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Chapter 2 - Medical Facilities And Patient Management

Part 4 - Staff Services/Special Programs

Title Section
Medical Facilities I.
Utilization Review Committee 4-2.1
    Purpose 4-2.1A
    Policy 4-2.1B
    Standards 4-2.1C
Standard for an IHS Inpatient Facility 4-2.2
    Purpose 4-2.2A
    Standards 4-2.2B
    Policy 4-2.2C
    Exceptions 4-2.2D
Policy on Smoking for Medical Care Facilities of the Department of Defense, Public Health Service, and Veterans Affairs 4-2.3
Handling of Contaminated Linen and Trash 4-2.5
    Purpose 4-2.5A
    Procedure 4-2.5B
    Contaminated Linen 4-2.5B(1)
    Contaminated Trash 4-2.5B(2)
    Clothing 4-2.5B(3)
Patient Management II.
Safekeeping of Patient's Property 4-2.10
    Purpose 4-2.10A
    Receipt and Storage 4-2.10B
    Changes on Property Record During Hospitalization 4-2.10C
    Withdrawals 4-2.10D
    Disposal of Hospital File Copy of Patient's Property Record 4-2.10E
Patient's Valuables 4-2.11
    Purpose 4-2.11A
    Objective 4-2.11B
    Responsibilities 4-2.11C
    Procedures 4-2.11D

Exhibit Description
4-2-10A Patient's Property Record, HSM 44-6 (Formerly PHS 2515-6)

I.  Medical Facilities


  1. Purpose.
    1. To establish a formal plan to maintain the highest possible quality of patient care and effective utilization of health services by routine audits of medical records to determine if medical care, and utilization of the facility are appropriate.
    2. To assure that Indian Health Service hospitals meet the standards of the Joint Commission on Accreditation of Hospitals.
  2. Policy.  Each IHS hospital will have in effect a plan for monthly utilization review of inpatient services to include at least:
    1. A review of the medical necessity of admissions.
    2. A review of professional services provided.  (Overuse or underuse, logical substantiation of diagnoses, proper use of consultants, whether required diagnostic workups were initiated and carried out promptly, etc.)
    3. A review and evaluation of the diagnostic procedures and treatment prescribed.
    4. A review of factors relating to duration of stay (hospital staffing, assistance in discharge planning, availability of out-of-hospital facilities and services which assure continuity of care, etc.)
  3. Standards.
    1. Approval and Operation of Plan
      1. The Area Office is responsible for the approval of the hospital's plan.
      2. The hospital's staff is responsible for its operation.
    2. Written Description of Plan

      Each hospital shall have a currently applicable, written description of its utilization review plan.  Such description includes:

      1. The organization and composition of the committee;
      2. Frequency of meetings;
      3. The type of minutes to be kept;
      4. The method to be used in selecting cases on a sample or other basis;
      5. Arrangements for committee minutes and their dissemination.
    3. Committee Composition

      The utilization review will be conducted by a staff committee or committees of the hospital composed of two or more physicians and the Director of Nursing with the inclusion of other professional personnel.

      Existing staff committees may assume the review responsibility stipulated in the plan.  In smaller hospitals, all of these functions may be carried out by a committee of the whole or a medical care appraisal committee.

    4. Records
      1. Minutes of committee meetings are to be kept of the activities of the committee.
      2. minutes will be submitted to the Service Unit Director and the Area Director.
      3. Minutes of each committee meeting will be retained as required by the Joint Committee on Hospital Accreditation.
    5. Follow-up
      1. The committee will make recommendations to the Service Unit Director for necessary action and follow-up to assure the best use of service and resources to obtain the highest possible care.
      2. The Service Unit Director will be responsible for the necessary corrective action.
      3. In the submission of the minutes to the Area Director the Service Unit Director will advise of corrective action taken or to be accomplished.


  1. Purpose.
    1. To establish criteria to determine the need for an Indian Health Service (IRS) inpatient facility; these criteria will be used to objectively evaluate the need to construct a new inpatient facility or to continue providing inpatient services at an existing facility.
    2. To promote quality care by setting a minimum inpatient work load.
    3. To ensure that the IHS utilizes its resources in an appropriate and efficient manner.
  2. Standard.

    The average utilization over the most recent three years (or projected demand in accordance with Facility Planning Forecasting Guidelines) should be at least 5,500 inpatient days (an Average Daily Patient Load of 15).

  3. Policy.
    1. In addition to this standard, proposed and existing inpatient facilities must be evaluated in relation to other IHS and non-IHS facilities as alternatives for patient care considering the following:
      1. Accessibility of alternate facilities (the IRS standard for accessibility is 60 road miles).
      2. Current and projected bed capacities of alternative facilities, medical and other health care services offered, ability and willingness to absorb IRS patients, condition of physical plant, manpower deficiencies, and IRS experience using the facility.
      3. Quality of alternate non-IHS facilities as determined by the Joint Commission Accreditation or the Health Care Financing Administration Certification status.
      4. Cost effectiveness of utilizing alternative facilities.
    2. Each IHS Area will review its existing inpatient facilities using this standard and the criteria above 1 and report to the Director, IHS at the end of fiscal year 1991.  In this report, facilities which fall below the standard shall be evaluated for discontinuance of inpatient services.  Any request for an exception shall contain a detailed justification for continuing inpatient Services.  Subsequently, such a review will be incorporated into the Area Health Facilities Master Plan.
    3. Proposed new or replacement facilities shall also meet this standard.  If the projected workload falls below this threshold, the reasons for building new facilities with inpatient services will be detailed in the Program Justification Document which must be approved by the Director, IHS.
    4. If discontinuance of the inpatient services at a facility is contemplated, the following are required:
      1. Tribal consultation.
      2. Sufficient Contract Health Services funds to maintain the existing levels of services.
      3. Congressional notification at least one year prior to closure.
  4. Exceptions.

    Exceptions to this standard may be granted on a case-by-case basis by the Director, IHS for proposed or existing inpatient facilities.  Geographic isolation, availability of alternative facilities, sire of the IHS population to be served and other relevant information will all be considered.


In view of the established fact that cigarette smoking is directly related to considerable excess morbidity and mortality and that cigarette smoking constitutes one of the nation's major preventive health problems, it shall be the policy of the Department of Defense, the Public Health Service, and the Veterans Administration in all medical care facilities under their jurisdiction:

  1. To educate professional and non-professional staff about the nature and magnitude of the health hazards of cigarette smoking, the behavioral change ramifications of the smoking practice, the educational approaches to preventing or alleviating the problem, and the exemplar influence of health workers and health service facility environments.
  2. Through firm administrative policies, to establish a health facility environment which discourages cigarette smoking and which reinforces non-smoking practices among employees, patients, and visitors.  This effort shall include:
    1. Proscription of the receipt of free cigarettes;
    2. Restriction of cigarette sales in hospitals, clinics, and other direct care facilities to canteens or similar areas where other products are sold;
    3. Discouragement of smoking by professional personnel and staff while in the presence of patients; and
    4. Restriction of smoking to visitor's waiting areas, patient day rooms, staff lounges, private offices, and specially designated areas.
  3. Aggressively to initiate and continue smoking cessation activities specially geared to high risk patients and to all other patients and employees who wish to stop or modify their smoking behavior.
  4. To encourage all medical service personnel to avoid the use of cigarettes when making formal public and professional appearances.
  5. To develop general health education activities with emphasis on smoking and health practices in hospitals and clinics.
  6. To cooperate with other community groups in the development and implementation of community-wide activities dealing with the cigarette smoking problem.


  1. Purpose.  In order to prevent the spread of infectious or communicable diseases, it is essential that certain precautions be taken by all persons having contact in any way with patients having such diseases and also with contaminated articles which are possible vehicles for spreading disease.

    It is considered equally important that personnel engaged in the collection and disposal of contaminated trash and those collecting and laundering contaminated linen and returning clean linen to the hospital units be fully instructed in the procedures established for self-protection and to prevent the spread of disease.  Adherence to these procedures should be verified from time to time by supervisors.

  2. Procedures.
    1. Contaminated Linen.  In the laundry, the handling of linen should conform as closely as is practicable to the procedures outlined in the Manual on Hospital Laundry Operation of the American Hospital Association.

      A recent study indicates that the normal sorting operation releases quantities of air-borne bacteria which are redeposited on the linen through the extractor air intake, during the folding operation, and in any subsequent handling of the clean linen.  This points up a potential hazard to personnel from air-borne bacteria.  The handling of contaminated linen should therefore be kept to an absolute minimum and shaking of linen avoided.  It is suggested that the normal classification of soiled linen be curtailed if necessary to reduce handling in the laundry.  Closed bags of a distinctive color or otherwise clearly identified as containing contaminated linen should be used so that they can receive special handling and not be utilized for any other purpose.

      The bags and transporting hamper bags should be laundered at the same time as the linen.  The truck used for transporting contaminated linen to the laundry should be specially marked to indicate its use, washed with soap and hot water and dried once a week (preferably by sunning) or before using for any other purpose.  The person collecting loose contaminated linen should wear a mask and gown during such operations.

    2. Contaminated Trash.  This includes all waste materials removed from an infectious disease area.  Contaminated newspapers and magazines should be placed in a plastic bag along with other trash for disposal by incineration.

      Sputum cups and used tissues should be collected in plastic bags (preferably identified by color or legend as containing contaminated materials to insure careful and expeditious handling), which should be tightly closed and disposed of by incineration.  A mask should be worn while collecting these items and the outside of the bag kept relatively free of contamination by careful handling.

      All other contaminated trash should be collected in plastic bags placed in large cans so that a cuff of the bag is turned over the rim of the can.  When the bag is two-thirds filled it can be tightly closed and removed for disposal by incineration without contaminating the hands or the outside of the bag.  Care should be taken to avoid tearing the bag.  The cans should be kept covered, clearly identified to insure careful handling, and used for no other purpose.  The cans should be sterilized according to approved effective technique with live steam following discharge of the patient.  Other cans or buckets used in the clinic area and treatment rooms should be done on a regular schedule based on the recommendation of the institutional sanitation consultant.

    3. Clothing.  A clean mask should be worn at all times when there is a possibility of inhaling grossly contaminated air such as while handling contaminated linen, loose trash as papers or floor sweepings, collecting sputum cups and used tissues, or while placing contaminated trash in the incinerator.  Masks should be changed often to avoid wearing one that has become moist.

      Clean communicable disease gowns should be worn over the regular clothing while working in a contaminated area.  The gown should be clean, long sleeved, high neck, and tie back.

      All persons should wash their hands immediately after handling contaminated linen, trash and other articles.

II.  Patient Management


  1. Purpose.  To prescribe procedures for the storage of clothing, luggage, and other personal items deposited for safekeeping during the patient's hospitalization.

    Form HSM-44-6 (Formerly PHS-2515.6), Patient's Property Record, has been developed to provide a record of clothing, luggage and other items of personal property deposited with the hospital.  The procedures also provide for a receipt Form HSM-128 (Formerly PHS-2528), Receipt for Temporary Withdrawal from Clothing Room, to be used for withdrawals of a temporary nature, such as, patient on pass, laundering or drycleaning of clothing, etc.  The patient's property record is available in two separate constructions.  In addition to a two-part set, the record is incorporated into the second part of the Clinical Record-Manifold Admission (Forms HSM-44~3, HSM-44-4, and HSM-44-5 (Formerly PHS-2515-3, PHS-2515-4 and PHS-2515-5) thus eliminating duplicate typing of identifying information on the record (patient's name, address, etc.) at time of admission.  The two-part set is designed for use when additional property is received or released.

  2. Receipt and Storage.  Form HSM-44-6 (Formerly PHS-2515.6) in duplicate, shall be forwarded to the clothing room or other area where property is to be stored.  The storekeeper or other custodian, shall list items, enter bin, locker or tag number and obtain signature in Item 10 of patient or no less than two witnesses if patient is unable to sign.  The Storekeeper or other custodian shall then sign the certificate in Item 11.  The original of Form HSM-44-6 (formerly PHS-2515.6) shall be given to the patient, or retained in his interest if necessary, and the duplicate deposited in the clothing room file.
  3. Changes on Property Record During Hospitalization.  Minor permanent changes in items stored shall be made by drawing a line through the appropriate item(s) if a withdrawal, or listing new item(s) if an additional deposit, and obtaining patient's initials and date next to change on on both the clothing room file and the patient's copy of the record.  A new property record shall be prepared for major permanent changes.
  4. Withdrawals.
    1. During Hospitalization.  Form HSM-128 (Formerly PHS-2528), Receipt for Temporary Withdrawal from Clothing Room, shall be prepared in duplicate for withdrawals of a temporary nature (patient on pass, etc.).  Carbon inserts are provided at the back of each pad of the receipt form for preparation of duplicates.  The duplicate copy of the receipt shall be given to the patient and the original securely fastened to the clothing room file copy of the Patient's Property Record.  Upon return of the items withdrawn, both copies of the receipt form shall be destroyed.  If items returned are not the same as those listed on the receipt, appropriate adjustment on the Patient's Property Record shall be made in accordance with paragraph C.
    2. Upon Discharge.  When the patient is discharged, all items listed on the property record shall be returned to the patient or released to his authorized representative.  The storekeeper or other custodian shall obtain the signature of the patient or his authorized representative on both copies of the Patient's Property Record.  This signature indicates that the stored items have been received by the patient and the hospital is released from any further responsibility.  The original shall be returned to the patient and the duplicate retained for the hospital file.
  5. Disposal of Hospital File Copy of Patient's Property Record.  The following schedule shall govern the disposal of the hospital file copy:

    Discharged Patient -- until next admission or 2 years after becoming inactive.

    Deceased Patient -- 5 years or as long as the clinical record is retained.


  1. Purpose.  To prescribe the procedures for safekeeping of patients? funds and valuables at Indian hospitals which do not have agent cashiers.  For those hospitals having now, or which may subsequently have agent cashiers, the patients? funds procedures prescribed in Chapter 10, Receipts and Disbursements Section of the PHS Manual of Budget and Finance apply; or, where it is considered more advantageous, stations may use the alternate procedure provided by PHS Budget and Finance Manual Memorandum of July 28, 1959.  All hospitals have responsibility for providing for the safekeeping of patients? valuables.
  2. Objective.  To provide hospital patients the opportunity to deposit their money and/or valuables for safekeeping during their period of hospitalization.
  3. Responsibilities.
    1. The designated Collector Agent shall be responsible for proper handling of patients? money and/or valuables.
    2. The Service Unit Director or his designated representative shall be responsible for conducting a monthly audit of all patients funds.
    3. During regular duty hours, Monday through Friday, all patients being admitted to the hospital desiring to deposit funds will be directed to the Collector Agent by the Admission Clerk in the Health Record Section.
    4. After regular duty hours, weekends, and holidays, it will be the responsibility of the Officer of the Day to ascertain whether the patient desires to deposit funds upon admission.
  4. Procedures.
    1. Form HSM-52 (formerly PHS-2923), Patient?s Funds and Valuables Record, shall be prepared in duplicate by either the Collector Agent or the Officer of the Day.  A notation should also be made on the patient?s clothes slip that money and/or valuables are deposited in the Administrative Office.
      1. Pill in blocks 1 through 4.  Enter date in block 12 and the amount deposited in block 13.
      2. List all valuables deposited in block 17.  Describe jewelry in terms of color of metal and stones, make of watch, etc.  If money deposited includes either Government checks or personal checks, make this notation in block 17.
      3. Have patient sign in block 6.  If unable to sign, use thumb mark or "X" and sign in block 7 as witness to signature.  Enter date in block 8.
      4. Person accepting deposit other than Collector Agent will sign in block 8.
      5. Place the money and/or valuables together with the original copy of Form HSM-52 (formerly PHS-2923) in prenumbered envelopes Form PHS-1224-2.  Prenumbered envelopes will be available in the Nursing Office for use after regular duty hours, weekends, and holidays.
      6. If deposits are received after regular duty hours, weekends, or holidays, the envelopes will be locked in a safe place and turned into the Administrative Office the morning of the next regular work day.
      7. The duplicate copy of Form HSM-5-2 (formerly PHS-2923) will be given to the patient with instructions that the receipt must be presented to the Collector Agent for any withdrawals during period of hospitalization or upon discharge.
    2. Dally Waiver.
      1. All adult patients will be offered an opportunity to deposit their money and/or valuables for safekeeping during their period of hospitalization.  However, if the patient refuses to do so they will be required to sign a "Daily Waiver" in one copy only releasing the hospital from all responsibility.