HEALTH CARE SERVICES

¨Health-care services to patients are provided primarily through physicians' offices (clinics) and in hospitals.

¨Pharmaceutical services to patients that are seen in physicians' offices have been provided through community pharmacies, while patients in hospitals normally receive pharmaceutical services through the hospital pharmacy.

THE HOSPITALS

¨ A hospital is may be defined in terms of its form, that is, its physical makeup and the quantitative nature of its services.

¨To be registered as an institution, it must meet certain requirements.

¨ A hospital may also be defined in terms of its broad purpose or mission instead of its physical form.

¨ It may be viewed as an organized structure that pools together all the health professions, the diagnostic and therapeutic facilities, equipment and supplies, and the physical facilities into a coordinated system for delivering health care to the public.

¨While the hospital once was considered only a place where patients were treated, today it is considered a viable institution that extends its services to patients wherever they may be located.

 Hospitals provide services to patients within the institution itself (hospitalized patients); in ambulatory-care clinics, emergency rooms, and emergency care centers; in physicians' offices at hospitals; in extended care facilities and nursing homes either affiliated with or owned by the hospital; at home, through home health-care services; at wellness centers; and at community health clinics 

THE CLINIC

¨ A clinic is a facility or area where ambulatory patients are seen for appointments and treated by a group of physicians practicing together, and where the patient is not confined, as in a hospital.

¨ The term clinic also is used to indicate the ambulatory patient diagnostic facility operated by a hospital and also facilities operated by other agencies for the care of indigent and medically indigent patients.

¨ In the past the term clinic usually has been reserved for facilities of a teaching nature where medical students and resident staff offered treatment to patients unable to afford private practitioners. 

REQUIREMENTS FOR ACCEPTING GENERAL HOSPITALS FOR REGISTRATION (a sample)

1.The institution shall maintain at least six inpatient beds which shall be continuously available for the care of patients who are nonrelated and who stay on the average in excess of 24 hours per admission.

2. The institution shall be constructed, equipped and maintained to ensure the health and safety of patients and to provide uncrowded, sanitary facilities for the treatment of patients.

3. There shall be an identifiable governing authority legally and morally responsible for the conduct of the hospital.

4. There shall be a chief executive to whom the governing authority delegates the continuous responsibility for the operation of the hospital in accordance with established policy.

5. There shall be an organized medical staff of physicians that may include, but shall not be limited to dentists. The medical staff shall be accountable to the governing authority for maintaining proper standards of medical care, and it shall be governed by bylaws adopted by said staff and approved by the governing authority.

6. Each patient shall be admitted on the authority of a staff member who shall be directly responsible for the patient's diagnosis and treatment. Any graduate of a foreign medical school who is permitted to assume responsibilities for patient care shall possess a valid license to practice medicine, or shall be certified by the Educational Council for Foreign Medical Graduates, or shall have qualified for and have successfully completed an academic year of supervised clinical training under the direction of a medical school approved by the Liaison Committee on Medical Education of the Medical Association and the Association of the country.

7. Registered nurse supervision and other nursing services are continuous

8. A current and complete medical record shall be maintained by the Institution for each patient and shall be available for reference.

9. Pharmacy service shall be maintained in the institution and shall be supervised by a registered pharmacist.

10. The institution shall provide patients with food service that meets the nutritional and therapeutic requirements; special diets shall also be available

11. The institution shall maintain diagnostic X-ray service, with facilities and staff for a variety of procedures.

12. The institution shall maintain clinical laboratory service with facilities and staff for a variety of procedures. Anatomical pathology services shall be regularly and conveniently available.

13. The institution shall maintain operating room service with facilities and staff.

DEVELOPMENT AND EXPANSION OF HOSPITALS

¨ Hospitals had their origin in Indian and Egyptian culture during the 6th century BCE.

¨ Evolution of the hospital is related to the sociological development of the individual's expansion of interest beyond himself and his family to the welfare of the community.

¨ Although early hospitals were really places to remove people from society to protect society-the insane, the incurables, and the contagious.

¨ Other hospitals were developed through religious and divine motives.

¨ The temples of the gods in early Greek and Roman civilization were used as hospitals where healing was associated with divine powers, while continued illness or death was associated with a lack of purity.

¨ Greek temples were forerunners of the modern hospital in the sense that they provided refuge and treatment for the sick and also provided for the teaching of young medical students.

¨ Such temples as the Temple of Aesculapius (Greek god of Medicine) existed in 1134 BCE, while the temple at Kos, Greece, was where Hippocrates (born about 460 BCE) practiced.

¨ One of the dominant factors in the development and expansion of hospitals was the religious influence.

¨Prior to the Christian Era, hospitals were temples dedicated to the god of medicine in which care of the sick was accompanied by magical, mystical, and religious ceremonies.

¨ The strong motivating forces of civilization (viz. toward one's fellow man gave impetus to the expansion of hospitals.

¨ Another major factor in the development and expansion of hospitals devolves from a military influence. Much of the impetus toward medical and surgical progress over the centuries has come from the urgent need for care of the wounded on the battlefield.

¨ Another factor that influenced the development and expansion of hospitals was medical education, which caused revolutionary developments in medical education and in medical internship training, which helped the development of minimum standards for patient care in hospitals.

¨ The activities of Florence Nightingale during and after the Crimean War, which served as the basis for revolutionizing the quality of nursing in hospitals and for the development of schools of nursing in the hospitals.  

¨The public interest in hospitals through greater dependence and improved confidence in hospital care also influenced the development and expansion of hospitals. This public interest extended its influence into private hospitalization insurance and government participation in health care.

¨ Beyond the three basic essentials of human existence (food, clothing, and shelter), the hospital has become a necessary instrument for providing a fourth basic element of survival health.

¨ Health care has become to a right for all, rather than a luxury for a few. In the future, hospitals will be an integral part of a health-care system rather than a free­standing entity.

¨ Hospitals will expand their scope of activity to include ambulatory care, wellness, acute care, emergency care, home-care, and long-term care

CLASSIFICATION OF HOSPITALS

¨ Hospitals may be classified in four different ways, by

        Type of service  Ownership

        Length of stay  Bed capacity

¨Hospitals are classified by type of service as either general or special hospitals.

¨ General hospitals provide care to patients with any type of illness: medical, surgical, pediatric, psychiatric, and maternity.

¨ Special hospitals are those that restrict the care they provide to special conditions, such as cancer, psychiatric, or pediatric cases.

 

 

 

¨Hospitals are classified by length of stay as either short­ term or long-term.

¨ A short-term hospital is one in which the average length of stay of the patient is less than 30 days. Patients with acute disease conditions and emergency cases usually are hospitalized for less than 30 days.

¨ Usually, general hospitals are short-term, since acutely ill patients usually recover in less than 30 days.

¨ A long-term hospital is one in which the average length of stay of the patient is 30 days or longer.

    © Such patients have long-term illnesses, such as

        psychiatric conditions.

¨Hospitals are classified by ownership usually as governmental or nongovernmental.

¨ Nongovernmental hospitals may be:

      Nonprofit hospitals

      Profit earning hospitals

Hospitals generally are classified by bed capacity according to the following pattern:

Under 50 beds

50-99 beds

100-199 beds

200-299 beds

300-399 beds

400-499 beds

       500 beds & over

GENERAL FUNCTIONS OF HOSPITALS

¨ Traditionally, the hospital's basic purpose for existence has been the treatment and care of the sick and injured.

¨ In conjunction with this basic function, hospitals have been concerned with teaching, particularly of medical students ever since the pre-Christian Era of Greek medicine.

¨ Research has been another function of the hospital. In modern times a fourth function has been assumed by hospitals, namely, public health (preventive medicine or wellness).

¨ Thus, the four fundamental functions of hospitals are patient care, teaching, research, and public health.

Patient Care:

¨The modern hospital is charged with maintaining and restoring health to the community that it serves.

¨ Patient care involves the diagnosis and treatment of illness or injury, preventive medicine, rehabilitation, convalescent care, dental care, and personalized services

¨The other three functions exist because they contribute either directly or otherwise to the care of the sick and injured.

¨ Emergency care of the injured commands prime attention in any hospital and is as important as the care of the in-patient.

¨ Ambulatory patient care also has become an important part of the hospital's responsibility to the community.

¨ In providing patient care, hospitals usually have two basic types of accommodations, based on the patient's ability to pay: the full-pay (private patient) and the partially or totally medical indigent (charity) patient. 

Education:

¨This is an important function of the modern hospital, whether it is or is not affiliated with a university.

¨ Education as a hospital function is of two major forms:

1.Education of medical and allied health professions: §This form includes physicians; nurses; medical social service workers; medical record librarians; dietitians; X-ray and laboratory technicians; medical technologists; respiratory, physical, and occupational therapists; hospital administrators; pharmacists; and others.

  § The hospital's educational program for these groups includes formal programs (such as medical and nursing schools); in-service training programs for professional per­sonnel, such as residencies; and on-the-job training programs for non­professional personnel.

 

. Education of the patient:

§ It includes providing general education for children confined to long-term hospitalization; special education in the area of rehabilitation-psychiatrically, socially, physically, and occupationally; and special education in health care, for example, teaching diabetics or cardiac patients to care for their ailment or teaching colostomy patients who require reorientation in caring for their personal needs.

Research:

¨ Hospitals carry out research as a vital function for two major purposes:

  · the advancement of medical knowledge against disease

  · and the improvement of hospital services.

¨Examples of research activities in the hospital include devising new diagnostic procedures, conducting laboratory and clinical experiments; developing and perfecting new surgical procedures or techniques, and evaluating investigational drugs.

¨ Other examples include research to improve administrative procedures for greater efficiency and lower cost to the patient; improvement of accounting procedures for more-equitable cost distribution of services; and designing, developing, and evaluating new equipment and facilities to improve patient care.

¨Many drugs are evaluated in hospitalized patients before they are marketed, and thus the clinical evaluation of investigational drugs presents many opportunities for the hospital pharmacist to participate in research.

¨ Pharmacists are involved in many other types of research, such as pharma­cokinetic studies involving individualization of drug-dosing in patients, biopharmaceutical studies of drug products and radiopharmaceutical dosage formulations, and pharma-co-economic studies, as well as administrative and professional studies on drug-distribution systems, the effectiveness of clinical roles of pharmacists, and drug-utilization review studies.

Wellness:

¨The prime objective of this function is to assist the community in reducing the incidence of illness and improve the general health of the population.

¨ Examples of public-health activities are the close working relationships many hospitals have with public-health departments of communicable diseases; the participation in disease detection programs as for tuberculosis, diabetes, hypertension, and cancer; the participation in mass public inoculation programs such as those against influenza and poliomyelitis; and the participation of hospital ambulatory-care departments in teaching better routine hygienic practices, wellness clinics, and exercise and fitness programs, as well as ways in which patients should care for themselves when illness strikes.

 Hospital pharmacists have an opportunity to contribute to this function by providing health-information brochures and services to outpatients and by instructing them on the safe use of drugs and poison-prevention measures

ORGANIZATION AND ADMINISTRATION OF HOSPITALS

¨ There is always a governing body of some sort to which the administrator, Chief Executive Officer (CEO), president, director, superintendent, medical director, and chief administrative officer must report.

¨ In governmental hospitals the governing body is usually from the political subdivision in which the hospital is located but need not be so when persons of special ability are concerned or in cases where political pressure is applied.

¨ In the nonprofit, nongovernmental hospital, there is usually a governing board, board of trustees, board of governors, or other titled group that assumes overall responsibility for the proper operation of the hospital so that adequate service can be rendered to the sick and injured at as low a cost as is compatible with efficiency.

¨ Legally the responsibility for injury or other act by a member of the hospital staff on the hospital grounds reverts back to the governing board, although the individual hospital personnel is involved.

¨The duties of the governing board which are performed through the chief executive officer, are:

   ·  the responsibility for the selection of competent personnel,

   ·  control of hospital funds,

   · supervision of the physical plant,

   · establish the working hours and conditions, salary schedules, and proper

       checks on personnel,

    · establish a schedule of room rates and other charges for hospital inpatient

       and ambulatory care

    · devise methods for obtaining endowments and other grants to supplement

      income from paying patients and help to balance the hospital budget

   · invest endowment funds and other grants, from which the interest is to be

       used for operating or other expenses wisely.

    · make certain that there is an adequate accounting system and provide for

       routine audit of the accounts.

   · determine the needs for additional or replacement construction of the

       physical plant of the hospital

   · contract with the most advantageous bidder

¨The governing board has its own internal organization, consisting of a president or chairman, vice-chairman, secretary, and treasurer. On many boards the chief executive officer of the hospital serves as the secretary.

¨ There are usually certain standing committees appointed, such as

         · The Executive Committee.

         · The Hospital Committee dealing with personnel appointments

             and with other activities of a departmental nature.

         · The Finance Committee, which is concerned with the hospital

            budget, room rates, and other financial matters.

         · A  Public Relations Committee, which is concerned with

           educating the community on the value of the hospital and with

           maintaining a desirable relationship with the community.

¨ There may be other committees appointed as the need arises, such as an expansion and development committee when the hospital is concerned with the need for construction of additional hospital beds.

¨The CEO is often the secretary of the governing board and reports to it all essential facts concerning the operation of the hospital and receives from the board all directives it issues.

 §The CEO must have initiative and leadership as well as executive ability to carry out his or her responsibilities.

 § All functions of professional care of the patient must be carried on within budgetary limitations, and there must be interdepartmental cooperation and harmony.

¨Depending on the size of the hospital there may be one or more associate and several assistant administrators.

¨ The CEO also appoints heads of departments.

¨ The department heads have the responsibility of operating the departments effectively and properly within the overall policies and philosophies established by the hospital's governing board.

¨Among the many departments that make up the modern hospital there are some in which the services involve primarily the professional care of the patient, while the services of other departments involve mainly the business management of the hospital.

¨ Some of the departments that deal with the professional care of the patient are:

Ambulatory Care, Anesthesia Blood Bank,

Clinical Laboratories, Dental Service,

Dietary and Nutrition Service, Electrocardiograph Laboratory, Electroencephalograph Laboratory, Emergency Room,

Medical Library, Medical Records, Medical Social Service, Nuclear Medicine, Nursing Service, Occupational Therapy, Pharmacy Service, Physical Medicine, Radiology & X-Ray Therapy, Respiratory Therapy.

¨Departments that deal with the business management or administrative side of the hospital include:

Accounting, Admitting, Biomedical Engineering, Business Office, Cafeteria & Coffee Shop, Central Transportation, Credit & Collection, Computer Services, Engineering & Maintenance Housekeeping, Information Service, Materials Management, Personnel & Payroll, Purchase & Store Room, Telephone Switchboard, Volunteer Service.

 

THE HOSPITAL PHARMACY

¨Institutional or hospital pharmacy may be defined as the practice of pharmacy in a hospital setting including its organizationally related facilities or services.

¨It also may be defined as that department or division of the hospital wherein the procurement, storage, compounding, manufacturing, packaging, controlling, assaying, dispensing, distribution, and monitoring of medications through drug-therapy management for hospitalized and ambulatory patients are performed by legally qualified, professionally competent pharmacists.

 

¨The practice of pharmacy in a hospital also includes broad responsibility for the safe and appropriate use of drugs in patients, which includes, among other things, the rational selection, monitoring, dosing, and control of the patients' overall drug-therapy program.

¨ This added dimension requires the application of patient-oriented services superimposed upon the pharmaceutical sciences - to the subject of rational therapeutics. This approach to pharmacy practice is termed as clinical pharmacy.

¨ Clinical pharmacy is simply good, professional, patient-oriented pharmaceutical services.

¨ Pharmaceutical care is the direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patient's quality of life.

EXCELLENCE OF HOSPITAL PHARMACY

¨ There are some socio-medico-economic factors and organizational forces that acts on the practice of pharmacy in the hospitals.

¨ A major factor is the organizational structure of a hospital.

    · A formalized pattern of authority, responsibility and coordination

       that affects every department of the overall health­care team.

¨ The administrator implements the policies and philosophies of the governing board, delegates authority, and passes on responsibility to department heads to carry out the patient care, teaching, research, and public-health objectives of the hospital.

¨ Department heads, such as the director of pharmacy, coordinate their services and activities with other department heads; the business and accounting department handles the financial affairs; the building services department provides the essential maintenance, housekeeping, and security functions; the human resources department implements personnel policies; the clinical laboratory department performs a multitude of patient laboratory tests and services; and dozens of other departments influence and affect the services of all hospital departments.

¨In addition to the traditional physician-pharmacist-patient relationship, there is a physician-pharmacist-nurse-patient relationship in the hospital. Thus, the hospital pharmacist must work not only with the physician but also very closely with the nurse.

¨ In addition to the internal forces operating within the hospital there are some external forces that affect, in various ways, the practice of pharmacy in the hospital setting.

   § For example, accreditation agencies exert their influence on professional standards of practice as they affect patient care.

    § Licensing agencies exert legal influences on hospital operations.

   § Social agencies and governmental welfare agencies influence the services provided to medically indigent and totally indigent patients.

    § The governing board and public opinion exert their influences over the policies, objectives, and philosophies of hospital operation and practice. 

DEPARTMENTAL FUNCTIONS OF A HOSPITAL PHARMACY

¨Within the organizational pattern, the functions of the department are:

1.To provide and evaluate service in support of medical care pursuant to the objectives and policies of the hospital.

2. To implement for departmental services the philosophy, objectives, policies and standards of the hospital.

3. To provide and implement a departmental plan of administrative authority which clearly delineates responsibilities and duties of each category of personnel.

4. To participate in the coordination of the functions of the department with the functions of all other departments and services of the hospital.

5. To estimate the requirements for the department and to recommend and implement policies and procedures to maintain an adequate and competent staff.

6. To provide the means and methods by which personnel can work  with other groups in interpreting the objectives of the hospital and the department to the patient and community.

7. To develop and maintain an effective system of clinical and/or administrative records and reports.

8. To estimate needs for facilities, supplies and equipment and to implement a system for evaluation, control and maintenance.

9. To participate in and adhere to the financial plan of operation for the hospital.

10. To initiate, utilize and/or participate in studies or research projects designed for the improvement of patient care and the improvement of other administrative and hospital services.

11. To provide and implement a program of continuing education for all personnel.

12. To participate in and/or facilitate all educational programs which include student experiences in the department.

13. To participate in and adhere to the safety program of the hospital.

SPECIAL QUALITY OF HOSPITAL PHARMACISTS

¨The setting within which the hospital pharmacist practices requires special education or experience to practice with maximum effectiveness.

¨Unlike the pharmacist in community practice, the hospital pharmacist must function within an organization that has additional responsibilities beyond patient care.

¨These additional responsibilities include education, research, and public health.

¨Thus, there is a healthy trend in developing toward group practice in hospital pharmacy, analogous to group medical practice.

¨ A number of these specialists in different areas of hospital pharmacy practice make up the team of pharmacists in today's progressive hospital.

ORGANIZATION AND ADMINISTRATION OF HOSPITAL PHARMACY

¨Within the organizational structure of the hospital, the director of pharmacy, as a department head, reports to the administrator of the hospital on the proper operation and management of the pharmacy.

¨ The director of pharmacy formulates and implements departmental administrative and professional policies of the pharmacy, subject to the approval of the administrator.

¨ The professional and clinical policies relating to hospital pharmacy practice, which have a direct relationship to the medical staff, are formulated and developed through the pharmacy and therapeutics committee and are subject to administrative approval.

 

¨ Coordination and integration of all the technical elements of practice must be implemented effectively into a total pharmaceutical service.