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Chapter III MEDICAL INSTITUTIONS

February 19, 2012


CHAPTER  III
MEDICAL  INSTITUTIONS

Section A – General

301. Definition of a  hospital:-World Health Organization defines the term “hospital” as an institution that provides in-patient accommodation for medical and nursing care. It further elaborates the definition to cover hospitals that assume additional functions- curative, rehabilitative and preventive services-directly or in a consultative capacity, also participating in the training of personnel and in research work.

Note:- Only those beds in hospitals  which provide nursing facilities as one of the basic
requirements, should be considered as hospital beds for the purposes of statistical information. This should also form the basis for formulating proposals for additional beds in hospitals.

302. Criteria for opening Railway Hospitals/Health units and for increasing their bed-strength:-
(1) Health units should normally be 80 kilometers apart, and under no circumstances should this distance exceed 160 kilometers. The latter figure would enable health units to be suitably located on sections where there is large traffic or where the density of railway population is not much high. The exact location of a health unit or hospital should depend on factors such as sufficient concentration of staff at that place, its degree of isolation, availability of non-railway medical facilities in the area, and availability of funds.

(2) The bed strength of the existing hospitals may be considered for increasing suitably when the
occupancy ratio exceeds 110 per cent and where every available space in the existing building has already been utilized for indoor beds.

(3) At places where there are no health  units at present but the minimum daily average outdoor
attendance is expected to exceed 30, a health unit may be planned. The  anticipated outdoor attendance may be determined by estimating the number of railway patients of that place attending the nearest railway/non-railway hospitals/health units or by putting a mobile medical van there.

(4) Building or rooms for ancillary services, such as laboratory, dining hall, X-ray department,
physiotherapy department etc., should be provided for those hospitals where there is justification for the same.
Note:-(i)The detailed procedure relating to preparation/processing of works programme of the
Railways has been enumerated in  Chapter VI –Investment Planning and Works Budget of the Indian Railway Engineering Code. Medical Officers should refer to these instructions while framing their proposals for Works Programme. However some general guidelines on preparation of works programme  are given in Annexure I to this chapter.

(ii) Creation of any additional asset in the form of a hospital, health unit or lock-up dispensary etc. or the closing down of any such institution requires the specific prior approval of the Ministry of Railways.

(MOR’s letters No. 61/M. & H./7/92,dated 3rd March 1962, No 62/H/7/2, dated /4th April1962
D.O.No.62/H/7/49, dated 30th May 1962 from Dr.L.N.Suri,D.H.,Railway Board to G.Ms.,all Indian Railways and No.76/H/3/6, dated 17th November 1977).

303. Criteria for increasing the bed-strength of a Hospital:- (1) All proposals for increasing the
bed-strength of a hospital should be subjected to the following evaluation:-

(a) for the month preceding the month during which the evaluation is undertaken (as per the
discretion of the C.M.D.), a list has to be  made out of all patients admitted to the hospital in question giving the following details:-

(i) Serial Number.
(ii) Name.
(iii) Age.
(iv) Sex.
(v) Disease.
(vi) Date of admission.
(vii) Date of discharge.
(viii) Place of residence
(ix) Place of work & designation.
(x) If operated, date of operation.
(xi) Place wherefrom referred (in case of referred cases).
47

(b) Thereafter, about 5% of these cases have to be picked up at random by applying the Fischer’s
Table.

(c) These sample cases are to be gone into minutely and critically by calling for their complete case
papers by the C.M.D. himself, to see:-

(i) If it were really necessary for all those cases to have come to the hospital.

(ii) If they could not be disposed of at the periphery by developing facilities there.

(iii) If a few could not have been admitted in a nearer hospital even  if it were necessary for these
cases to have been referred to.

(iv) If some of them could not have been discharged earlier with better discharge notes for a good
follow-up in the OPD/Health Unit.

(v) If the stay could not have been made shorter by quicker investigation, better diagnosis and active treatment.

(d) If a systematic appraisal, as indicated above, shows even a very small number of cases which
should not have been admitted, the significance is enormous.  For example, if the number of cases admitted per month is 1,000, 5% of the same would require a detailed examination, viz., 50 cases. Even if one case out of these 50 random cases proves to be a case, the admission of which could have been avoided, it would mean there are 2% of such cases.  In 1,000, therefore the total would come to around 20 such cases, by no means negligible.

Note:- By going through the list as given in sub-paragraph (1) (a) above, particularly items (v),(viii), (ix) & (xi), it may be possible to find out if a certain disease is endemic in a certain area and if it is advisable to take special preventive steps or create  suitable facilities there to bring down the number of such references.

(Ministry of Railways’ letter No. 77/H/3/1/, dated 22nd July 1977).

304. Provision of consulting rooms at the residences of Railway doctors:-(1) In case of such of the Railway doctors only as are allotted quarters at a distance from health units or hospitals, the Administration may provide properly equipped consulting rooms at their residences for dealing with emergency cases and may bear the rent for such accommodation as also the electricity and water charges therefor.

(2) The scale of equipment, the extent  of remission of rent, and the electricity and water charges
should be settled by the Railways in each case in consultation with their Financial Adviser and Chief Accounts Officers.

(Ministry of Railways’ letter No.60/M. & H./12/4, dated 9th October 1961).

305. Equipment for Hospitals.-The type of equipment should vary with the size of the hospital,
facilities offered and should be as per the instructions issued from Railway Board from time to time.

306. Air conditioning of Hospitals:-The following units of a Railway hospital may be provided
with air-conditioners if and when the funds permit.

Operation theatre suites (exclusive of central sterilizing rooms and store rooms), recovery rooms, children’s ward and nursery, a small percentage of the total bed strength of the hospital for serious cases.
X-ray rooms and developing rooms, labour rooms, laboratory  and one consultation or examination room at
one major hospital preferably the headquarters hospital of each Railway for common use by attending medical officers for examining such of the cases as would merit the use of an air-conditioned room.

(MOR’s letters No.61/Elec./115/4, dated 1st May 1964 and 6th September 1966)

307. Prevention of radiation hazards in the radiology department.:-The medical officer in charge
of the radiology department shall take necessary steps to prevent radiation hazards. Besides refinements in the technique, the following steps shall be taken:-

(i) Staff of the radiology department should avoid exposure to radiation as far as possible by
standing behind  protective screen while taking radiographs.

(ii) They should use protective devices like aprons, gloves, etc., when exposure cannot be avoided as in screening.

(iii) All staff of the radiology department should be monitored with film badges provided by the
Atomic Energy Establishment and suitable action taken as advised by them.

(iv) Where repeated over exposures are noticed, investigation of the source should be undertaken in collaboration with the Atomic Energy Establishment and any instructions given by them regarding X-ray Department and the staff should be strictly followed..

(v) All staff exposed to radiation should have total R.B.C.and  W.B.C.count, Hemoglobin
percentage and the differential white cell count done once in three months.

(MOR’s letters No.60/M. & H./7/69, dated 22nd/23rd July 1961 and, dated, 17th Febuary1962)

308. Hospital Visiting Committees.- Hospital Visiting Committees may be formed on the railways
to provide patients with amenities not normally provided under the rules.

(MOR’s letter No.60/M. & H./7/108, dated 18th May 1961)

309. Hospital Advisory Committees.- (1) These Committees shall be formed at Railway hospitals
wherever convenient.

(2) The Committees shall consist entirely of ladies. As far as possible, the members of the Committee
should be wives or other dependents of the Railway employees. The Medical Officer in charge of the hospital may in addition invite ladies not connected with the Railways but interested in social and voluntary hospital work to serve on these Committees.

(3) The Committee will ordinarily consist of not less than four members and not more than eight.
(4)  The membership of the Committee will be by invitation.
(5)  The Committee will elect its president and secretary from amongst its members.
(6)  The members or the office-bearers of the Committee will not be paid any remuneration or
honorarium. The members of the Committee are however allowed to use the Railway staff car free of charge for journeys connected with their duties as members of the Committee.

310. Functions of the Hospital Visiting/Advisory Committees:-(1) The Hospital Visiting/Advisory Committees shall advise the hospital authorities on-

(a) the nature of amenities which should be provided in the hospital;

(b) The arrangement in the wards of the hospital in order to improve the appearance of the wards, e.g., presentation of a shield for the best kept ward;

(c) the ways to make the patient’s stay in the hospital both pleasant and comfortable;

(d) the preparation of menus of the hospital diet taking into consideration the medical aspect of diet; and

(e) the methods to bring about other improvements in the services provided by the hospital.

(2) The Hospital Visiting/Advisory Committees will enquire after the well being of the patients and assist them by bringing their social difficulties to the notice of the hospital authorities.

(3) The Hospital Visiting/Advisory Committees will have purely advisory functions and no executive authority. They will, however, be expected to do voluntary social work in the hospital and its clinics.

Section B-Returns

311. Returns:-(1) The Railway hospitals and health units are required to submit various returns etc.as follows:-

(A) Monthly:-(i) The health units and the outpatients department of hospitals are required to submit information  in the proforma as given in section A of the Monthly Statistical Return (Medical)as circulated under Ministry of Railway’s letter No.64/H/7/34,dated 23rd/26th April 1966, as amended from time to time, directly to the Chief Medical Director. A copy of the return from the health unit should, however, be routed through the CMS/MS of the division, who, before submitting the copy to the Chief Medical Director, should furnish his observation on special features, if any.

(ii) The hospitals are required to submit information relating to the different section of the hospital, as well as the various special clinics under them, in the proforma as given in Section B to L of the Monthly Statistical Return (Medical) as circulated under Ministry of Railway’s letter referred to in the previous sub-para, directly to the Chief Medical Director.

(iii) Further compilation and analysis of the data is to be undertaken in the office of the Chief Medical Director.

(iv) All in-charges of Production Units/Divisional hospitals/Central hospitals should send M.C.D.O every month to their respective C.M.Ds. The chief Medical Directors should send M.C.D.Os to the DG(RHS) every month as per the  proforma. C.M.S/M.S in charge of Production Units should also send a copy of their M.C.D.Os  directly to the DG(RHS).

(B) Annual:- The proforma in which  the General Manager’s Annual Narrative report (Medical
Section) should be prepared, and submitted to the Ministry for information, is as given in Annexure III to Ministry of Railway’s letter referred to above.

(C) Others:-(1)Statistical returns which are  required to be submitted to different authorities like the local and state authorities, the central government and the international agencies like W.H.O.etc.,are required to be compiled in the office of the Chief Medical Director, and forwarded to the authorities concerned.

(2) The Chief Medical Director may also prescribe, keeping in view the local conditions, a restricted number of the other periodical returns, e.g. in  respect of imprest cash, loss of railway property, first-aid boxes and inspection reports of the accident relief medical equipment, etc.

(3) Certain items of the statistical data referred to in the preceding paras should be exhibited in a
standardized graphic manner and should be available in each health unit and hospital in order to provide a ready visual means of assessing and appreciating the work of a particular health unit or hospital, and thehealth problems confronting it.

(4) Besides exhibiting the graphic representation of certain selected statistical data on boards hung up on the walls, a graph book should also be maintained at every health unit and hospital in kalamazoo or similar binder so that it becomes a permanent record of information regarding that particular health unit or hospital.  The graphic representation book will also help in any epidemiological research or study that may be undertaken at any time.

Note: All returns should be analyzed at every  level and appropriate remedial action should be
taken with an aim to improve the performance.

(Ministry of Railways’ letters No.64/H/7/34 dated, 23rd/26th April 1966, 14th October 1966 16th August 1967 and 16th October 1967)

Section C- Boards and Notices

312.  Display of boards and notices :-(1) The boards and notices as indicated below should be
displayed in the various medical institutions.  In addition, some more boards and notices may have to be exhibited to suit local conditions, as also to satisfy statutory obligations.

(i) Sign board of the hospital/health unit       ..      At the main gate.
(ii) Notice board                                  ..      In the verandah.
(iii) Working hours of the hospital/health unit    ..      In the verandah of the out-patients department.
(iv) List of staff on duty                         ..      At some conspicuous place in the verandah of
the out-patients department.
(v) Complaint /Suggestion  Box           ..      At some conspicuous place.

Note :- (1) The sign board  of the hospital/health unit should be written in bold block letters(both in Hindi and English.

(2) The notice board  should  be of  sufficiently  large  size  to  permit  display  of circular for the
information  of the staff.

(3) Complaint boxes are to be maintained at each  hospital/health unit at an easily accessible
place into  which any employees may drop  his  complaint/Suggestion  duly  signed  and  bearing his complete address. The key of the box will be kept by the Medical officer in charge of the hospital/health unit who  will open the box when  he visits  the  hospital/ health  unit  and  after  entering the complaint in the  register, the complaints with the remarks of the Medical Officer in charge of the Hospital/Health  unitin respect of the facts as ascertained by him will be forwarded to the Chief Medical Director, to enable him to decide what action, if  any, should  be  taken.  Minor complaints can, however, be disposed off on the  spot by the  Medical Officer in charge of the Hospital/Health unit.

(2)  Boards regarding prohibition of smoking in Hospitals, dispensaries etc.,(a) In order to
protect non smoking public from hazards of passive smoking at least in public places where large number of people are expected to be present for prolonged periods, it has been decided to prohibit tobacco smokingto start with in a few selected places namely hospitals, dispensaries and other health care centres.

(b)In every room of the office or institution a Board having the following words may be
displayed in Hindi and English “ NO   SMOKING”

( c )Similar Board should be displayed on the wall outside every room of the institution
or office, if there is ample vacant space available for eg., Corridor, Out Patient Department etc.,. Suchboards should be displayed at a distance of every 3 Metres and at a minimum height of 1.5 meters.

At every entrance of the building and also at the entrance of the compound of the building the following words should be displayed prominently in Hindi and English with suitable visuals

“ SMOKING STRICTLY PROHIBITED INSIDE THIS BUILDING AND COMPOUND ”

(G.O.I‘s.O.M.No27/1/3/90-Cab.dt.07/05/1990-DG(RHS)D.O.No.88/H/16/49
dt.09/05/90)

Section D- Fire Fighting

313. Fire Precaution :- In addition to the precautions that one is normally expected to undertake for prevention of fire, hospital personnel have to take special care in respect of inflammable materials like methylated spirit, X-ray films, etc.  where such materials are handled.  Care has also to be taken to see that no leaking plug points, etc. are nearby.

314. Local instruction to Staff regarding fire fighting:- All staff of hospitals/health units i.e., nurse,
pharmacists, clerks, cooks, chowkidar, sweepers, etc. should be instructed as to how they should speedily remove the patients if necessary, and how to extinguish the fire by all available means. Special instructions should be given in Hindi or the regional language to Group D staff.  They should all be instructed how to  handle the effective extinguishing agents, viz.., water, sand, and fire extinguishers of all types.

315. Instructions of Medical Officers in charge regarding fire:- Medical Officers in charge should
also draw up, for each hospital or health unit under their control, the procedure to be adopted in case of fire breaking out, apportioning the duties of each member of the staff.

316. Fire Orders :- (1) Any individual discovering an outbreak of fire will take all necessary steps to quench the outbreak, without causing alarm, if it is in his power.  Should the outbreak be beyond his control, he will give an alarm by means of specified signal.

(2) On receipt of the alarm, a Medical Officer or any other responsible person will inform the fire
brigade, if there be any.

(3) He will inform the Medical Officer in charge, R.P.F. and Govt. Railway Police. The hospital staff
will be organised in two parties. viz..:-

(a) One to remove the patients and Railway property from the place of conflagration; and
(b) The other to extinguish fire and prevent its spread.

(4) Party No. 1 will-

(a) remove all helpless patients to a place of safety on stretchers, backs and hand seats, etc. as the
condition of the patient and the circumstances warrant.
(b) utilize all able-bodied patients in removing the patients and the Railway  property to a place of safety.
(c) remove inflammable drugs, tinctures, etc. first, lest they should catch fire.
(d) collect hospital/health unit records, surgical instruments, portable special medical appliances and
other  portable  equipment  like   clocks, etc., in bed-sheets and remove to a place of safety instead of attempting to remove them to almirahs, and
(e) remove bulky articles, or articles of lesser value, or such articles which are less likely to be
damaged by fire, last of all.

(5) Party No. 2 will-

(a) switch off the electric current.
(b) use fire extinguishers.
(c) draw out water from the nearest taps/wells and throw water on the fire, and
(d) take necessary action in handling  the  patients  whose  clothes  might  have  caught fire like laying them   flat on the ground and covering them with blankets, etc.

317. Fire drills:- Fire drills according to these instructions and according to local instruction issued by the Medical Officer in charge, should be practiced once a month under personal supervision of either the Medical Officer in charge or a Medical Officer nominated for the purpose and recorded in a register.  At the time of their periodical inspections of hospitals and health units, Medical Officers in charge should see that the rules are displayed at conspicuous places and they should satisfy themselves that the instructions are observed and that the staff are aware of their duties when fire breaks out.

Section E-Preservation of records

318.  Preservation of records related to medical department:  Various  records of the hospitals and Health units may be  preserved  as  under :
Particulars of records.                                                                         Period of preservation
1) Tour programmes.                One year
2)  duplicate slips of prescription.                                                      Oneyear
3) Prescription registers of indoor patients.                                Two years
4) Inspection reports of refreshment rooms,  food vendors , stalls etc.                             Two Years
5) ARME/First Aid Boxes inspection reports.                                        Two Years
6) Registers of vaccination/inoculations.                                              Two Years
7) Office copies of inspection reports on Hospitals & Health Units.                Three Years
8) Office copies of reports of infectious cases and deaths                           —-Do—–
9) Works programmes/M&P programmes.                                                 Five years
10) General correspondence files.                                                                  —-  Do—-
11) Ordinary X-ray plates.                                                                              —-Do—-
12) Medical Examination records of Members of Railway Claims Tribunals  ——Do—-
13) Bed-head tickets/Temp.charts/OPD tickets of patients reporting sick  Ten years
14) Sickness, Continuation sickness & fitness  Certificates     —-Do—-
15) Sick / Duty certificates.                                                                                —-Do—-
16) MMR of candidates and X-ray plates pertaining to chest clinic                                      Fifteen years.
17) Medical Board reports.                                                                             —-Do—–
18) Invalidation certificates.                                                                            —–Do—–
19) Initial Medical examination.                                                                    Thirty years
20) Periodical medical examination.                                                             ——Do—–
21) Files of circular letter on policy matters                                                    Permanent
22) Accident reports.                                                                                          —-Do—-
23) Birth Registers.                                                                                             —-Do—-
24) Death Registers.                                                                                           —–Do—-
25) Death certificates.                                                                                          —-Do—-
26) Medico Legal case reports.                                                                             —-Do—-
27) X-ray plates of Medico Legal cases.                                                               —-Do—-

A  strict compliance is necessary in this regard for the sake  of  uniformity.

( Railway Board letter No.92/H/16/9,dated 12/1993and No.94/H/5/8 dt. 01/12/94)

ANNEXURE I

( See Para 302 )

Guidelines on works programme

1. Ministry of Railways during every 5-year plan advises the Zonal Railways the
proposals to be initiated by the Railways to fulfil the plan objectives, subject to availability of
funds. At the zonal level, for the medical Department, the CMD depending upon statistical returns
and discussions with various unit heads should decide where the assets are to be provided on
priority basis to various divisions.

2. Divisions should then formulate the proposals along with detailed justification,
recurring expenditure including abstract of staff, with a sketch plan, duly vetted by Associated
Finance and submit the proposals through the DRM or where they themselves are independent
heads to CE (Planning) endorsing a copy to CMD by 30th April.

3. The Chief Engineer of the Railway will be primarily responsible for ensuring that
the proposals prepared by the various departments are complete in all respects and are correctly
prepared. He will also fix the overall priorities within the ceiling given by the Board in consultation
with the General Manager and other Heads of Departments. He will be responsible for the
preparation and timely submission of the Preliminary and the Final Works Programme.

4. In or about June/July each year the Railway Board should convey to each
Railway, in respect of each plan Head, the total outlay within which the Works Programme should
be framed by the Railway. On receipt of this financial ceiling the Railway Administration should
take stock of the schemes already formulated and those under considerations and select for
inclusion in the Works Programme within the financial ceiling such works as are expected to yield
the maximum benefits to the Railways, preference being given to the works in progress. Further
necessary changes in the investment schedule may be made in order to work within the financial
ceiling for the year such modifications being taken note of in framing the Preliminary Works
Programme and revising the financial implications, if necessary.

5. The Railways  should submit to  the Board  the Preliminary Works Programme
for the following year by 1st week of September or such earlier date as prescribed by the Board..
Proper financial appraisal of each work should be given in the Preliminary Works Programme
together with the comments of the Financial Adviser and Chief Accounts Officer.

6 The project cost should be based on firm data both as to quantity and rates at
current price levels and should any increase occur in prices during the period intervening
between the initial preparation of the project estimate and its inclusion in the works Programme,
the estimate should be updated taking into account any significant changes in the wages and
material prices as well as increase in freights and fares. No other increase, such as on account of
change in the scope of the project, should be allowed without prior reasons being adduced for
acceptance by the Railway Board. Sketch  showing the proposal  should accompany each
proposal.

7. In deciding the outlays for the various works, Railway Administration must
endeavor to process all works in progress speedily and bring them into use at the earliest
possible date. A work which has been sanctioned and for which funds have been allotted for in
the original or supplementary budget of a year should be treated as a work in progress for the
next year and provided for as such in the programme.

8. The Railway Administration should make a realistic assessment of the amount
required for each work in progress and necessary provision should be made for it in the works
programme. In estimating the provision for works during the budget year a generous allowance
be made for those delays in execution which though unforeseen are known from experience to be
so liable to arise particularly prior to inception and during the initial stages of the large projects.
The provision made should take into account adjustment on charges connected with the project.

9. In exhibiting the outlay for the current year against individual work in the works
programme, the outlay should be as per pink book and in exceptional cases where the Railways
propose any substantial increase in the outlay with corresponding reductions against other works
such revised outlay may be shown separately in brackets below the outlay as furnished in the
pink book duly explaining the reasons for doing so in footnotes at the appropriate places. As far
as possible only the last sanctioned cost should be exhibited. Where it is visualized that the cost
would involve an excess over the last sanctioned cost effective steps should be taken well in time
to have the revised estimates prepared and sanctioned by the competent authority before the
works programme is sent to the Board. In case where the revised estimates are sanctioned
subsequent to the dispatch of the final works programme but before the end of January of the
following year the, same should promptly be advised to the Board to enable the latest sanctioned
cost being exhibited in the pink book to be circulated along with the budget. In all cases of the
revised cost sanctioned by the Board, reference to the letter of sanction should invariably be
indicated.

10. Works once introduced through a works programme and taken up after the
estimates have been sanctioned by the competent authority should continue to be included every
year till they are finally completed, except in cases where the works have reached the completion
stage and where funds required are meager and  could be found by reappropriation.

11. The items in the work programme should be grouped under the following categories
1) New works.
(2) Works in progress.
(3) Works approved in earlier years which have not been actually commenced and on which no
expenditure has been incurred till 30th June of the year previous to the programme year.

4) Works approved in earlier years but estimates for which have not been sanctioned by 30th
June of the year previous to the programme year.

12. After having examined the individual Railway’s programme and discussion with
the general managers, the Railway Board will  decide the works which should be undertaken
during the following year and which should be included in the final works Programme. The
Railway Administration will then modify their works Programme as a result of the Boards decision
and send their final works Programme to the Railway Board by the stipulated date.

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