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Home - Strategy - Article


Streamlining Linen in Hospitals

Information technology, ozone laundry systems, disposable linen and outsourcing are changing the face of linen management in hospitals, finds out Sonal Shukla

Location courtesy: Jaslok Hospital

Bad linen services is one of the most frequently heard complaints in a hospital. Attention to patients' personal needs and comforts are as important as the physician's medication and therefore adequate supply of clean linen becomes imperative. Besides helping in maintaining a clean environment, clean linen is a vital element in providing high-quality medical care. Also, pleasant employees in a fresh and neat uniform go a long way in creating a positive image of the hospital.

"Linen management plays a great role in patient satisfaction, reduces infection rate and operation costs and plays an important role in physician satisfaction," says Dr J Damodharan, Medical Director, SRMC, Chennai. Agrees Savinder Kaur, Director, Support Services, P D Hinduja Hospital, Mumbai, "Efficient supply of linen without any defect and delay in time becomes a good support towards delivering timely quality healthcare services to the patients." If the hospital does not have proper supply chain of linen, then this may lead to the delay in OT and ICU procedures, patient care services, delay in CSSD operations and ultimately the entire hospital operations suffer.

Sufficient Quantity

"Linen management reduces infection rates and plays an important role in physician

- Dr J Damodharan
Medical Director
SRMC, Chennai

"In-house activity can ensure that quality control is exercised at all times"

- Col Manesh Masand
Jaslok Hospital, Mumbai

In today's medical care facilities, patients expect daily linen changes. In areas like ICUs, linen has to be changed even more frequently. Often, the requirement of linen increase by 25 per cent in OT, cath lab and ICUs areas. "To enable the laundry to meet such a demand, the hospital should have a sufficient quantity of linen for circulation," shares Col Manesh Masand, CEO, Jaslok Hospital, Mumbai.

Its supply is crucial in the public's perception of the quality of patient care provided by the hospital. Some hospitals also have contract with third parties to manage its laundry requirements. Relationships between the launderettes and hospitals get strained as hospitals face shortage of linen during crisis. Many a times, it is difficult to count soiled linen. This creates a rift between the hospital and the linen contractor. Consequently, hospitals lose on stock of linen, as new linen needs to be constantly bought to replace torn and soiled ones.

Shortage of linen leaves patients dissatisfied. Sometimes, even surgeries get cancelled due to shortage of operation theatre linen. Also, due to uncertainty in arriving at correct stock, new linen is purchased which results in increasing costs. "In order to overcome the above problems, it is imperative to have a linen management system that automatically tracks soiled and clean linen items continuously through the entire linen cycle. It is also essential to reduce the quantity of buffer linen stock at hospitals and ensure service quality standards," shares R Jeyakumar, General Manager, KG Hospital, Coimbatore.

Laundry Services

Laundry of linen is another essential function for all institutional housekeeping departments, but in healthcare facilities, laundry plays an even more important role—it not only contributes to comfort and aesthetics, but also assists in infection control. Because of its high level of energy, chemical and water consumption, laundry processing also has a significant impact on hospitals' environmental and financial bottom line. A study by American National Standards Institute (ANSI) and the Association for the Advancement of Medical Instrumentation (AAMI) showed that when laundered properly, reusable garments and drapes are 70 per cent more effective in providing barrier protection. Like any department, laundry services must continuously find ways to increase efficiency and decrease costs. Today, several developments in laundry technologies and products have enabled laundry managers to reduce energy and water-use significantly and to reduce the impact of laundry chemicals on the environment.

Hinduja Hospital is updating its laundry module in the hospital information system. "We have been following concepts such as supply chain management and EOQ model for inventory management," shares Kaur. The hospital has streamlined this area by acquiring new technology for laundry equipment, updating laundry module in HIS through BPR, applying quality chemicals for laundry operation for effective results, quality circle in linen management and continuous training for all team members.

IT in Linen Management
A few of the modules and programmes that are being implemented by IT in linen management are as follows:

Central Laundry Linen Management Software System: Within large central laundries, there is a need for systems to manage linen flow throughout the operation. The following systems provide a complete loop control system.

Shipping System: A weight-based system that allows for the capture of total weight being shipped, total soil being received and tracking of linen carts as they are shipped to customer sites.

Linen Quota Management System: Represents daily linen requirements for all customers, prints linen orders that are filled in a production facility, provides analysis for production requirements, labor costs and billing.

Uniform Tracking System: By employing bar code technology, this system provides comprehensive tracking of scrub suits, lab coats, patient linen and hospital-owned linen.

Linen Billing System: Models all billing requirements that may be encountered by a linen management facility, such as weight, piece, soil ratio and linen loss.

Linen Inventory Management System: Comprehensive management of linen inventory. Provides detailed analysis reports of new and used inventory.

Controlling Infection

Linen can be contaminated via blood and any other body fluids, as well as by improper handling and storage. Clean linen does not need to be sterile (free from all microbes), but correct handling can help prevent the growth of micro-organisms that can develop under poor conditions.

"Although soiled linen can be contaminated with pathogenic microorganisms, actual disease transmission from linen has been demonstrated to be negligible if it is handled, transported and laundered in a manner that avoids dispersal," says Dr BK Rao, Chairman, Sir Ganga Ram Hospital, Delhi. The right choice of linen should also be kept in mind as it affects patient care and healthcare costs. The inventory needs to be scientifically stocked and maintained. "It should be remembered that, 'more is not always better' and any benign abuse is preventable, though margin for pilferage needs to be accommodated in the inventory stock," shares Dr Rao.

Ozone Laundry Systems

Hospitals benefit by having a laundry module in HIS

Hospitals are using ozone treatment as an adjunct to conventional laundry chemicals

The linen room must be close to the laundry or washing area to facilitate movement

An increasing number of institutional laundries are today adapting ozone treatment as an adjunct to conventional laundry chemicals and methods. Ozone laundry systems work by injecting ozone into washwater. The ozone molecule breaks down rapidly, oxidising the fatty oils that cause dirt to bind to cloth, disinfecting water and bleaching linens while doing so. Ozone's only breakdown by-products are oxygen and water. Because it involves no chemical residues in fabrics, it requires less rinsing than other bleaching agents. "Ozone technology promises better deodorisation, shorter laundry cycles and improved sanitation, all with the use of lower temperature water, which saves on energy consumption and costs," states Jeyakumar.

Purchasing & Stocking

In a multi-specialty hospital, the ratio of beds to linen should be in the ratio 1:4 or 1:5. "In an eye hospital, the ratio 1:3 is sufficient, as the patients do not stay in the hospital for more than two days, and there is very little scope for emergency change of linen, such as blood stain or oozing of wounds," states Jeyakumar. The type of linen purchased depends on the culture and system of the organisation. The linen may be cotton or terry-cotton, printed or plain, with or without logo of the hospital printed on it. The linen may be uniform for all rooms or different categories of rooms, and different wards may have different colours.

"All linen must be stored in a central place—the linen department. This way it is easier to have a better control on the washing, distribution and maintenance of linen. This linen room must be situated close to the laundry or the washing area to facilitate movement," says Jeyakumar. Experts suggest that linen should be stored in cupboards which are neatly labeled on the outside and on the inside, indicating the type of linen stored and the area to which it belongs. Stock of all linen should be taken every week. This helps tracing any linen that has been misplaced, and also helps in tracking damaged linen. Repair to damaged linen should be carried out immediately. Linen that cannot be repaired has to be set aside for condemnation, which should be carried out once a month. This close monitoring of linen helps in good maintenance of linen and stocks.

Disposable V/S Reusable

Many hospitals in India prefer using re-usable linen (which can be washed) over disposable due to its high cost. The disposable linen includes caps and masks while reusable linens are bed sheets, gowns, pillow covers, draw sheet, blankets and green linen. "The disposable linens cannot be washed.

The advantage of disposable linen is that they are 100 per cent impervious to blood and body fluids as well as virus and bacteria. The operation room table, mattress, armboards and positioners will stay clean and dry, no matter how messy the case. "This will greatly enhance infection control, dramatically improve turnover time and allow for reuse of foam positioners, thus decreasing cost and decreasing waste," states Jeyakumar.

In countries like the US, they say that disposable linens are not more expensive when one considers the benefits of the impervious sheets compared to the linen sheets. The impervious linens improve turnover time, enhance infection control, eliminate abuse of linens and extend the life of positioners and/ or table mattresses. But in Indian hospitals, the tendency is towards reusing the linen after proper washing and sterilising, which also results in cost effective and inflectionless treatment. "For highly infected patients like HIV positive, HBSAG positive and HCV positive, we may use disposable linen, instead of reusable linen, so as to avoid infection,' adds Jeyakumar.

Experts feel that using reusable linen products rather than disposable linen can help healthcare organisations achieve its waste reduction goals and also reduce costs. The quality and practicality that comes with the conventional linen can never be replaced or substituted by the coarse feel of disposable linen and that professionally laundered linens provide the healthcare facility with a more crisp and customer-centered image.

"Disposable products are often touted as less costly, but at the end of the day when a life cycle analysis is used, this argument should be reassessed. Consistent with a facilities mission of environmental stewardship and cost containment, healthcare facilities can effectively reduce solid waste in their operations and save money by switching to reusable products where feasible," believes Dr Rao. True and actual costs of disposable linen via cost analysis which should account the purchase price along with parameters like cost of waste disposal, occupational health cost(s), opportunity cost, carrying cost and environmental impact. "It's a known fact that disposable products come with an added burden of excess waste generation and costs incurred in labour and waste disposal need to be considered at the time of deciding between it and the conventional counterpart," adds Dr Rao.

Technology to Aid

The advent of computer and microprocessor controls in the various laundry equipment has revolutionised their performance and dramatically reduced the number of employees as well as working hours per employee.

Other state-of-the-art technologies include computer programmable washer hydro-extractors. They have introduced the concept of Programmable Logical Controllers (PLCs) which are the 'keys' used to control operation and stoppages of equipment. These collect and transmit information to a central computer regarding the actual processing, quality and any disturbances which occur. There is also the use of continuous batch processing systems known as tunnel washing systems. These systems have made the process more efficient and economically more acceptable. There are also available modular finishing machines in the market, which have automated feeders, ironers, folders and stackers, giving the linen a more hygienic and acceptable look. These finishing systems provide a high throughput via energy efficient methods at a consistent quality.

Electronic cameras have replaced human eyes in quality control, because the speed at which the linen passes through an ironer makes it impossible and tiresome for the human eye to detect holes/ stains in linen. These are ergonomically designed so as to drastically reduce the number of working hours per employee. These are also available as separate machines, which can be adapted to other laundry equipment. "The challenge today is not just of incorporating as well as switching over to new technologies that are being introduced in the market, but it is the continuous updating and upgrading of existing health care facilities, which is the ultimate challenge faced by administrators," believes Dr Rao.

IT for Linen Management

IT plays a vital role in linen management. It gives laundry professionals the tools to control costs and manage their linen budgets by tracking and analysing linen usage and establishing inventory and par level requirements. A linen tracker will help keep the linen inventory at the appropriate levels by tracking the linen use of each department. The system is also said to improve the order accuracy by eliminating the guesswork in setting proper stocking par levels. Linen tracker system will also simplify the job of overall linen management, by comparing actual linen usage with the total inventory and establishing linen ordering budgets. Comprehensive management of linen inventory provides detailed analysis reports of new and used inventory, usage analysis and life of linen. The IT modules today cater to the full range of linen management from procurements to the discarding stage. A complete inventory of linen in store is kept in washed condition, stock of back-up linen to be kept as reserve is maintained and whenever any stock has been replenished, the information is updated to re-stock maintenance levels. The software keeps a track record of linen at various cycles in the hospital. "It is necessary to develop a software according to hospital specifications wherein proper system is to be adopted. Efficiency of software will be accurate once we enter the details into the system and it has to be sorted out wardwise/department wise and so on," says Prakash Zachariah VP -operations, BGS Global Hospitals, Bangalore.

Outsourcing v/s In-house

Many healthcare facilities today decide, for reasons of space, or economies of scale, to outsource laundry functions. Yet a significant proportion of facilities still manage laundry on-site, or through a central laundry owned and operated by their health system. "A hospital's capital expenses are zero when it chooses to use an outside linen supply company. They do not make initial investments in linens, nor do they have operational expenses like utilities and employees," states Zachariah.

When analysing the financial viability of in-house laundry facilities, experts feel that it is important to consider facility upgrades as a possible means to saving money and improving environmental performance while maintaining control over laundry processing. Assessing the comparative environmental and cost impacts of transportation for pickup and delivery of linens is also important. "But whether laundry services are outsourced or handled in-house, implementation of innovative programmes and technologies can reduce environmental impact and should be promoted through service agreements or purchasing specifications," opines Jeyakumar. Outsourcing linens provides relief from inventory purchasing and maintenance hassles. In addition to providing adequate supply, the linen company should also monitor usage as census increases or decreases.

Hospital labour costs alone account for 45 per cent of the expenses in the average community hospital with another 15 per cent going to employee benefits. The major tactic for reducing hospital costs is by flattening the cost of labour and its associated employee benefits. "Employee shortages, high physical plant costs, critical space deficits and the need for increased on-site patient care and related functions—all create situations where hospital administrators have to rethink their priorities. What must be kept on-site and what can be outsourced? Increasingly, economics is driving the most logical decisions. That includes all textile-related services," states Dr Rao.

Innovations in laundry equipment have led to tremendous increases in efficiencies. According to the 2005 Comparative Operating Revenues and Expense Profile for the Healthcare Textile Maintenance Industry, healthcare textile linen rental companies are more efficient in their use of energy and chemicals.

"In-house activity can ensure that quality control is exercised at all times. Also decision making is quick as response time is critical to ensure quality service," shares Col Masand. "One is unsure of the type of treatment given to clothes by outside laundries since they use stronger chemicals and acids, which tend to weaken fabrics, besides increasing the quantity of discard. In-house laundry is a better choice as one can choose the right chemicals for higher production and longer life," shares Zachariah.

Future Trends

Experts believe that total quality management, stringent guidelines, process automation and implementation of IT in the linen management are few of the things that will drive the laundry services to the next level. Total computerised tracking systems will also be the norm. "We visualise that in the future, disposable linen at cost effective rates would be made available in the country including sterilised items for use in OTs and ICUs," says Col Masand. The focus will also be on ways and means to reduce linen costs and manpower requirements for the department.



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