals, Hyderabad.
37
MANPOWER: 1Billing Manager for inpatient, outpatient and corporate cell ,and front office. Inpatient and corporate cell has three supervisor and 7 assistant including junior and senior. Outpatient department has 1 supervisor and three assistant.
JOB DESCRIPTION: BILLING INCHARGE •
Cooperation and coordination of billing department function with all other related department.
•
Super vision of the billing function as a whole.
•
Communicating the Information of the performance related report and other vitals to the management as per requirement.
•
Formulating different policies and procedures to be followed by the billing department personnel.
•
Authorisation of all the documents regarding free /discount /etc. bill as per the requirement of the patient and authority.
•
Delegating the authority and responsibility as per the qualification and skill ,and continuous motivation of employees billing being a monotonous work.
BILLING SUPERVISOR: •
Individual supervision of the work area to which they are related as cash , credit, bill making,OP.
•
Coordination of billing assistant to guide and counsel the patient as per their queries.
•
Responsibility of the area to which they are related.
BILLING ASSISTANT: •
Their Primary job is bill generation in the work area
•
Checking the actual bill made by the patient and cross checking to different department regarding the bill and the services actually availed by the patient.
•
Direct communication with the patient hence clearing patient doubt regarding charges discount etc.
•
Entry of all the transaction in the computer regarding the services availed and hence proper documentation of the records.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
TYPES OF BILLING: 1. CASH 2. CREDIT 3. FREE
OJT Team A, I Batch
38
Apollo Hospitals, Hyderabad.
39
4. DISCOUNT
CASH PATIENT: •
Both Inpatient and outpatient cash payment facility is provided.
•
Cash ,cheque and credit card facility all are considered as cash payment.
•
Different credit card facility provided are Master Visa,American Express,Citi Bank, Diner club.
•
The return for such payment is in terms of cash only.
CREDIT PATIENTS: •
Both inpatient and out patient are provided this facility.
•
This facility is given on two basis :
•
Companies patient on the submission of company credit letter with which Apollo has a corporate tie up.
•
Authorisation from a higher authority and also from the billing manager.
•
All the information regarding the facilities that is approved by the company for the patient , determines the service to be provided by the hospital and the bill will be made according to that.
•
In case of an emergency the person is asked to provide the I-card and for the credit letter within certain time period ,if the letter is not received within the time the patient is considered as a cash patient and has to make the full payment.
FREE PATIENT: •
The billing is made free on the basis of authorization from the higher authority, billing manger and for certain hospital staff and for top management personnel.
•
This service can be provided to an outsider on the basis of appropriate authorization only.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
40
DISCOUNT PATIENT: •
Discount is given to the patient on the basis of the packages availed by them or in case of higher authority permission .
•
This can also be received if the person is a hospital staff ,student or a member of Apollo family ,Apollo share holder etc.
FOR AMBULANCE CHARGES:
•
Ambulance charges are not necessarily considered as OP charges but if the patient is discharged from the Emergency directly without admission than the charges are considered as OP charges, and if the patient is admitted in wards operation or Icu’s than the billing is done as Inpatient.
•
The Ambulance charge is according the distance traveled.
OUTPATIENT BILLING:
•
The out patient department caters to the patient for the laboratory, diagnostics, pathological, blood bank , and other OP services provided by the department.
•
The out patient department has a separate supervisor for coordination of the outpatient billing and Inpatient and corporate billing .
•
This department works upto 8’0’ clock in the night after that the inpatient is considered as both inpatient and out patient.
•
Inpatient charges for patient’s ophthalmic surgeries are predetermined by way of packages.
•
Ophthalmic bills are prepared separately by ophthalmic billing and the cash is paid to the cashier at the ophthalmic block prove to surgery, three copies of bills are issued (Patient copy, Cashier copy, Accounts Copy).
•
Daily revenue collection of Op is between 1,00 ,000-1,50,000/-
Bill generated: Three bills are generated in this counter that are as follows for the CASH PATIENT:
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
41
GREEN BILL: This copy is kept by the patient and is shown to the department while report collection. ORANGE BILL:This copy of bill is given to the department in which the test is conducted and kept as record for the department and entered by the department in the system. BLUE BILL: This copy of the bill is kept with the billing department for maintaining the record of the services provided by the departments,diagnostics etc.and used for tallying and cross checking purpose. CREDIT PATIENT Though all the colour bills are generated for this department also but the Green colour bill generated is given to the credit cell for the account keeping of the companies. BILL INFORMATION: OP NO. NAME DOCTOR DATE TIME TEST TO BE DONE
INPATIENT BILLING: This department facilitates to all the inpatient services provided to the patient and considers all the charges as room charges ,OT charges,F&B charges Laundry,etc.which a patient utilizes during the stay in the hospital. Daily revenue collection differs between 1,50,000- 2,00,000/The Inpatient area is divided into four counters Cash Counseling: It helps to give the patient an estimate of the amount of expenses at the time of admission, reminds the patient periodically about the bill to be paid, returns the excess of initial payment over expenses in the form of cheque. Credit counter: It helps to prepare bill of credit patients, checks for the validity of credit letter and the services approved by the respective company ,coordinates with the credit patient for getting the credit letter, informing the credit limit, counseling of credit patient for the payment of net amount apart from that which are covered by the company after explaining the breakup and enter the accounts of the patients which have not been entered into the system at the time of the procedure.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
42
Cash counter: Receives cash payment and gives a clearance slip to the patient about the discharge .It calculates the balance amount to be paid by the patient after deducting the deposit of the patient . Bill making counter: This counter prepares the bill of the patient at the time of discharge by checking the activity card and the discharge summary from the typing pool or the nursing station and again checking for the facilities availed by the patient for different services over computer as all department are connected online. Running bill: The running bill is generated for the patient during the stay in the hospital on a daily basis . A minimum of 10,000 balances is kept for such patient and patient relatives are intimated about the bill status and are counseled if the bill exceeds the minimum deposit amount. This keeps a regular track of the bill incurred by the patient, reduces the chances of lag payment as the payment is received regularly, and helps the patient to ray in installment instead of the whole bill amount at once. Bills generated: There are two copies of bill generated over here that are as follows: GREEN COPY: This copy is given to the patient as personal copy contains all the break up of the bill and for cash patient the counseling is done at the cash counseling counter and the cash is paid at the cash counter PINK COPY: This copy is kept with the billing department as a record of the inpatient and thus gives a proper documentation system for the billing department for the internal audit purpose. CASH PATIENT: For cash patient the green copy is given to the patient and pink copy remains with the department only. CREDIT PATIENT: For them the green copy is not given to the patient is retained with the department to submit in the corporate cell to be sent to the company. Types of bill: ICS:CASH RATIENT ICR:CREDIT RATIENT IPK:PACKAGE PATIENT IFR:FREE PATIENT
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
BILL INFORMATION: I P NO. NAME ADDRESS REFERENCE BED NO./IF CHANGED DURING THE STAY UHID NO. DATE OF DISCHARGE TIME OF DISCHARGE ADMISSION DATE DISCHARGE ALL DENOMINATION OF BILLS SIGNATURE OF CASHIER/PREPARED BY/MANAGER
BILLING DEPARTMENT FORMAT
I.P BILLING:
DESCRIPTION AMOUNT
I.P NUMBER
U
HID
BED/ROOM
W
ORD
NAME
BILL AMOUNT TAX DISCOUNT AMOUNT
ADDRESS
CREDIT AMOUNT
SEX
DEPOSIT AMOUNT
AGE
REFUND AMOUNT
DOCTOR NAME
RECEPIT AMOUNT
ADMITION DATE AND TIME DISCHARGE DATE AND TIME COMPANY IN WORDS -----------------------------------------------------
OJT Team A, I Batch
BALANCE
43
Apollo Hospitals, Hyderabad.
44
PACKAGEES
RECALCULATE
BILL DETAILS
CREDIT DETAILS
DISCHARGE
PRINT
TAX DETAILS
CLEAR
DEPOSITE DETAILS
DISCOUNT DETAILS
REFUND DETAILS
CLOSE
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
IP BILLING:
IP NUMBER BED/ROOM NAME OJT Team A, I Batch
45
Apollo Hospitals, Hyderabad.
46
CORPORATE CELL: •
This cell is under the supervision of the supervisor in Ip billing counter along with two assistant .
•
The main function of this department is to prepare the bill of credit patient from companies having corporate tie ups with the Apollo .
•
It sends the bill to the internal audit for the cross checking and again sends the bill to the corporate cell with the bill details, credit letter copy and other documentation required.
•
It maintains the accounts of the company and credit it with the respective patient bill charges.
•
It receives the bill from the company and sends it to the accounts department and settles the companies account for this department for the particular transaction.
•
Inform the department about the changes in the new tie ups and the approved format or facilities to the patient.
ACTIVITIES: CASH COLLECTION: •
At the out patient counter the patient pays for the tests prescribed by the doctor. The data entry operator feeds the data into the computer.
•
Three copies of the bills (different colors) are made. One for patient, one for the accounts department and one for the concerned department.
•
The Cash collected is handed over to the bank after the morning shift, but in the case of night shift it is only on the following day that the cash is deposited in the bank.
•
The Outpatient billing cashier collects the registration money separately and deposit’s it in the bank.
•
There are two shift for depositing the money in the bank for both the inpatient and the outpatient.
RECORDS ,JOURNALS MAINTAINED: •
All data are stored in the computer hence not much records are maintained manually.As all the department are connected online the services that are provided are entered online and hence at the time of preparing the final bill the information is checked online with the activity and the discharge card.
DOCUMENTATION: OUTPATIENT: Doctor consultancy fee book
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
47
Log book:daily collection Day care surgery book: break up details of surgery Iom file Letter file INPATIENT: Credit letters file Iom file Performance report file Log book
DISCHARGE PROCEDURE: •
The doctor allows the patient to be discharged the discharge card and the activity card is received by the Inpatient billing department.
•
After the clearance of the bill the discharge slip for clearance at the nursing station for the patient to be discharged is given and a white slip is given for the clearance at the security at the gate.
•
Discharge can be done at any time during the general shift , no patient are discharged during night.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
48
Apollo Hospitals, Hyderabad.
49
OUTP
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
50
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
51
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
52
Apollo Hospitals, Hyderabad.
D
OJT Team A, I Batch
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Apollo Hospitals, Hyderabad.
54
OPHTHALMOLOGY OUTPATIENT BILLINGS: •
Registration is carried out at the Apollo eye research foundation on payment of the registration fees. The patient fills an initial patient record.
•
A consultation fee is paid at the registration counter with a registration fee of Rs.50/- as a prove to meeting the doctor.
•
If the patient required purely ophthalmic tests, the payment is done at the OP billing counter.
INPATIENT BILLINGS: •
All inpatient billing is done in the main IP counter like any surgery ,operation charges, and other inpatient stay and service charges.
CANCER UNIT Outpatient Billing: •
A separate billing counter is there for the cancer block and money is collected separately at the reception of the cancer block as per the procedure .
•
The charges are posted according to the investigation prescribed by the doctor and bill is ,made on the basis of charges of different diagnostics or therapeutic procedure charges.
•
The cash deposit of the billing is sent to the bank separately and than is given to the accounts department for record keeping.
Inpatient billing: •
The inpatient billing is done through the main IP billing for operative procedures and charges are posted here as OT charges and other charges during the stay.
•
The information regarding the credit billing is same as main reception is sent to the corporate cell
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
55
POLICIES AND PROCEDURES 1.50-55% of the collection goes to the credit patient and credit process is given a vital importance in the department and confusions regarding all such matter is solved by the corporate cell. 2. For Surgeries cash is collected before the surgery. 3. A minimum deposit is taken for the patient admitted as the inpatient as secured money or caution money. 5.
The minimum caution money is maintained till the stay of the patient i.e 10,000/- and the track of this is kept by generating the running bills everyday.
6.
10-15% of discount is given to the patient relative in case of death of the patient or as allowed by the M.D as per the request of the patient relative.
7.
For free patient white ration card is required ,but medicine charges are collected and discount is given as per M.D ‘s instruction.
8.
Charges for employee is free but Ct scan and MRI are charged. Wife and children:75% Mother & father:50% Discount is given as per the above policies.
9.
All employees have an insurance coverage of Rs/- 30,000.
10. Apollo has a tie up with 30-40 companies whose employees are considered as credit patients and they have different tariff facilities according to which the bill is decided for the respective employee. 11. Daily deposit of the cash collection is done but the amount collected in the night shift is deposited with the next day 1st shift . 12. The marketing department does the corporate tie up and intimates the billing department,corporate and credit cell
PERFORMANCE APPRAISED SYSTEM: The performance appraisal in billing department is done by H O D employees are appraised on factors like hours of work put in his motivation, commitment and cooperative attitude. These appraised are kept in mind for approvals.
TRAINING PROGRAMS: The personnel department carries out regular training programs for all the departments in areas like communication, time management, fire safety and fighting etc.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
56
There is Job rotation for the personnel’s to have an interdepartmental training and also within the department there is job rotation.
INTERACTION WITH OTHER DEPARTMENT: Accounts department: Keeps the record of all the information and
submits the bank deposit receipt
to the accounts department for the realization of revenue collected.
Corporate Cell: Sends the credit letter and bill to this department for keeping a track and realization of revenue incurred by the hospital services towards credit patients.
Front Office: It is the next service availed by the patient after the front office ,collects the revenue generated in the registration counter , recording and posting all the vital information regarding patient generated in the front office as UHID no.,bed charges according to the availability as of information in admission counter. Interact with all other department providing direct services to the patient as Wards ,ICU’S, Operation theatre , Labs, Diagnostics, Food and Beverages, etc. for keeping an original record of actual charges for different test and cross checking of the services availed by the patient during preparation of the final bill.
COMPUTERISATION: Billing department is fully computerized. There is a single computer on the LAN, which is primarily used as a stand alone for the purpose of creating computerized bills using standard codes for data entry.
OBSERVATION OUTPATIENT BILLING: •
The time taken for the outpatient billing generally varies between 3minutes to 7 minutes depending on peak hour off peak hour and the no.of investigation.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
•
57
There is no separate waiting and sitting arrangement for the Out patient billing counter.
•
Cash collection requires much higher level of security and caution.As the OP billing counter is open the security purpose is not solved as a huge money transaction is also done in this area.
•
A simple tariff chart can be displayed for solving the queries of patient regarding the charges
INPATIENT BILLING:
•
There is no separate notation for the counters inside the Inpatient billing counter and the patient relative move from one counter to another as they don’t know to go to which counter directly.
•
There is not sufficient sitting arrangement for the waiting patient.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
58
I P
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
59
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
60
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
61
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
62
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
63
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
64
OJT Team A, I Batch
1
Apollo Hospitals, Hyderabad.
2
INTRODUCTION In the last two decades or so, hospitals around the world have become a dynamic industry, which is expanding and becoming more complex with the passage of time. Technological advances have become the order of the day and with the increased number of sophisticated equipments being used in the day-to-day activities for providing quality healthcare maintenance of these equipments and different plants is posing a big challenge for the hospital authority. This challenge, has given rise to the need of developing a professional team and the maintenance department whose prime responsibility is to ensure smooth functioning of the central plant; generation, storage and distribution of steam, cold and hot water; refrigeration; ventilation; air-conditioning and electricity. Besides adequate capacity, reliability is a major concern , primarily because of the many life saving services provided by the hospital . the activities of the engineering department include highly specialized services which should be determined by the specialist engineers, consultants and architects of the planning and design team. The engineering and maintenance department is charged with the responsibility for ensuring safe and economical operation and maintenance of hospital facilities and expensive equipment. The department should be capable of providing technical and management support to the hospital.
OBJECTIVES To adopt a planned procedure for checking and maintaining all equipments that comes under the list of in-house maintenance as well as external agencies though annual maintenance contract.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
3
LOCATION AND ACCESSIBILITY The department is located in the cellar at the G2 level. The other departments located in the floor are housekeeping, stores and pharmacy stores. Most of the equipments under the control of this department are located either in the same floor or outside the hospital building. Since the department’s service is not obtained by coming to the department physically the location is not a matter of great concern. But the location of the department of the location cannot be considered safe as in case of any eventuality like accidents the whole building will be in potential danger.
UNITS UNDER THE DEPARTMENT A/C Plant Boilers Central Gas Supply Scheme Water supply Autoclaves Electrical Substation Water Purification Plant Plumbing, electrical works and carpentry
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
4
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
5
Apollo Hospitals, Hyderabad.
A
OJT Team A, I Batch
6
Apollo Hospitals, Hyderabad.
7
JOB DESCRIPTIONS CHIEF ENGINEER •
Fixing the target for the department
•
Planning, scheduling and controlling jobs to be done by the department and coordinating with other departments in achieving the above goals.
•
Responsible for major renovations like building and expanding the existing area.
•
Looking for negotiations and approving the technical aspect of the new equipment and also responsible for approving installations.
•
Responsible for day-to-day ongoing activities of the department.
•
Responsible for approving the plans of preventive maintenance.
JUNIOR ENGINEER The department has two junior engineers. One is responsible for civil works and the other for mechanical and electrical works. They are responsible for •
Planning and preparing the breakdown estimates
•
Earliest possible execution of jobs.
•
Material indenting and follow up with the purchase department and the related contractor.
SUPERVISORS •
Correspondence, execution and follow up of work plan by engineers with the help of the workers.
•
Supervisor is responsible for the execution of the preventive maintenance schedule.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
BOILER OPERATORS •
Responsible for preventive maintenance, upkeep and routine operation of the boiler plant.
•
Checking proper supply of hot water and steam to required place.
ELECTRICIAN •
Responsible for proper functioning of generators, panel boards in his shift
•
Preventive maintenance of power and lighting distribution boards.
•
Responsible for the prevention of general breakdown.
A/C PLANT OPERATOR •
Responsible for proper functioning of the air conditioning plant and the related equipments like window A/C, AHUs, FCUs, split units, package units and deep freezers.
PLUMBER •
Responsible for proper functioning of pumps, supply of water to all areas of the hospital.
•
Check tank levels for routine fill and quantity of water being supplied from the outside suppliers.
CGSS ATTENDER •
Responsible for ensuring the constant supply of oxygen and nitrous oxide to operation theatres as well as to other areas as and when required.
•
Responsible for placing empty cylinders on time.
LIFT OPERATORS
OJT Team A, I Batch
8
Apollo Hospitals, Hyderabad.
•
9
Responsible to provide continuous and pleasant service to patients through perfect operation of lifts and to ensure that the lift is in presentable status functionally and aesthetically.
PCC TECHNICIAN •
Responsible for the repairs of air conditioning, mechanical and electrical works and the minor carpentry jobs in patient areas.
FITTER •
Responsible for the general mechanical fitting and fabrication work in the department.
DESK CLERK •
Responsible for registering complaints from the different departments and informing the concerned person through the supervisor and also helping the department in other clerical works.
TYPES OF MAINTENANCE WORKS PREVENTIVE MAINTENANCE: Maintenance works on a piece of equipment on a planned schedule to prevent breakdown is called preventive maintenance. The work consists of inspection, adjustment, and calibration, cleaning, repairs e.t.c. Preventive maintenance is carried out periodically by all sections of the department. The schedules are prepared by the engineers and maintained in each section. There are daily, weekly, monthly, bimonthly, quarterly, OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
10
annually conducted preventive maintenance schedules. This depends on the nature of the equipment.
EMERGENCY AND ROUTINE MAINTENANCE: Immediate repair of vital piece equipment is known as emergency maintenance. While maintenance on routine basis, which can be classified under non-urgent repairs such as replacing of tiles, e.t.c, which can wait until scheduling is possible, is called routine maintenance. Complaints pertaining to lighting, air conditioning and plumbing are brought to the notice of the maintenance department and is done through job orders from various departments, which is passed on to the PCC. In case of breakdown of equipment serving a particular department, the time required for the repair of the equipment is intimated to the H.O.D. of the concerned department so that the H.O.D can plan out his work accordingly. If the equipment is under service contract, the supplier is informed of the breakdown and the complaint is entered in the breakdown register. On receipt of the job order, verbal or telephonic complaint the desk clerk or the supervisor incharge makes sure that the maintenance work is done through the concerned department. When the job is completed the job order is handed over to the desk clerk, which is an indicator that the maintenance work has been done. CONTRACT MAINTENANCE: Under this system repair of equipment is done through contract labour and materials under annual maintenance agreements. This can be done either on a routine basis or on a piece of equipment under service contract. Many of the costly equipment come with a warranty for a particular period and after the expiry of the warranty normally a contract for maintenance is entered with the supplier.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
11
AIR CONDITIONING SYSTEM Air conditioning is required in a hospital to achieve a certain level of temperature, humidity, filtration and circulation. Areas like operating rooms, ICUs, nurseries are some of the areas which require air conditioning. Sophisticated medical equipments are sensitive to temperature and humidity, which if not maintained can affect the performance of the equipment. Air conditioning system ranges from a battery of small self contained window units to complex central air conditioning system. The following are the air conditioning systems under the control of the department: •
Central A/C Plant
•
FCU
•
AHU
•
Package Units
•
Window Units
The basic principle of an A/C is cooling using a refrigerant. Air in the room is taken into the A/C unit and exposed to a refrigerant medium that takes up the heat and then the cool air is returned back to the room. The main components involved in the process are •
Compressor
•
Condenser
•
Refrigerant medium – gas or water
•
Inlet and outlet pipes
•
Ducting system
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
12
CENTRAL A/C PLANT: The central A/C plant has a large capacity compressor that pumps refrigerant gas to the condenser. The refrigerant gas is cooled by the water-cooling system and is condensed to liquid form. The liquid absorbs heat from the water coming from the various units at the cooling tower and again is converted to gas. The gas is then circulated back to the compressor. This is continuous cycle. Temperature at the cooing tower is maintained at Ο
13 C. The chilled water goes back to the FCUs and is pumped to the various rooms and wards. The department has seven compressors with a total capacity of 620 tons.
Blue Star
100T
Kirloskar (2)
80T each
Accel (2)
80T each
Dunham Bush
100T
VAM Thermax
100T
The central A/C plant caters to the need of all single and semi private rooms.
FCUs: Ο
The FCUs maintain room temperature at 23 C. The FCUs has an A/C grill, filter, coil system over which chilled water runs cooling air and releasing it back into the room.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
13
AHUs: The AHUs handle air in areas where intermixing of air of two different areas needs to be avoided to control hospital-acquired infection. The AHUs have a ducting system that brings air from the respective areas, which pass through filters, and is cooled by blowing the air over water coolants. There are eight AHUs in the second floor terrace, which cater to the need of the Ots and the ICUs. The AHUs caters to
All OTs - OT1 and OT2 have single AHU and all other have one AHU each. CT Scan Nephrology and Burn Unit MD’s office CT post and SICU
PACKAGE UNIT: These units are used in areas where low temperatures have to be maintained than that provided by the central plant. The package unit has two compressors, one located at the required area, which is connected to the other at the second floor terrace through ducting system.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
WINDOW UNITS: Window units are wall mounted and self-contained units that have components in one cabinet. There are around 40 such units. Some of the areas, which the window units serve, are •
Blood bank
•
Casualty
•
Cath Lab
•
EDP
•
Physiotherapy Labs
•
MICU
•
ECG
•
TMT
•
GM Operations
In addition there are split A/Cs which caters to the need of •
All Laboratories
•
MICU
•
Super deluxe rooms
•
Eye block
•
IHC
•
Minor OTs
•
Gamma Camera Room
•
Administrative Block
ELECTRICAL SUPPLY SYSTEM Electrical energy is an essential source of power, the pivot which almost every function of the hospital revolves, and the system is increasingly becoming more demanding,
OJT Team A, I Batch
14
Apollo Hospitals, Hyderabad.
15
complex and crucial. This is partly because of the specialized and medical equipments used for diagnosis. Treatment and rehabilitation of patients is partly because of the larger load of power needed in today’s hospitals. In the electrical system the main concern of the design team and the hospital engineer is the power distribution system, which, it is rightly said, is the electrical lifeline of the hospital. There are also other concerns like an adequate and dependable supply.
The substation of the hospital is located behind the main block opposite to the maintenance area. The entire area is covered with 2 – 3 inch layer of gravel to drain off the rainwater in order to prevent electrical short circuits. The area is fenced and has security personnel posted round the clock. The objective of having a substation is to have uninterrupted power supply.
The hospital receives power from AP TRANSCO, Jubilee hills. In case of shortage or interruption Chandrayangutta substation fulfils the requirement. The hospital has two transformers of 1000KV capacity each. The voltage supply to the transformer is brought down to 220 volts. The power enters into two different areas of the hospital through two separate Control panels, one of which is the circuit board from where electricity is distributed to the main areas like the OTs, ICUs, CT post and other areas. The second line provides electricity in case of breakdown. In case of trip downs there is a remote control panel, which is charged by a set of batteries, which automatically restart the panel or the transformer.
The hospital has two generators of Kirloskar and Jyoti make. The load to be placed on the system has to be carefully determined. The load can be transferred from the direct power source either manually or automatically. Jyoti is on manual transfer mode whereas
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
16
Kirloskar is on automatic transfer mode wherein the electricity is restored within seven minutes of power failure.
The consumption is monitored continuously by the technical staff comprising of one electrician, one assistant engineer, and one supervisor. When the load is high the equipment not in use are shut down and all A/Cs and lights not required are shut down.
The safety measure that are followed by the department are Substation is covered with gravel to prevent electrical short circuits The main station flooring is done with rubber. Fire extinguishers are placed at strategic points.
WATER SUPPLY SYSTEM Water is one of the critically important utilities in a hospital, yet its supply is often taken for granted. Much of the hospital’s engineering service is concerned with installing, repairing and maintaining the systems that deliver utilities and services, water being one of them in a functional continuing and safe manner. The hospital requires a copious supply of water. While the nation’s population and demand for water is increasing, the country’s water supply is diminishing. This puts a tremendous pressure on the ability of the administrators and hospital engineers to supply pure and safe water to the hospital. The water flow from Krishna Nagar is first collected at the pump house near Andhra Bank. The pump house receives 2 lakhs gallons of water per day. From the pump house
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
17
water is transferred to the underground tank near the cancer block. The water passes through the process of filtration before being pumped to eight overhead tanks present at the main building having a capacity of 1,50,000 litres. Water supply to the administrative block and research foundation building comes from the cancer block. There are four plumbers who support the junior engineer in maintaining a proper supply of water. Monthly microbiological tests are performed to ascertain the safety of the water. Effluent water from the bathrooms and other used water outlets are pumped into the water effluent plant. The plant contains two chambers where sludge is separated from the water using oxygen. Fiber raisins are added to remove the bacterial content. Purified water from the plant is sent to the tube settlers. The fresh water that comes out after this process is used for gardening, boiler, A/C plant e.t.c. Samples of this water are tested regularly to ascertain the purity.
TRANSPORT SYSTEM There is one patient lift in the cancer block and two in the main building adjacent to the ramps. There is also a service lift near the staircase. The maintenance of these lifts is under contract with Kone company who have installed the lift. The minor problems are looked after by the department and in case of severe problems the contract company is summoned. The company people also do a routine maintenance of the lifts. There is a operator in every shift who mans the lift and reports to the front office manager.
BOILER The two boilers used are oil fired, coil type automatically packed manufactured by Thermax with a capacity of 600 Kg/Hr and only one is used at any particular time whereas the other is standby. The total running time of the boiler is around 11 – 12 hours per day. The boiler is used for the purpose of supplying hot water to patients, sterilization
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
18
in CSSD, cooking, washing and sterilization in F&B and washing in the laundry. The boiler uses 540 litres of water per hour and the efficiency of the steam generated is 80%. Ο
The pressure of the steam generated is 15 kg/cm2 and the temperature is 180 C but the Ο
hot water sent to the patient room has temperature of 40 - 50 C. Water softening is done once in every two days and infection control testing is done every month. The department does all major and minor maintenance. There are four boiler operators one in every shift, they report to the H.O.D. maintenance. CENTRAL GAS SUPPLY SYSTEM The CGSS provides medical gases and vacuum at required points in the hospital viz. OTs, ICUs and patient bedside in the rooms and wards. The plant is located in the G2 level of the hospital.
OXYGEN: The company called Oxyco supplies the major portion of the oxygen required by the hospital. The daily consumption of oxygen is between 8 – 8.5 kg/ hr. An average of two trailers each containing 52 cylinders is consumed daily. Several oxygen cylinders are placed at wards and other strategic points of the hospital to meet any emergency requirement. In addition to the supply by Oxyco the hospital also produces its own oxygen. Oxygen pipes are yellow in colour and are available at the bedside, which supplies liquid oxygen.
NITROUS OXIDE: The average consumption per day is 450 cubic meters. Each cylinder contains 7.1 cubic meters. Pressure is to be maintained at 40 – 60 lbs. 60 portable cylinders for OT and ICU are used. BOC India Limited is the major supplier of nitrous oxide.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
19
MEDICAL AIR: There are two medical air compressors; one is used whereas the other is standby. The medical air generated is supplied to OTs, Casualty, Nephrology, Burns Unit, Lithoscopy and CT scan area. There are three personnel in the department and only one person is posted in every shift. There is the system of returnable gate pass for all the cylinders. Preventive maintenance is done for the compressor on a monthly basis. Bedside vacuum units are also checked once in a month. Valves, connection points and pressure gauges are checked every week. AUTOCLAVE The hospital has autoclaves in the laboratories and CSSD. In CSSD there is one horizontal high-pressure steam sterilizer and one sterilizer in the Laboratory. The concerned department does weekly microbial tests of efficiency. Maintenance department does bimonthly check of the pressure gauge, valves, nuts and gaskets etc.
PATIENT CARE CELL The PCC is located on the first floor beside guest relations. The daily work schedule of the department is to receive •
Complaint calls and check back on them
•
Daily rounds to all rooms and ICUs
•
Accept job order and attend to them
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
20
There are 2 – 3 members working in three shifts. Every floor has one incharge from PCC. They take only written complaints. The usual complaint form contains the following. Room No Nature of complaint Complaint receiving time Completing time Material used Signature of the technician There is a logbook, separate daily report register, ICU and OT register and material requisition voucher book. IMPORTANT DOCUMENTS MAINTAINED BY THE DEPARTMENT •
Working instruction for various equipments
•
Breakdown register
•
Complaint register
•
Calibration record
•
Preventive maintenance schedule for A/C Plant, plumbing, boiler plant, electrical and oxygen plant
•
Daily status report
•
Electrical safety test register
•
Service record
TATA HONEYWELL ENERGY MANAGEMENT
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
21
Apollo Hospital, Hyderabad is the first hospital in India to install state of art energy management and building automation systems in collaboration with Tata Honeywell Limited (THL). The company is in performance contract with the hospital to achieve energy efficient and eco friendly environment. The energy management system developed in collaboration with THL and the contract is drawn out for eight years. The performance contract allows the consumer to increasingly save on energy and build up on infrastructure without out of pocket capital investment at the same time with guaranteed success. BENEFITS: •
Increase in competency and profitability
•
No capital investment
•
Scientific analysis
•
Positive or neutral cash flow
•
Efficient utilization of resources
•
Positive environmental impact
•
Training, monitoring and continuous improvement
OBJECTIVES OF THE CONTRACT: •
To provide an aesthetic and patient friendly atmosphere in the hospital, with enhanced patient care to achieve faster recovery
•
Optimum utilization of resources like water, electricity, fuel etc. to cut down operational cost.
•
Recycling of resources like water and in turn reduce stress on government services.
•
Energy is an important part of infrastructure development. The tie up would help in upgrading the quality and sustainability of the infrastructure.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
•
22
With the vast industrial development the term eco friendly deserves utmost importance. The tie up ensures minimum wastage and thereby culminates into eco friendly set up.
PHASEWISE IMPLEMENTATION OF THE PROGRAMME PHASE I: Energy audit with respect to electricity, water, and fuel consumption was performed Consumption and utilization patterns of resources were studied Study of maintenance of utilities and associated cost were ascertained. It was found that the hospital spent 5% of the sales turnover on these resources.
PHASE II: The above information was used to draw out energy management schedules. Revamping programme of certain equipments and facilities were done. Financing of these equipments were done by SBH.
IMPLEMENTATION AREAS: •
Air Conditioning equipments
•
Steam control
•
Optimization and systems
•
Water system conservation and recovery
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
•
23
Automation
A 100-ton screw chiller, 100-ton Vapor Absorption Machine (VAM) and the water recycling plant were introduced. The screw chiller used for air conditioning consumes 70 – 80% of energy compared to conventional systems. The VAM air conditioning plant operates on excess steam generated by the boiler also conserves energy and hot water residual is again for laundry systems and food warmers in the kitchen and dining halls.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
24
PHASE III
The automated system, which could control temperature of the various AHUs was installed. Various equipments like CT scan, MRI etc. are required to be maintained at particular level of temperature, which was made easier by making the system computerized. This improves the quality and the life of the equipment.
PHASE IV The staffs of the hospital were trained to run the system. The programme focuses on continuous maintenance of the new and existing equipments and training of the maintenance staffs.
BENEFITS TILL DATE: Power consumption has been reduced in all the AHUs mainly by installing monitors, which continuously logs readings facilitating online monitoring Within the first three months of its operation the hospital managed to save Rs. 17 lakhs. The power consumption, which was 15000 units per day, has been brought down to 12000 units per day. Out of the total power consumed by the hospital 60% is for A/C Plant, 20% on lighting, 10% on bio medical and 10% on accessories. The savings on power was made possible only from A/C plant as the other areas are not under the contract of THL.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
The hospital needs 1,50,000 litres of water per day. A sewage water cycling plant was installed to treat the wastewater from the hospital. This water is used for gardening, cooling tower and flushing. This provides saving of the money to be paid to the corporation and helps attain selfsufficiency.
OJT Team A, I Batch
25
Apollo Hospitals, Hyderabad.
26
INTRODUCTION: Hospital acquired infections is a serious problems the health care industry is facing today. The approach to the combat this problem is effective method of disinfections and sterilization and in our hospital it is centrally done at the Central Sterilization &Supply Department, it is an integral and vital part of present day hospitals. LOCATION: It is located on the third floor adjacent to the Conference hall and opposite to the lift , the flow of people are less in this area as compared to the other floors, there is separate lift for dispatch of sterilize material to different departments. The lift opens in the OT AIMS: CSSD is a vital department of the hospital and is responsible for receiving, storing, processing, sterilizing distribution of medical supplies and instrument to all departments of the hospital. The department is based on GCP and run appropriate controls to ensure sterile supply of each article thus help in reduction of incidence of hospital cross infection. OBJECTIVES: The Objectives of the CSSD are: 1. To provide supplies of sterile instrument, linen packs and other sterile items used in patient care. 2. To ensure each cycle has passed the load quality check before dispatch. 3. To maintain records of sterilization process. 4. To monitor and enforce appropriate control necessary to prevent cross infection according to infection control policy. 5.To maintain an inventory of supplies and equipments. 6. Regular update on development in the field. 7.To provide a safe environment for the patient and staff. ACTIVITIES OF THE DEPARTMENT The primary activities of the department are:
Receiving the solid material Cleaning Inspecting equipment, instruments and linen Wrapping for sterilization Sterilization Storing Distribution WORK FLOW: The flow is unidirectional and the personnel must follow the rules strictly. There should be a one person in the sterile dispatch area and this person must not circulate In un-sterile area.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
STAFF & SHIFTS: There are total of 10 members in the CSSD. 3 Shifts from 8 a.m. to 4 p.m. 12 p.m. to 8 p.m. 8 p.m. to 8 a.m.
OJT Team A, I Batch
27
Apollo Hospitals, Hyderabad.
28
PR
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
29
O
EQUIPMENTS USED IN CSSD:
One ETO (ethylene oxide) machine for plastics reuse materials like catheters, ambubags, bed pans, its capacity is 10 bags per load, There are total three auto claves in which two are manual and one is rectal autoclave it is automatic ,used for linen, all surgical instruments, trays, gowns, Temperatures maintained to sterilize the equipments are:
Linens and articles at 20 pound pressure at 30 minutes or 30 pounds pressure at 20 minutes at 120 degrees centigrade temperature. Rubber goods and all glass materials at 10 pound pressure in 15 minutes or 20 pounds pressure in10 minutes at 121 degrees centigrade temperature. The materials which melts at high temperature under steam sterilization they can be sterilized under gas sterilization covered polythene sheet at 56ocentigrade temp for 16 hours by using ethylene oxide gas. The expiry date for autoclave items are 3 days or 72 hours.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
30
The expiry date for ETO items are 6 months.
MONITORING PROTOCOL:
Scope : These guidelines covers the monitoring system for evaluation and validation of the following : Sterilization process including steam, ETO.
Equipment control : Maintenance department must carry out thermocouple test, leak test ,and air detection test periodically
Load control: Done by PCD- PROCESS CHALLENGE INDICATOR DEVICE –every load must have this test passed. Apart from this Biological indicator must be run once every week, incubated and results recorded. These controls help ensure the sterilizing system is working fine, and the specific load is free of any spores . There are different PCD for ETO and steam sterilization.
Exposure and pack control:
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
31
chemical indicator tapes. These controls help issuing officer and user identify a sterile pack and ensure that only sterile item enters a sterile area. CODING FOLLOWED: Color coding is followed in the CSSD according to the department for consistency those are : Color Department Blue Ortho OT Green /White General Surgery Light blue Ophthalmology Maroon Wards and Departments Violet Pediatrics ward Brown Neuro OT A tape attached to each and every kit to indicate load, temperature, date and sterilization. This tape will be in blue color before sterilization and it turns to light green when it is sterilized, to ensure the sterilization. In case of urgency, concern dept.should be mentioned on the kit. QUALIFICATIONS: A diploma or degree in nursing and suitable combinations of education and experience may be considered. A minimum of five years clinical experience working in an acute care environment. Previous experience working in a sterile processing department or operating room is preferred. JOB RESPONSIBLITIES :
Picks up and delivers equipments from all areas of the hospital. Disassembles, clean and checks for proper function of equipments, such as suction machines, feeding pumps, I.V. infusion pumps, etc., Perform minor repairs on equipments, replace worn hoses and installs spare parts as needed. Installs equipment, such as side rails trapeze assembly and Stryker frames, at bedsides as needed. May provide some functional guardians to personnel operating equipments on units. Operates gas and steam sterilizer following authorized procedures Stocks shelves with clean and sterile supplies. Washes and disinfection items, such as bedpans, scissors gloves syringes and tubing with prepared antiseptics solutions and detergents. Dries, wraps ,bags and seal items in preparation for sterilization . Cleans and disinfects the work area. RECORD KEEPING : Scope:
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
32
These guidelines shall cover the record required to be maintained by CSSD with respect to processing equipments,instruments and personnel working in CSSD. Processing equipments : Steam sterilizers: The following records shall be maintained for the sterilizer.
Record of thermograph for each cycle.
brecord of every load PCD.
Chemical indicator.
Weekly biological indicator results.Crush vial(containing bacillus stearothermophilus)after cycle and incubate at 56o C for 48 hours and looked for colour changes.
All records should be kept for 2 years. ETO Sterilizers: The following record per cycle per day for sterilizer shall be maintained.
Chemical indicator.
Spore test or biological indicator results.via (contains Bacillus subtilis subspecies niger)is crushed after the cycle and incubated at 37o C for 48 hours. There should be colour change.
All records should be kept for 2 years. Instruments : Packs trays shall be identified by : Date of sterilization, date of expiry, pack name, operator name, and method of sterilization
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
BILLING DEPARTMENT
OJT Team A, I Batch
33
Apollo Hospitals, Hyderabad.
34
INTRODUCTION: The billing department represents the efficiency of the hospital in providing quality patient care, through revenue collection of various services , rendered by the hospital to the patient
The billing department is divided into following areas as per the services provided: 1) OP billing 2) IP billing 3) Corporate cell
OBJECTIVES: •
The primary objective of the department is to collect the revenue through OP/IP/Corporate billing.
•
Direct patient interaction and clearance of doubts of patients regarding the final bill, charges ,discount etc as per the queries.
•
Keeps proper documentation of the revenue generated and hence gives the information to the management regarding the efficiency and feasibility of the department .
•
Settlement of the doctors fees.
LOCATION: This department is located in the ground floor close proximity to the front office and have a direct accessibility for the patient .
OP Billing: This department is located on the left side of the front office and on the right side of the main entrance.
IP Billing : This Area is located Just behind the Op billing area in the ground floor near the front office.
Corporate Billing : This cell is located in the ground floor behind the main reception but the original corporate /credit bill is generated in the billing section which is located inside the MHC .
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
35
Credit Cell: This is located in the administrative building as it has no direct patient interaction. ACCESSIBILITY: •
Both the IP and OP billing area are directly accessible to the patient and in close proximity to the front office and hence a suitable location for efficient traffic flow.
•
The corporate billing which does not has a direct patient relation but has a functional relation with IP and OP billing is located in the less important area but is easily related to the IP and OP billing.
DESIGN OP Billing: •
There is only a single OP billing for all the services as lab,diagnostics,pathological test,etc.
•
The OP billing doesn’t have a separate waiting area or sitting arrangement but as located close to the main reception the waiting area can be used for the OP billing waiting purpose.
IP Billing: •
The IP billing as located in a separate cabin has a good waiting area but insufficient during peak time.
•
It is divided into four major sections according to the patient requirement as cash, credit, bill making, counseling.
•
There is separate cabin inside the IP billing department for the Billing in charge.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
36
Apollo Hospitals, Hyderabad.
37
MANPOWER: 1Billing Manager for inpatient, outpatient and corporate cell ,and front office. Inpatient and corporate cell has three supervisor and 7 assistant including junior and senior. Outpatient department has 1 supervisor and three assistant.
JOB DESCRIPTION: BILLING INCHARGE •
Cooperation and coordination of billing department function with all other related department.
•
Super vision of the billing function as a whole.
•
Communicating the Information of the performance related report and other vitals to the management as per requirement.
•
Formulating different policies and procedures to be followed by the billing department personnel.
•
Authorisation of all the documents regarding free /discount /etc. bill as per the requirement of the patient and authority.
•
Delegating the authority and responsibility as per the qualification and skill ,and continuous motivation of employees billing being a monotonous work.
BILLING SUPERVISOR: •
Individual supervision of the work area to which they are related as cash , credit, bill making,OP.
•
Coordination of billing assistant to guide and counsel the patient as per their queries.
•
Responsibility of the area to which they are related.
BILLING ASSISTANT: •
Their Primary job is bill generation in the work area
•
Checking the actual bill made by the patient and cross checking to different department regarding the bill and the services actually availed by the patient.
•
Direct communication with the patient hence clearing patient doubt regarding charges discount etc.
•
Entry of all the transaction in the computer regarding the services availed and hence proper documentation of the records.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
TYPES OF BILLING: 1. CASH 2. CREDIT 3. FREE
OJT Team A, I Batch
38
Apollo Hospitals, Hyderabad.
39
4. DISCOUNT
CASH PATIENT: •
Both Inpatient and outpatient cash payment facility is provided.
•
Cash ,cheque and credit card facility all are considered as cash payment.
•
Different credit card facility provided are Master Visa,American Express,Citi Bank, Diner club.
•
The return for such payment is in terms of cash only.
CREDIT PATIENTS: •
Both inpatient and out patient are provided this facility.
•
This facility is given on two basis :
•
Companies patient on the submission of company credit letter with which Apollo has a corporate tie up.
•
Authorisation from a higher authority and also from the billing manager.
•
All the information regarding the facilities that is approved by the company for the patient , determines the service to be provided by the hospital and the bill will be made according to that.
•
In case of an emergency the person is asked to provide the I-card and for the credit letter within certain time period ,if the letter is not received within the time the patient is considered as a cash patient and has to make the full payment.
FREE PATIENT: •
The billing is made free on the basis of authorization from the higher authority, billing manger and for certain hospital staff and for top management personnel.
•
This service can be provided to an outsider on the basis of appropriate authorization only.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
40
DISCOUNT PATIENT: •
Discount is given to the patient on the basis of the packages availed by them or in case of higher authority permission .
•
This can also be received if the person is a hospital staff ,student or a member of Apollo family ,Apollo share holder etc.
FOR AMBULANCE CHARGES:
•
Ambulance charges are not necessarily considered as OP charges but if the patient is discharged from the Emergency directly without admission than the charges are considered as OP charges, and if the patient is admitted in wards operation or Icu’s than the billing is done as Inpatient.
•
The Ambulance charge is according the distance traveled.
OUTPATIENT BILLING:
•
The out patient department caters to the patient for the laboratory, diagnostics, pathological, blood bank , and other OP services provided by the department.
•
The out patient department has a separate supervisor for coordination of the outpatient billing and Inpatient and corporate billing .
•
This department works upto 8’0’ clock in the night after that the inpatient is considered as both inpatient and out patient.
•
Inpatient charges for patient’s ophthalmic surgeries are predetermined by way of packages.
•
Ophthalmic bills are prepared separately by ophthalmic billing and the cash is paid to the cashier at the ophthalmic block prove to surgery, three copies of bills are issued (Patient copy, Cashier copy, Accounts Copy).
•
Daily revenue collection of Op is between 1,00 ,000-1,50,000/-
Bill generated: Three bills are generated in this counter that are as follows for the CASH PATIENT:
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
41
GREEN BILL: This copy is kept by the patient and is shown to the department while report collection. ORANGE BILL:This copy of bill is given to the department in which the test is conducted and kept as record for the department and entered by the department in the system. BLUE BILL: This copy of the bill is kept with the billing department for maintaining the record of the services provided by the departments,diagnostics etc.and used for tallying and cross checking purpose. CREDIT PATIENT Though all the colour bills are generated for this department also but the Green colour bill generated is given to the credit cell for the account keeping of the companies. BILL INFORMATION: OP NO. NAME DOCTOR DATE TIME TEST TO BE DONE
INPATIENT BILLING: This department facilitates to all the inpatient services provided to the patient and considers all the charges as room charges ,OT charges,F&B charges Laundry,etc.which a patient utilizes during the stay in the hospital. Daily revenue collection differs between 1,50,000- 2,00,000/The Inpatient area is divided into four counters Cash Counseling: It helps to give the patient an estimate of the amount of expenses at the time of admission, reminds the patient periodically about the bill to be paid, returns the excess of initial payment over expenses in the form of cheque. Credit counter: It helps to prepare bill of credit patients, checks for the validity of credit letter and the services approved by the respective company ,coordinates with the credit patient for getting the credit letter, informing the credit limit, counseling of credit patient for the payment of net amount apart from that which are covered by the company after explaining the breakup and enter the accounts of the patients which have not been entered into the system at the time of the procedure.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
42
Cash counter: Receives cash payment and gives a clearance slip to the patient about the discharge .It calculates the balance amount to be paid by the patient after deducting the deposit of the patient . Bill making counter: This counter prepares the bill of the patient at the time of discharge by checking the activity card and the discharge summary from the typing pool or the nursing station and again checking for the facilities availed by the patient for different services over computer as all department are connected online. Running bill: The running bill is generated for the patient during the stay in the hospital on a daily basis . A minimum of 10,000 balances is kept for such patient and patient relatives are intimated about the bill status and are counseled if the bill exceeds the minimum deposit amount. This keeps a regular track of the bill incurred by the patient, reduces the chances of lag payment as the payment is received regularly, and helps the patient to ray in installment instead of the whole bill amount at once. Bills generated: There are two copies of bill generated over here that are as follows: GREEN COPY: This copy is given to the patient as personal copy contains all the break up of the bill and for cash patient the counseling is done at the cash counseling counter and the cash is paid at the cash counter PINK COPY: This copy is kept with the billing department as a record of the inpatient and thus gives a proper documentation system for the billing department for the internal audit purpose. CASH PATIENT: For cash patient the green copy is given to the patient and pink copy remains with the department only. CREDIT PATIENT: For them the green copy is not given to the patient is retained with the department to submit in the corporate cell to be sent to the company. Types of bill: ICS:CASH RATIENT ICR:CREDIT RATIENT IPK:PACKAGE PATIENT IFR:FREE PATIENT
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
BILL INFORMATION: I P NO. NAME ADDRESS REFERENCE BED NO./IF CHANGED DURING THE STAY UHID NO. DATE OF DISCHARGE TIME OF DISCHARGE ADMISSION DATE DISCHARGE ALL DENOMINATION OF BILLS SIGNATURE OF CASHIER/PREPARED BY/MANAGER
BILLING DEPARTMENT FORMAT
I.P BILLING:
DESCRIPTION AMOUNT
I.P NUMBER
U
HID
BED/ROOM
W
ORD
NAME
BILL AMOUNT TAX DISCOUNT AMOUNT
ADDRESS
CREDIT AMOUNT
SEX
DEPOSIT AMOUNT
AGE
REFUND AMOUNT
DOCTOR NAME
RECEPIT AMOUNT
ADMITION DATE AND TIME DISCHARGE DATE AND TIME COMPANY IN WORDS -----------------------------------------------------
OJT Team A, I Batch
BALANCE
43
Apollo Hospitals, Hyderabad.
44
PACKAGEES
RECALCULATE
BILL DETAILS
CREDIT DETAILS
DISCHARGE
TAX DETAILS
CLEAR
DEPOSITE DETAILS
DISCOUNT DETAILS
REFUND DETAILS
CLOSE
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
IP BILLING:
IP NUMBER BED/ROOM NAME OJT Team A, I Batch
45
Apollo Hospitals, Hyderabad.
46
CORPORATE CELL: •
This cell is under the supervision of the supervisor in Ip billing counter along with two assistant .
•
The main function of this department is to prepare the bill of credit patient from companies having corporate tie ups with the Apollo .
•
It sends the bill to the internal audit for the cross checking and again sends the bill to the corporate cell with the bill details, credit letter copy and other documentation required.
•
It maintains the accounts of the company and credit it with the respective patient bill charges.
•
It receives the bill from the company and sends it to the accounts department and settles the companies account for this department for the particular transaction.
•
Inform the department about the changes in the new tie ups and the approved format or facilities to the patient.
ACTIVITIES: CASH COLLECTION: •
At the out patient counter the patient pays for the tests prescribed by the doctor. The data entry operator feeds the data into the computer.
•
Three copies of the bills (different colors) are made. One for patient, one for the accounts department and one for the concerned department.
•
The Cash collected is handed over to the bank after the morning shift, but in the case of night shift it is only on the following day that the cash is deposited in the bank.
•
The Outpatient billing cashier collects the registration money separately and deposit’s it in the bank.
•
There are two shift for depositing the money in the bank for both the inpatient and the outpatient.
RECORDS ,JOURNALS MAINTAINED: •
All data are stored in the computer hence not much records are maintained manually.As all the department are connected online the services that are provided are entered online and hence at the time of preparing the final bill the information is checked online with the activity and the discharge card.
DOCUMENTATION: OUTPATIENT: Doctor consultancy fee book
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
47
Log book:daily collection Day care surgery book: break up details of surgery Iom file Letter file INPATIENT: Credit letters file Iom file Performance report file Log book
DISCHARGE PROCEDURE: •
The doctor allows the patient to be discharged the discharge card and the activity card is received by the Inpatient billing department.
•
After the clearance of the bill the discharge slip for clearance at the nursing station for the patient to be discharged is given and a white slip is given for the clearance at the security at the gate.
•
Discharge can be done at any time during the general shift , no patient are discharged during night.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
48
Apollo Hospitals, Hyderabad.
49
OUTP
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
50
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
51
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
52
Apollo Hospitals, Hyderabad.
D
OJT Team A, I Batch
53
Apollo Hospitals, Hyderabad.
54
OPHTHALMOLOGY OUTPATIENT BILLINGS: •
Registration is carried out at the Apollo eye research foundation on payment of the registration fees. The patient fills an initial patient record.
•
A consultation fee is paid at the registration counter with a registration fee of Rs.50/- as a prove to meeting the doctor.
•
If the patient required purely ophthalmic tests, the payment is done at the OP billing counter.
INPATIENT BILLINGS: •
All inpatient billing is done in the main IP counter like any surgery ,operation charges, and other inpatient stay and service charges.
CANCER UNIT Outpatient Billing: •
A separate billing counter is there for the cancer block and money is collected separately at the reception of the cancer block as per the procedure .
•
The charges are posted according to the investigation prescribed by the doctor and bill is ,made on the basis of charges of different diagnostics or therapeutic procedure charges.
•
The cash deposit of the billing is sent to the bank separately and than is given to the accounts department for record keeping.
Inpatient billing: •
The inpatient billing is done through the main IP billing for operative procedures and charges are posted here as OT charges and other charges during the stay.
•
The information regarding the credit billing is same as main reception is sent to the corporate cell
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
55
POLICIES AND PROCEDURES 1.50-55% of the collection goes to the credit patient and credit process is given a vital importance in the department and confusions regarding all such matter is solved by the corporate cell. 2. For Surgeries cash is collected before the surgery. 3. A minimum deposit is taken for the patient admitted as the inpatient as secured money or caution money. 5.
The minimum caution money is maintained till the stay of the patient i.e 10,000/- and the track of this is kept by generating the running bills everyday.
6.
10-15% of discount is given to the patient relative in case of death of the patient or as allowed by the M.D as per the request of the patient relative.
7.
For free patient white ration card is required ,but medicine charges are collected and discount is given as per M.D ‘s instruction.
8.
Charges for employee is free but Ct scan and MRI are charged. Wife and children:75% Mother & father:50% Discount is given as per the above policies.
9.
All employees have an insurance coverage of Rs/- 30,000.
10. Apollo has a tie up with 30-40 companies whose employees are considered as credit patients and they have different tariff facilities according to which the bill is decided for the respective employee. 11. Daily deposit of the cash collection is done but the amount collected in the night shift is deposited with the next day 1st shift . 12. The marketing department does the corporate tie up and intimates the billing department,corporate and credit cell
PERFORMANCE APPRAISED SYSTEM: The performance appraisal in billing department is done by H O D employees are appraised on factors like hours of work put in his motivation, commitment and cooperative attitude. These appraised are kept in mind for approvals.
TRAINING PROGRAMS: The personnel department carries out regular training programs for all the departments in areas like communication, time management, fire safety and fighting etc.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
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There is Job rotation for the personnel’s to have an interdepartmental training and also within the department there is job rotation.
INTERACTION WITH OTHER DEPARTMENT: Accounts department: Keeps the record of all the information and
submits the bank deposit receipt
to the accounts department for the realization of revenue collected.
Corporate Cell: Sends the credit letter and bill to this department for keeping a track and realization of revenue incurred by the hospital services towards credit patients.
Front Office: It is the next service availed by the patient after the front office ,collects the revenue generated in the registration counter , recording and posting all the vital information regarding patient generated in the front office as UHID no.,bed charges according to the availability as of information in admission counter. Interact with all other department providing direct services to the patient as Wards ,ICU’S, Operation theatre , Labs, Diagnostics, Food and Beverages, etc. for keeping an original record of actual charges for different test and cross checking of the services availed by the patient during preparation of the final bill.
COMPUTERISATION: Billing department is fully computerized. There is a single computer on the LAN, which is primarily used as a stand alone for the purpose of creating computerized bills using standard codes for data entry.
OBSERVATION OUTPATIENT BILLING: •
The time taken for the outpatient billing generally varies between 3minutes to 7 minutes depending on peak hour off peak hour and the no.of investigation.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
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There is no separate waiting and sitting arrangement for the Out patient billing counter.
•
Cash collection requires much higher level of security and caution.As the OP billing counter is open the security purpose is not solved as a huge money transaction is also done in this area.
•
A simple tariff chart can be displayed for solving the queries of patient regarding the charges
INPATIENT BILLING:
•
There is no separate notation for the counters inside the Inpatient billing counter and the patient relative move from one counter to another as they don’t know to go to which counter directly.
•
There is not sufficient sitting arrangement for the waiting patient.
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
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I P
OJT Team A, I Batch
Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
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Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
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Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
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Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
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Apollo Hospitals, Hyderabad.
OJT Team A, I Batch
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Apollo Hospitals, Hyderabad.
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