l l' H ‘ WI 1 WM m | 1 II I t ll A PARTEAL AE‘V‘ALYSES OF THE PROBLEMS ENVOLV’ED éN MEETENG THE INCREASED DEMANQ FOR LENEN EN HOSFETALS Thesis ‘or the Degree of M. A. M35316“ STATE UNWEESITY Matthew Ray Ferguson 1959 ' LIBRARY Michigan Stats University A PARTIAL ANALYSIS OF THE PROBLEMS INVOLVED IN MEETING THE INCREASED DEMAND FOR.LINEN'IN'HOSPITALS By Matthew Ray Ferguson A THESIS Submitted to the College of Business and.Public Service Michigan State University of.Agriculture and Applied Science in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Hotel, Restaurant and Institutional MAnagement 1959 ,';I'.' '1; ...~ / $95 5 ~ 5 ~42!- ACKNOWLEDGMEN T The author appreciates the valuable time and information contributed by the persons affiliated with the numerous organizations and institutions contacted during the writing of this thesis. In particular, the counseling of Dr. Ralph D. Wilson, Associate Professor in the School of Hotel, Restaurant and Institutional Management, Michigan State University, proved invaluable in completing this study. WW-X—XW TABLE OF CONTENTS CHAPTER Page i INmeCTIONOCOOOOO'OOOOCOOOOOOOOOOO....00...COOOOOOOOOOOOO deayts mass building programs have left many hospitals with totally inadequate laundry operations........... RBView 0f related literature............................ Statement Of the pmblemoooo00000000000000...ooooooooooo Purpose Of the problem.................................. Delimtations Of the Study'cooooooooooooooooo000000000000 Sources of data and methods of procurement.............. Definition Of terms used................................ Organization 03‘: the study............................... II ONhPREMISE CONSIDERATIONS FOR MEETING-INCREASED DEMANDS FOR MOOOOOOO...OOIOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO I. More Efficient Use of Present Facilities and Personnel"....................................... Usage Of 11.113110000900000.ooooooooooo00000000000000 Damaged linen"................................... 139.1de? manager qualifications".................. Working ConditiOIISooooooocoo-coco...00000000000000 Employee SChedumgooooocooooooooooooooooooooooooo Linen Storage..................................... Sterile techlfique................................. Work Simplification StUdiBSoooooooooooooooocoococo Rearranging laundry equipment..................... II. Expansion of Present Facilities and Personnel........ Hospital laundry advantages"..................... Patient serviceooooooooooooooooooooooooooooooooooo HOSpi'bal linen needSoooooooooooooooooooooooooooooo Additional Shiftsooooooooooooooooooooooooooooooooo Linen inventory................................... Supplementing personnel and equipment............. Building expansion and machinery replacement...... New equipment saves money......................... sumr‘Yoooooooooooooooooooo000000000000.ooooooooooooo iii 1 QUIEF‘UJWNN 10 10 12 12 12 15 18 18 19 20 21 23 2S 26 P? s. . ax. 1" i h N A f V .\ ‘ < r \ \ r - » *2 . . . .. g . I D " I' ' s -’ 1th" 0 ~ I *0 a o A A W O 0 I c- a Q n r l- . F g o- a \ c. n x G \ " 9 ' 0 A \ ~ - ~ ' \ n 1 o a g . In B 0| R TABLE OF CONTENTS — Continued CHAPTER ‘ Page III OFF-PREMISE CONSIDERATIONS FOR MEETING INCREASED DEMANDS FOR LINENOOOOOOOOOOOOOOOOOOOOOOOOOOOCOOOOOOOOOOOOOOOOOOO I. Centralize Area.Hospital Laundry Facilities.......... Participating hospitals”.....;................... Centralized laundry ponCieSoooooooo0000000000000. centralized lalmdry problemS...................... II. Contracting Linen Needs to Commercial Firms.......... Commercial laundl'y lindtationS.................... DireCt expense reduction.......................... Commercial terms available........................ Linen ContI‘Oloooooo0000000000000.coco-0000000000.. Commercial laudry price qllOtation3.oooooooooooooo comerCial laundry 0031330...00000000000000.0000... Linen rental seI'vice.............................. Summary.............................................. IV APPLICATION OF CONSIDERATIONS TO.A SPECIFIC HOSPITAL....... Lallndry 0peratiCn................................. Building program.................................. Slipplemental measureS............................. Improve effiCienCYOOOQOOOO00.000000000000000cocoa. comercm Contract..."........................... Linen rental SGI’V‘lCB.............................. Extensive laundry renovation...................... SW000000000000000.0000...00000000000000.oooooooo v SUMAM)CONCILUSIONOOOOOOOOOO0.00000...0.000000000000000 I. SWOCQOOOOOOQooooooooo00.000009000000000cocoooooo II. Conclusion........................................... BEIIIWICAL WTMESOOOOOOOOOOOOOOOOOOOOOOO00.0.00...00.0.00... iv - . a n A - 0 § p a ‘ O - ' Q n ' R p n r‘ ‘ a A . e b t‘ r‘, v § 0 V a r g n A l N ‘. - L - o ‘I r I. u. f‘ O ‘ ‘ o e . r , s r . ' 5‘ - c. . r s Q t u " 1 s A I '\ g A 3 Q Q ' C -‘ . CHAPTER I INTRODUCTION The hospital administrator traditionally has not considered the laundry service of major importance. The administrator‘s attitude has ranged from indifference to contempt. The administratien in operating its own laundries frequently considered them occupational.hazards and a continuing expense. The laundries were frequently located in the most remote Spot of the hospital due to the noise factor. The remote physical location of the laundry often reflects the administrations consideration of laundry service problems. Traditionly the laundry service was classified as a non revenue producing department. Expenses were met through patient charges, private bequests, contributions and endowments. The laundry manager was instructed to keep the hospital adequately supplied with clean linen. .Therefore, as hospitals began to expand, rather than expand the laundry preportionately, extra shifts were hired to operate the same machinery in the same inefficient manner. The personnel were relatively unskilled workers receiving low wages. Some administrators refused to consider the advantages or dis- advantages of Operating a hospital laundry because of a personal dislike for soiled linen. Others, notably medical men, have expressed feelings that hospitals should stick to patient care and leave such things as the laundry to the professionals outside the hOSpital. Today's mass building programs have left many hospitals with tom inedecnlate laundry operations. Equipment is antiquated and mal- functioning, methods are poor and excessive personnel are required to turn out an often unsatisfactory end product. The increased demand for clean linen has forced administration to choose between taking necessary steps to provide an adequate laundry within the hospital or contract the business comercially. The trend of reduced philanthropy toward hOSpitals has encouraged management to appreciate the importance of an economical laundry operation. Review of related literature. No related studies were found in checking with the American Hospital Association, the National Association of Institutional Laundry Managers, the American Institute of Laundering or in published theses. However, articles appearing in various periodicals that dealt with specific hospital laundry situations, revealed two opposing viewpoints. The viewpoints state that (1) hospitals should operate their own laundry facilities, and (2) contract their linen needs comercially. The argument in favor of a hospital operated laundry is illustrated by Mr. Heywood M. Wiley in an open letter to managing directors of institutions entitled, It Pays to Operate Your Own Institutional 1 Laundg. Mr. Wiley states, "It is too simple to believe that where JHeywood M. Wiley, "It Pays to Operate Your Own Institutional Laundry," Hospital Management, 82:118, October, 1956. you have a complete laundry, operating at maximum capacity, under total economic conditions, that the same services may be obtained from another laundry at the costs you are now paying."1 The.American.Institute of Laundering supported the conviction of persons who felt hospitals should subscribe to commercial firms for processing or supplying their linen needs. The sentiment is summed up by Mr. David T. P. Nelson in an article entitled, A Comparison of Laundry Costs. Mr. Nelson concludes, "As long as there is ample out— side service available at reasonable rates, we would be wise to use that money allocated for laundry use to buy'hospital equipment that is now on our alternate list."2 Most of the articles consulted dealt with a single method of provide ing an adequate hospital linen supply or the initiation of a Specific procedure to improve an existing method. This study will attempt to mold these isolated cases into more universal considerations. Statement of the problem. The study is designed to partially analyze some of the problems involved in meeting the increased demand for linen in.hospitals. Purpose of the problem. The purpose of this study is to consolidate the various methods a hospital may employ in meeting an increased demand lIbid . 3David T. P. Nelson, “A Comparison of Laundry Costs," Selling Laundry Service to Hospitals, Hotels and Motels, Special Report No. 237, Jbliet, Illinois, American.Institute of Laundering, 1957. for linen and illustrate the application of the method to a specific hospital. Delimitations of the study. The wide variation and peculiar problems of hospitals in general would prove too bulky. Therefore it was necessary to limit this study to help establish its scope. The study will include only those considerations involved in a general, short term, non—profit hospital. The hospital furthermore should be currently engaged in a bed expansion program or considering such a program in the near future. It is assumed that the hospital is operating its own laundry and is providing routine patient service. Sources of datg;and methods ofpprocurement. The data for this study was obtained from the following sources: 1) articles appearing in hospital periodicals written by laundrymen or those closely associ- ated with laundries, 2) letters from two of the major laundry equipment manufacturing companies, 3) correspondence with a laundry consulting firm, several hOSpital laundry managers and hospital administrators, h) review of articles and excerpts from the library of the American Hospital.Association, and 5) copies of published talks given.before the American.Institute of Laundering. Personal interviews were also con- ducted with area laundry managers, laundry machine company representa- tives, local architects and engineers, area hospital administrators and a linen supply company representative. Finally, valuable infor- mation was derived from personal on-the-job experience while assisting in planning for the new laundry at Edward W} Sparrow Hospital, Lansing, Michigan. .Definition of terms used. The study necessitated the use of many terms that would ordinarily be familiar only to those acquainted with the operations of an institutional or commercial laundry. Other terms necessarily explained pertain basically to hOSpitals. The author has attempted to present a more easily understood study and to limit the reader's concept of the terms to this specific study. 1: Automatic folder -- a machine attached to the end of the flat work ironer'Whioh, by means of air jets or mechanical blades, automatically folds linen as it comes through the ironer. 2. Base hospital - that hospital chosen to house the laundry equipment and process linen for several other hospitals. 3. Contaminated linen.- hospital linen which has come in contact with a patient who has a contagious disease. h. Extractor -- a machine used to remove water, by centrifical force, from linen that has just been washed. 5. Fluff dry —- process by which linen is dried by merely being exposed to hot air jets while being rotated in a revolving cylinder (see tumbler). This linen needs no ironing. 6. Mangle or flatework ironer -- machine consisting of 8 steam fed rollers through.which linen is passed to be ironed. 7. Nonrprofit, general, short term hospital —- a hospital whose governing board receives no benefits or financial rewards for their services (all profits are turned back into the hospital operation); care is not limited to a single type affliction and patient periods of hospitalization average between S and 7 days. 8. Patient Care Committee -- a group (professional and non- professional) formed within the hospital to study how each service rendered affects the patient and make recommendations for improvement where necessary. 9. PSI .-- per/square/inch. 10-. Sheet-spreader - mechanical apparatus which drapes sheets, fully spread out, over an iron rack to facilitate speedier feeding into the flat-work ironer. ll. Soiled linen ~- term used to designate how dirty linen actually is (heavily or lightly soiled). 12. Tumbler -- this mchine receives linen from the extractor and actually removes )4 pounds of moisture per minute while fluff drying or pre-conditioning linen for the mangle. mention of the study. The remainder of the study is divided into four chapters. Chapter II relates to the considerations in meeting increased demands for linen with a hospital operated laundry. Chapter III deals with the considerations for external means of satisfying an increased demand for linen. In Chapter IV the author attempts to show how the information may be applied to a specific hospital. Finally, Chapter V contains the author‘s summary and conclusions of the study. CHAPTER II ONrPREMISE CONSIDERATIONS FOR MEETING INCREASED DEMANDS FOR.LINEN In Chapter I an endeavor was made to justify the presentation of this study by discussing the background of hospital laundry operations and the present situations that are forcing hospitals to re—evaluate their laundry programs. The contents of Chapter II are directed toward internal measures which can be taken to insure the hospital of an adequate supply of linen. Many hospitals throughout the country are now faced with or soon will be facing a demand for an increased supply of linen. Following final approval of a hospital's expansion plans and determination of the approximate ultimate bed—capacity production capabilities of the hospital laundry should receive careful consideration. Is the present laundry operation capable of satisfying increased demands for clean linen resulting from the expansion program? If not, to what extent will the laundry Operation have to be revised or expanded? I. More Efficient Use of Present Facilities and Personnel The decision to expand or renovate the laundry should not be made in spite of an increased linen load until the following factors can be evaluated: l) employee morale, 2) use of linens, 3) linen damage, h) laundry manager qualifications, 5) working conditions, 6) employee scheduling, 7) linen storage areas, 8) linen handling technique, 9) work simplification, and 10) laundry equipment. Employge morale. As a result of low employee morale or complacent attitude, laundry personnel may never have extended themselves prior to the increase in.bed capacity. The laundry manager and his employees have'been regarded as inferior members of the hospital organization while administration looked at the laundry as a necessary evil. Each day administration is becoming more aware that this necessary evil requires an expenditure of between four per cent and six per cent of the total operating expense of the hospital.1 The basic human need for recognition exists in the laundry worker just as surely as it exists in the most highly trained professional person in the hospital. When the need for recognition is acknowledged and satisfied by adminis- tration, the disagreeable aspects of laundry employment do not seem to matter as much as before. The recognition can be established through proper inter and intra departmental relations. A.special.understanding of each other's problems through close association Must be developed with nursing,-maintenance and housekeeping departments. Usage of linen. A more discriminate use of linen can result from a closer'working relationship with nursing and laundry personnel. The laundry manager must counsel all linen using departments regarding I . 1Heywood Me'Wiley, "Today‘s Managers Will Shape Tomorrow's Laundry," Hos itals, 32:71, March 16, 1958. . - ways and means of getting the maximum use out of linens. Following the opening of the neW'wing at Edward W. Sparrow Hospital, the laundry suddenly became swamped with soiled linen even though allowances had been made to handle the anticipated increased load. Investigation revealed that two regular sheets, the draw sheet, the bed spread and pillow case were being changed daily. Administration.had anticipated that the normal procedure for changing bed clothes would be continued. The procedure involved the routine change of one sheet and pillow case and a complete bed change only when the patient goes home or in the case of excessive soiling. The nursing department was informed of the additional costs being created through overtime pay to laundry employees. Increased use of laundry supplies and utilities ‘was cited along with excessive wear and tear on the linens. A normal operation was again resumed following these disclosures. If the hospital policy dictates a deluxe patient service, excessive linen usage will have to be accepted and not considered as an unnecessary expense. Igmpppd linen. The laundry is actually stymied in its attempt to reduce the total time required in processing soiled linen and returns ing it to patient floor areas because of excessive linen damage. .Chief causes of linen damage result from a variety of foreign articles mixed in with the soiled linen before it comes to the laundry. Most damaging Of these are scissors, razor blades, syringes and scalpels. If these items escape the eyes of the linen sorter and get into the washwheel or tumbler and become wedged in the rotating cylinder, an 10 entire wash load may be ruined. Investigation into an increasing amount of torn linen at Sparrow Hospital revealed the practice of pinning waste paper bags on the bedside, firmly securing the bottom sheet to the mattress. Rather than unpin the sheet after the bag had been ripped off, the sheet was also jerked off leaving a three-cornered tear. Laundry manager qualifications. The laundry manager may not have a thorough understanding of washing formulae and cause many loads to be rewashed. He may also unnecessarily prolong the washing cycles to insure cleanliness of the linen. He may not know the proper setting of the mangle thus causing linen to be run through twice in an effort to get it dry. A background in chemistry, familiarity of materials and a knowledge of mechanics is desirable fOr the person serving as laundry manager. He should also assume the responsibility of keeping abreast of the latest laundry procedures, cooperate with all departments served by the laundry and make recommendations concerning standards, policies and procedures affecting linen supply. Perhaps by standardizing on light weight linen that requires little or no ironing, the number of pieces per wash could be increased. The items could then be fluff- dried, a much faster and less expensive method than processing each piece througi the mangle. Working conditions. The existing conditions under which laundry employees must work may be. a factor affecting production. Difficulty may be experienced selling a person on the value of proper lighting and adequate ventilation in terms of money saved, increased production or better employee morale. However, both of these factors possibly con- tribute to a varying degree toward the efficiency of any operation. The laundry, with its many steam operated machines, readily lends itself for improvements in the area of ventilation. The area near the hand presses and the mangle at Edward W. Sparrow Hospital, has produced temperatures recorded at 105°F during the summer months. By cross- training the laundry staff, proficiency may be gained in every type operation conducted in the laundry. This will allow rotation of personr nel from hot, monotonous jobs every fifteen or thirty minutes, create a more thorough employee understanding of the entire laundry operation and offer protection against slack not being taken up during periods involving sick time, days off and vacations. The laundry manager will also be better able to match the right employee with the right job. Employee scheduling. Rather than working a regular eight hour shift where all employees come and go at the same time, the daily report- ing time for these same employees could be staggered to provide coverage during a normal work day for ten or twelve hours. In this manner, employees are scheduled to insure maximum coverage during peak periods of the day; 'Washmen could arrive on the job two hours before the mangle operators thus allowing for a sufficient buildup of flat-work material so the mangle operators can.begin work immediately. The back- leg of flatdwork material can be finished during the hours after the washmen go home. 12 Linen storage. A thoroughly integrated laundry and linen service which provides for maidmm storage areas may help relieve a linen shortage. Proper utilization of this space will enable a larger linen reserve to be maintained on the patient floor and in the linen room. Implementation of this practice would depend largely upon how much linen the hospital is willing to put into circulation. Sterile technicme. A question may be raised concerning the sterile technique used by laundry, housekeeping and nursing employees when handling ordinary soiled linen. The Patient Care Committee of the hospital can determine the necessity for each person handling soiled linen to don gown, cap, gloves and mask. The committee can also advise on the practice of placing each patient‘s bed clothing in a separate laundry bag for shipment to the laundry. These sterile technique pro- cedures are time consuming and create additional linen to be laundered. Recent emphasis placed on staphylococcus infection has led administration to feel that sterile technique cannot be over-employed no matter what the cost. Work simplification studies. Perhaps a work simplification study is in order, whereby, through greater measures of efficiency, the increased linen load may be handled. Utilization of flow process charts and time and motion studies may aid in determining how much extra handling, picking up and laying down procedures (those extra motions which dissipate time and serve no useful purpose) are being performed. 13 By following four work simplification principles, a more efficient operation should be realized. These are: -- The activity must be productive. -~ There must be a smooth flow of work. -- It must be simple. -- There must be a personal interest on the part of those who are engaged in the particular activity or work}L In getting employees to accept suggested changes, one can either tell them, sell them or consult them. By using the latter method, ideas of all the workers can be tapped. After all, who knows his job better than the employee himself? Most times he simply needs someone to organize and channel his thoughts. The resentment, criticism and resisting of change is minimized through a consulting type of approach. The first step in implementing a work simplification study is to tackle the largest, most glaring problem. Then break the job down, listing each ninute detail as it occurs in the operation and ask these questions of each detail: -- What are we doing? -- Why are we doing it? -- When should it be done? -- Where should it be done? -- Who whould do it? 2 How is the best way? 1W. H. Wagner, "Elements of Work Simplification," Tne Manual, lhz3o, July, 1957. . albido, po 32. Following satisfactory answers to these questions, the new method Should be developed and application made of the method. Malben Chest Hospital, Beer Yaacob, Israel, increased its laundry production 70 per 1 cent by performing such a study and implementing the changes. Rearrangingglaundry equipment. .After all of the previously mene tioned possibilities for better utilization of existing facilities and personnel have been considered or attempted without a satisfactory increase in production, a revised layout of equipment may be the answer. It is entirely possible and most desirable that this type of project be incorporated with a work simplification study. The relocated laundry machinery should be arranged to insure that linen processing follows the most direct and simplest route without any backtracking or crisscrossing of procedures. Physical plant limi- tations may prohibit the implementation of this possibility. Several other plans of attack are available in solving an increased linen load if this particular method cannot be exploited. II. Expansion of Present Facilities and Personnel There are two basic considerations that must be resolved in a laundry expansion program involving machinery, building and personnel. The considerationslare space and money; City ordinances and boundary lines must be checked when considering Space to insure that the hospital 1ChaimAschheim, "How'a.Laundry Methods Study Raised Productivity 70%," Hos itals, 33:99 a 102, March 16, 1959. 15 is within its right to expand a building. The money consideration implies that the capital necessary to finance any one of these ventures should be on hand or readily obtainable. The extent of an expansion program will.be influenced by the availability of space and money. Will an increase in linen inventory suffice or will it be necessary to add a second or third shift to the operation? Both the machinery and the personnel may be slightly supplemented or the laundry plant can be expanded to facilitate the purchase of altOgether new equipment. The building of a new laundry plant and installation of new equipment is the final and possibly the most expensive consideration. The mechanical soundness of the laundry equipment and the availability ofia labor force will influence the final decision. Hospital laundry advantagg_. The operation of an "on the premise" hospital laundry make many advantages apparent. .An inplant type Operation seems to be the most convenient, the most dependable and with proper machinery and management can become the most economical way of providing hospital linen.service. Facilities are immediately available to handle all departmental orders of an emergent or special nature. The supply of linen is not affected by external conditions over which the hospital has no control. An.esprit de corps and pride in their work is more easily developed among a group of hospital employees processing hospital linen. The hospital has complete control over the laundry operation for it never leaves the premises. A hospital operated laundry should lead 16 to a reduction in linen loss due to excessive handling and mixing of other institutional orders. Control regarding the reuse and discard- ing of linen is pinpointed. Saturday, Sunday and holiday requirements are met without overstocking linen inventories. Special clothing and technique are utilized in processing contaminated linens, thereby, reducing the danger of spreading infection throughout the community. The operation of an institutional laundry means a savings of 30 percent or more compared to what it would cost to have the same volume of laundry done in an outside laundry.1 The laundry is operated by'a minimum number of employees and has only one payroll to meet rather than part of another laundry's payroll. .A minimum of capital is tied up in linen inventory because of fewer delays in processing linen. The life of linens should increase and loss in tensile strength minimized because of specially adapted formulae designed to cope with all degrees of soil. The.American Institute of Laundering, in its reports to commercial laundry managers, allow 10 per cent loss in tensile strength with 96 per cent to 98 per cent whiteness retention after 20 washings of its standard linen test pieces. In a well run hospital laundry with equipment especially adapted to hospital needs, it is not at all unr common to have tensile strength loss of 1.5 per cent to 2 per cent with whiteness retention from 97 per cent to 99 per cent for the same 2 20 washings of the same test pieces. The expense of meeting market 1Fritz Field, Consulting Editor and Supervisor of Laundry, The Mbunt Sinai Hospital, New York City, Letter to the author, March 15, 1959; Rogers B. Johnson, "Hospital vs Commercial Laundry Processing,“ The Laundryman, 13:13, September, I§E73 Heywood TL Wiley, "It Pays to Operate Your Own Institutional Laundry," Hospital Management, 78:118~ 120, October, 1956. 2Johnson, pp;_c_i_t_., p. 1h. 17 prices determined by outside laundries, usually based on'what the traffic will bear, is avoided. The cost of external collections and transportation does not become a factor. A modern, efficient hospital laundry should be capable of process- ing its linen cheaper than another laundry can. The following statis- tics published by the.American.Hospital Association, indicate this statement is endorsed by the majority of hOSpital laundrymen. According to the l95h National Hospital Laundry Operation Statistics, indications are that l) as hospitals increase their bed capacity, likewise the percentage of those operating their own laundries increases, 2) the percentage of those hospitals utilizing'both an inrplant and a commercial laundry operation is very small in all bed capacities listed, and 3) hospitals contracting out their entire linen volume decreases as bed capacities increase. l95h NATIONAL HOSPITAL LAUNDRY OPERATION STATISTICS1 5' Under NOnprofit Hospitals 25 to to ' to to to and . beds 19 39 199 299 gh99 over Number of hospitals reporting: 98 222 332 391 223 111,7. 35 Hospitals operating their own laundries and processing all their soiled linen: Number 0 o o o o o o o 0 SO 98 182 311 200 136 32 Percent. o a o o o o o o 51.0 1411.01 514.08 79.5 89.7 92.5 91.1.]. Hospitals operating their own laundries but processing only part of their soiled linen: Number.........10 9 1h 19 9 6 2 Percent. . . . . . . . . 10.2 h.l h.2 h.9 h.O h.l 5.7 Hospitals not operating their own.laundries and having all soiled linen processed out— side the hOSpital: Number......... 38 115 136 61 DJ. 5 1 Percent. . o o o 0.0 o . 38.8 51.8 11.1.0 4.5.6 6.3 3.1+ 2.9 tEdwin L. Crosby-(ed.2, fflnspita” TRTFiTEHUPQTatlnn, National, 195h3" 18 Patient service. The type of patient service the hospital now renders or contemplates should be determined when planning a laundry ' expansion. This can be accomplished in accordance with the total bed capacity, the allotment of beds to various services, plans for quar- tering personnel (interns, residents, etc.) or for a school of nursing, installation of or present diagnostic and therapeutic facilities and the extent of the service areas. A personnel interview with the responsible department heads is desirable to learn of projected or present hospital policies. The hospital director should be queried to insure his ideas coincide with those of his subordinates. A comparison of this information can also be made by obtaining statistics from comparable hospitals . Hospital linen needs. Two of the least expensive methods of determining the hospital’s linen requirements are 1) to have the study performed by hospital personnel, or 2) a laundry machine company representative can perform the study. The latter, althougl offering free consulting service rakes his living by selling laundry equipment and may have a tendency to over sell. The architect engaged to prepare the blueprints of the building expansion could possibly determine linen requirements and recommend appropriate machinery to do the job. However, an approved blueprint does not always fit a hospital‘s specific laundry requirements. If administration doubts the accuracy of the study performed by any of these sources, a final alternative is available . 19 By retaining the services of a specialist in this line of work, the laundry management consultant, it is supposedly possible to obtain an impartial, unbiased report. These professionals operate on a pre- determined fee basis and have only their services to sell. The cone sultant will project machine capacities, linen usage and expected output per employee. He will determine machine specifications, pipe sizes, electrical requirements, drainage requirements and finally draft what he considers to be the most efficient and economical laundry layout possible for a particular hospital. The laundry consultant's recommend- ations should tend to be more conservative than those of the laundry machine company‘s representative or of the architect, who's fees are partially based on a percentage of the total contract. His recommend- ations are likely to be more accurate than the hospital performed survey because of his wider range of experience. Additional shifts. If results of the study indicate a one shift laundry operation should be supplemented by hiring a second shift rather than take more extensive measures, actual production hours can be doubled. This does not mean production will be doubled but the substantial increase realized may adequately satisfy the immediate linen needs. In.most one shift laundry operations, 50 per cent of the linen used in one day is usually processed during that particular day.1 Under a two shift operation tomorrowis linen could be produced today. The anxiety of there being enough linen to carry through the night tDon.A. Rece, “TWO—Shift Operation Solves Laundry Problem," Hospital Management,.85:llh, June, 1958. 20 and the threat of overtime in the laundry can be a constant menace to high employee morale. A second shift extends the period of coverage for meeting emergency demands. However, a second shift may not be feasible if existing machinery will not endure the strain of doubling operation hours. Linen inventory. Many hospitals operate their linen service on the basis of three sets of linen per patient bed. Normally one set is needed to supply afll.beds and patients, a second is kept on floor shelves and the third set is in transit and/or being processed in the laundry.1’ Placing two additional linen sets into circulation could conceivably reduce a normal six day work week to five days. A total of five sets of linen in circulation would create a reserve which could probably satisfy week-end requirements plus handle emergency requests. Employee days off, formerly staggered to effect a hO hour work week, could all occur on Saturday and Sunday. Maximum utilization of all employeescduring the remaining five days of the week could stabil- ize linen production at a point higher than normal daily requirements. The daily excess will furnish the surplus necessary to carry the hospital over'week-ends and emergency situations. Elimination of relief personnel necessary under the staggered days off situation will help amortize the cost of the additional linen 1Rubin R. Braun, "Double-Barreled Planning Brought Triple Results," Hos itals, 33: 87, January 16,1959. 21 inventory. A reduction of steam and utility costs will also aid in amortizing the expense of two extra sets of linen. Linen turnover will occur every five days instead of three, thus adcfing to the length of linen life. A general rise in employee morale storming from a full week-end off each week should become noticeable. .A similar program was adopted by Beth Israel Hospital of New York City and it reports as follows: "From the vantage point of a full year‘s operation, the plan has lived up to all of its promises. Labor costs . have been reduced, linen service has been improved and utility costs have decreased even more than expected ."1 A sound relationship would have to exist between the laundry and linen using departments to dis- courage the indescriminate usage of linen and minimize the problem of linen control. The possible expense of constructing additional storage space to accommodate the extra linen.should be considered. Increasing the linen inventory should be less expensive than the remaining alternatives about to be mentioned. Supplementing personnel and equipment. The possibility of supple- menting existing machinery and personnel may satisfy increased linen needs. Perhaps the addition of a newer type washer, extractor, tumbler or mangle will increase production sufficiently that further expenses are not required. Today's self-dumping washers, hydraulic extractors and mechanically loading and unloading tumblers are capable of raising 11bid . 22 production standards without hiring new employees. The life expectancy of the existing laundry machines deserves consideration to avoid the possibility of supplementing a plant full of antiquated, mal-functioning machinery. .Any conceivable savings could be quickly devoured by costly repairs and replacement of parts. A review of maintenance repair records at Sparrow'Hospital covering a twelve month period, revealed major repairs (excluding routine, daily maintenance) to its out-dated laundry equipment,exceeded $2,h00. Two installations of supplemental laundry equipment will illustrate how laundry production was increased in spite of employee reductions. Three women were formerly employed to shake out sheets in preparation of sending them through the flatwork ironer of the Michigan State University laundry. A sheet Spreader was purchased at an approximate cost of $2,000,but it replaced two of the shake-out ladies whose com- bined salaries approximated $5,000 annually. A savings of $3,000 the first year was estimated and the efficiency of the sheet spreading operation was augmented. The time required to feed sheets into the mangle was shortened. At Sparrow Hospital four ladies were employed in the linen repair (sewing) room. An.electrically heated, air operated linen patching machine was purchased for $595 and replaced two sewing room personnel. Salaries for these two employees were valued at $h,h00 annually, thus allowing an immediate savings of $3,805. The patching machine applies a permanent patch on linens in 15 seconds enabling a fairly adept operator to make 600 to 800 repairs in an eight hour day which probably doubles the output of an average seamstress 23 using a sewing machine.1 Linen can be placed back into circulation much faster because of modern repair methods. The processing of flat work at Mount Sinai Hospital, New York City provides another example of employee reduction prefaced by the instal- lation of supplemental machinery} A conveyor, a sheet spreader and an automatic folder used in conjunction with one of the two flatwork ironers operated and an automatic stacker attached to the other mangle has reduced the number of personnel needed for this operation from 19 to 11.5.2 Future expansion plans may relegate the measures discussed thus far to temporary stop-gap positions. The need for similar studies and decisions would once more become essential. Building expansion and machinery replacement. The complete expansion of the laundry building and purchase of totally new equipment provides a final means of satisfying increased linen requirements from within the hospital plant. A large amount of ready'cash is desirable but not necessary when.pursuing this approach. Troy Laundry Machinery Company and.American.Laundry Machinery Company, two of the major laundry machine manufacturing companies, will offer terms of 20 per cent to 25 per cent down on the equipment investment with 36 months to pay the balance. In.cases where the present laundry is equipped with 1Fritz Field and Thomas P. 'Weil, "How Increased Our Laundry's Capacity," Ho itals, 32: 61,.August 16,1958. 2Ibid., pp. 60-61. 2h manually operated machines, the installation of fully or semi-automatic equipment to replace manually operated machines will reduce employee payroll sufficiently to permit direction of these savings toward liquidating the laundry equipment debt. A projected laundry cost study indicates Sparrow Hospital can expect to save in the vicinity of $2,500 per month as a result of a $62,000 new equipment purchase.1 Swedish HOSpital of Seattle, Washington, saved $2,000 per month with an $85,000 purchase of new equipment.2 Few will argue that an investment which will pay for itself in three to five years is not sound. After the study is made to determine present and projected linen needs of the hospital (15 pounds per patient per day is the accepted average with three bassinets ecpal to one adult bed)3 administration should decide how many hours a day and how many days a week the laundry is to be in operation. A no hour a week, one shift operation, five days a week seems to be gaining popularity in today‘s hospitals. Immediate acquisition of the entire equipment list which will handle the ultimate bed capacity may not be possible. However, an endeavor should be made to purchase that equipment which will adequately fulfill the immediate increased linen demands. Space can usually be allotted lDonald H. Pound, Special Report to General Operations Committee of Edward H. Sparrow Hospital, January, 1959. 2Ed Lucas, "An Efficient Laundry is Equal Parts Good Equipment and Good mnagement," Hospital Management, 89 8118, October, 1957. 3"Troy Hospital Data Sheet," Troy Laundry Architects and Con- sultants Book. Troy Laundry Machinery Division of American Machine MMetab, Inc. East Moline, Illinois: 1957. 25 in the expanded plant for installation of additional equipment at a later date. Special attention must be given to the amount of presswork, flat- work, rough dry and starching that is anticipated for a particular hospital. The percentage of each type procedure will determine the number of press units and what size mangle will.be installed. Perhaps the purchase of a special cotton treated, no iron linen will eliminate the need for an approximate $30,000 expense in the form of a mangle and automatic folder. New equipment saves money. Probably the greatest savings realized through the purchase of all new automatic equipment is in employee salaries. Sparrow Hospital originally employed 35 laundry personnel who operated two Shifts five days a week and one shift on Saturday totalling 82.5 hours per week. The installation of new equipment will reduce employee work hours to to hours per week, five days a week and require 2h employees. Laundry output is expected to increase from approximately 2h,128 pounds per week to approximately 50,820 per week. Baton Rouge General Hospital, Louisiana, out two shifts totalling 19 employees who operated the laundry 85 hours a week to 12 employees working to hours a'week.l Other areas of savings will be realized through reduced maintenance costs. Standardization of equipment will eliminate the need for 1Robert Guy, "A Practical.Approach to Lower Laundry Costs," Hos itals, 32:75-76, January 16, 1958. , 26 stocking costly duplicate parts. A reduction in the cost of supplies and utilities should result and wear and tear on linens should be reduced. Baton Rouge General Hospital reduced the cost per pound of processing linen from a previous 3.5 cents to 2 centslwhile Sparrow Hospital anticipates a reduction from a recent 6 cents to 3.2 cents 2 per pound . Summary In Chapter II the author attempted to examine the various possible existing conditions, whereby, through their discontinuance, improve- ment or modification, linen demands for an increased bed capacity may be met without extensive laundry expansion procedures. The author also intended to point up several factors which should be considered before implementing, to any degree, the expansion of present facilities and personnel. The undertaking was made to acquaint the reader with several methods of determining hospital linen needs. A few proposals regarding how an increased linen demand may be met through varying degrees of expansion of facilities and personnel were proposed. A trend was also indicated by depicting the popularity of hospital operated laundries _v_§_ commercial contracts among various size hospitals. Attention will now be directed toward several external sources available to hospitals for providing an adequate supply of clean linens. 11bid., p. 77. 2H. S. Rohm, Unpublished Report to Edward W. Sparrow Hospital, October 31, 1958. CHAPTER III OFF-PREMISE CONSIDERATIOBB FOR IviEETING INCREASED DEMANDS FOR LINEN In the preceding chapter, various internal considerations available to a hospital for satisfying its linen requirements were discussed. If these possibilities do not prove acceptable or feasible to a particular 8 hospital, the remaining alternatives are: l) a possible centralized hOSpital operated laundry or 2) contracting the laundry or linen require- ments of the hospital. to a. commercial firm. Hospital responsibility for supplying linen under these alternatives is either partial or com— pletely removed. I. Centralize Area Hospital Laundry Facilities A consideration in attempting to satisfy the demands of an in- creased bed capacity is the centralization of laundry facilities for hospitals in a given. area. Concentrated effort by such a group will combine the work of several institutions and may result in a lower linen processing cost due to the following: 1. A standard price would be established for processing the linen of all hospitals. 2 . Volume buying through a centralized purchasing department should introduce lower costs of supplies. 3. The installation of modern, automatic equipment should reduce employee payroll and replace present inefficient, outdated MGM—new. 2'? 28 Participatinthospitals. Consideration of area hospital laundries for centralization should be preceded by the decision of which hospitals will be included and the location of each. The production capacity of the hospitals should be determined along with the daily linen require- ments of each. Is there a centrally located hospital'within the group presently capable of processing the total linen requirements? If not, will there be a minimum or maximum expansion of the base hospital‘s laundry facilities in Order to meet these requirements? .An inability to expand the physical plant or to find a satisfactory location for a base hospital may precipitate the construction of an entirely new laundry plant. The important area of administration for the over~all program can stem from either 1) a representative group comprised of members from each participating hospital or 2) the administration of the base hospital where the laundry is to be located. The representative group will most likely be formed when none of the hospitals contemplating centralization are capable of processing the combined workload of the group. In cases where a capable hospital laundry exists, administration of this hospital would probably dictate the policy under which the system will operate. The availability of labor, water and supplies should be studied ' thoroughly before concluding a satisfactory base hospital exists. Once all these prerequisites can be met, plans to integrate the various laundry facilities should commence at once. A The centralized laundry probably tends to benefit smaller hospitals of 50'to 100 beds more than larger hospitals. Already many small 29 hospitals share the services of such professional employees as radiolo- gists, pathologists and pharmacists. The arrangement is encouraged by the.American Hospital Association‘s Commission on Hospital Care in the United States as a measure for minimizing the cost of patient care. The concept of a centralized laundry operation appears to be increasing in popularity for the same reason. Centralized laundry policies. Uniform policies concerning the operation of the centralized laundry should be formalized at early meetings of the group. Standardization of linen items used by each hospital.will facilitate a smoother operation. .All linen could then be marked with a single identification and exchange of linen would be on a clean for dirty'basis (piece by piece). Standardizing will also place the central purchasing department in a strong bargaining position to command sizable discounts through quantity purchases. The type of patient service rendered by each hospital should coincide as closely as possible. Regular pickup and delivery schedules should not interfer with patient service. .An.analysis of laundry requirements for member hospitals will help stabilize the work load. The analysis should in- clude allowances for meeting emergency linen.requests. The installation and utilization of the most up-to-date, automatic machinery can yield a centralized laundry that boasts top efficiency and effectiveness. The initial capital outlay for expansion, building or machine costs could be prorated percentagewise in proportion to the size of each hospital. By purchasing the largest washers, extractors, 30 tumblers and ironers incorporating mechanical feeders, Spreaders, folders and stackers, in the latter, the cost per pound of processing linen can be kept at a minimum. Transportation must be carefullyconr sidered to insure an attempt is not made to cover too wide an area. Savings may otherwise be burned up in the form of gas, oil, truck re- pairs and drivers salaries. A plan for the exchange of linen.hetween member hospitals and the base hospital is as follows. Each hospital must operate a central linen storage and sorting center of its own.in addition to the base hospital‘s clean linen bank. Soiled linen is gathered on.the patient floor area or in a specific department and is placed in bags bearing the identification mark of that particular area. The bag is then sent to the hospital‘s soiled linen collection point where a linen count is performed (piece by piece). The sender is credited for each piece of linen sent to the collection point. The credit list is then used to restock each section from the hospital's central linen storage area. Totals of the credit lists are compiled into a bulk list comprising the entire "pickup" for transportation to the base hospital laundry. The bulk list is checked upon receipt at the base laundry and a replace— ment order is issued from the clean linen.bank for delivery to the appropriate hospital's central linen storage area. ‘Weight of the replacement order is recorded and the particular hospital is charged accordingly. The individual hospital's central linen store provides ’ a cushion for week-end service and emergency situations. 31 In the Northern Ireland Hospital Authority eight area laundry schemes have been approved (seven of them completed). Four schemes involved the construction of entirely new laundry buildings and three the adaptation of existing buildings. Five more schemes are anticipated bringing the total to thirteen. The total number of beds presently being served by the 60 member hospitals is 111,901; as opposed to a 12,993 bed capacity before any expansion was started. An incident was reported by the Authority as causing them some consternation. A suitable container for returning clean linen was sought; one which was dust proof, easily cleaned and, required minimum storage space when empty. After choosing canvas as the material for their laundry hampers because of its conformance to the desired specifi- cations, it was discovered that the lack of rigidity in the canvas out- weighed its advantages. Finished linen was arriving at the hospitals in a somewhat crumpled and unattractive condition.1 Four hospitals comprise the Lewisham, England group. Prior to centralizing their laundry facilities, two of the hospitals processed their entire linen requirements. A third was required to send its surplus linen to a commercial firm while the last contracted its entire linen workload commercially. A decision was made to centralize at the largest hospital after observing that the maintenance of three separate laundries, which encompassed only 75 per cent of the groups total needs, was quite uneconomical. Total cost of the extensive conversion of the 1Robert H. Law, "Hospital Laundering in Northern Ireland ," Hospital and Health Management, 20332-1314, April, 1957. 32 base IaUndry was £2h,OOO. Linen work contracted commercially before the conversion totaled more than £10,000 annually. Following the centralizing of these services, linen output increased from 55,000 pounds per week to'l70,000 pounds per week. Member hospitals have expressed their satisfaction for this type operationsL I The centralized Welfare Laundry of New York City is based on the principle of gravity flow from one operation to the next. A unified management, group supervision and bulk handling, are provided all hospitals under the control of the Department of Hospitals and Public Works of New York City. An efficient laundry service is provided at a savings of approximately $100,000 annually ($65,000 in labor alone) and an estimated to per cent is saved in utilities and supplies. A forty hour work week provides a 7 ,000 ton linen output annually:3 The base. laundry of the North County Hospitals Incorporated four member group is located at Gouverneur, New York. One hospital is to miles from Gouverneur while the other two are approximately 25 miles away. A local country club‘s flatwork is processed during the hospital‘s low volume summer months. A centralized laundry service was first . considered in the interest of economy and avoidance of duplication of facilities. Results of this particular arrangement have reduced the cost per pound of processing linen, the number of employees, the 1A. John Tasker, "Lewisham Group's New Central Laundry," Hospital and Health Management, 2022358280, August, 1957. iPOrpha Daly and David Patterson, "Laundry Centralization Saves Almost $100,000," Hospital Management, 69:120-122, April, 1950. 33 1 amount of equipment and the expense of maintenance. The Royal Melbourne Hospital Central Linen Service and Group Laundry Service in Melbourne, Australia serves 28 small and large institutions. A charge per pound for linen processed is calculated to build up funds for purchasing linens (in great quantities ,, the purchase of new machinery and research. lire service operates on a non-profit basis and at the end of each year, returns any profits to the partici- pating institutions in proportion to their laundry bills.2 Three hospitals plus nine regional services (a chronic hospital, a home for the aged, a house of friendship, Rotary Center for crippled children, etc.) are served by the Regional Laundry Service at the Kitchener-Waterloo Hospital, Kitchener, Ontario. The latest model automatic equipment is used to provide the optimumin economic and efficient service. Two other hospitals 80 and 70 miles away respec- tively have expressed a desire to join the group, but the Service feels to exceed a 25 mile radius would render the arrangement impractical. Similar advantages listed previously regarding savings in personnel and machinery, purchasing power and cost of processing linen are also reported. Problem areas did not differ from those found in any a ordinary laundry operation. Centralized laundrlproblems. The mere fact that a hospital sub- scribes to a centralized laundry arrangement does not mean all laundry 1Leon Bennet-Adler, Administrator, Couverneur Hospital, Gouverneur, New York} Letter to the author, March 18, 1959. afield, 2.9-2. 22:13.0 3Walter Hatch, Administrator, Kitchener-Witerloo Hospital, Kitchener, Ontario; Letter to the author, March 20, 1959. 3h problems cease to exist. In addition to the cost of having the linen processed, the expense of creating and maintaining a larger linen.invenr tory will be necessary. .An increased inventory is logically accompanied by an increased problem of control. Linen room personnel will have to be increased to effectively handle the large volume of linen sorting, to man the linen loading and receiving areas and to maintain accurately the necessary paper work inherent in such an operation. Experiencing the problem of guaranteeing quantities when placing orders would not be unusual. The ultimate selection of a satisfactory linen supply source depends entirely upon the environment of the particular hospital in question. A feasible solution to one hOSpital may be impractical or entirely impossible for another. If complete satisfaction has not been obtained through the study of methods mentioned thus far, the possibility of contracting linen needs to a commercial firm can be considered. II. Contracting Linen Needs to Commercial Firms Another option is available when it is determined the present laundry is incapable of meeting the newly increased demands placed upon it. Administration may decide to contract out commercially the excess linen or eVen the entire work load. A hospital may resolve to divorce itself entirely from the direct responsibility of providing and processing clean linen.hy initiating a contract with a linen rental 35 service. ‘Whether a hospital should continue to operate its own laundry or contract commercially is by no means a trivial matter. The' answer is dependent upon peculiar situations existing in and around the hospital. Commercial laundry limitations. Firms capable of offering complete or partial laundry service to a hospital will.usually agree to accept the hospital's order to fill slack periods. Pick up and delivery service willfbe provided five days a'week, excluding holidays. Charges for providing the linen service are either computed on a per pound basis or by the piece. A combination of the two methods of charging is known to exist. Charges are further broken down according to the amount of flatwork, rough dry and machine or hand pressed work for uniforms. 'Qirect expense reduction. .A commercial contract system should allow immediate, direct savings through the reduction of laundry payroll.by 50 per cent or possibly even.by'75 per cent. A hospital work force is still required to pick up, sort and deliver linen and to maintain added linen records within the hospital. Depreciation of machinery will no longer be of concern and costly maintenance repairs will be eliminated. The cost of utilities and supplies are erased and Valuable space is made available for storage or the installation of a possible revenue producing venture. Finally, capital investment in.building renovations and equipment purchases are avoided. 36 The variation of hospital costs between regions and circumstances surrounding the commercial contract influence the final decision. If hospital. laundry cost figures are available, the task of comparing them with the terms offered in a commercial contract will not be difficult. A danger exists when either or both parties fail to include all direct and indirect costs. Commerciali terms available. The following contractual arrange- ments are advised following a decision to process linen commercially. Request the use of a washing formula which will minimize loss of tensile strength in linens and provide for protection against loss and damage to linens. Obtain assurance of a steady flow of clean linen, thereby, guarding against the hospital‘s linen being delayed in preference for a more lucrative order. Provision should be made for periodic bacterio- logical and tensile strength tests. Bargain for a linen charge based upon per pound of dry weight and then standardize on light weight linens. For example: a savings can still be realized even, though the lighter percale sheet may wear out faster than the heavier muslin sheet. Based on a cost per pound of $.08 and assuming a 300 bed hospital uses 700 sheets per day we find: Thread Count Cost Per Daily Yearly 1226 Sheet . PSI Weiggt Sheet Cost Cost Muslin 11.0 1.5 lbs $.12 $8h.00 $30,660.00 Percale 180 1.2 lbs $.09S $67 .20 $2h,528 .00 Annual Savings - $ 6,132.00 1 1Statement by Sam Berger, Whitehouse Linen representative, personal interview. 37 A safety valve is recommended for hospitals adopting a commercial contract. Do not dismantle the hospital laundry until a prolonged and satisfactory relationship with the commercial firm has been experienced. Remember, the disposal of your laundry equipment compromises your bargaining power. Administration.may overlook many indirect costs or possibly for personal reasons may choose to look no further than.the direct savings. Some familiar arguments against a hospital operated laundry were observed by the author while researching this thesis. 1. A.1aundry takes up too much extra room-however, probably the only space actually salvaged by contracting commercially is that which was previously occupied by the machinery. thh of the same space may necessarily be converted into linen storage and sorting areas. Linen circulation must be increased to a minimum of h8 hours supply and occasionally to three days when a holiday falls in conjunction.with a week-end. Generally, commercial laundries won‘t'work week-ends or holidays merely for the convenience of the hospital. 2. Extra equipment will have to be bought—~however, even though the hospital'wonlt'be buying its own machinery by having the laundry done outside, it'will be paying indirectly for someone else's equipment. The situation is sometimes compared with renting a house. I 3. Laundry payroll will be increased by hiring more employees-- however, the purchase of modern, automatic machinery has 38 reduced the required number of laundry personnel in numerous cases. h. We simply can't affbrd it--however, the hOSpital takes on the added responsibility of indirectly paying the salaries of such commercial laundry employees as: a superintendent, a sales manager, a route supervisor, a.bad accounts man, a credit manager, a laundry salesman, additional auditors and office force, engineers and maintenance men. There is also something the commercial laundry can't afford for which the hospital pays and that is not make a profit for its owners or stockholders. Linen control. Serious consideration should be given to linen control when considering a commercial contract. Most hospitals experience sizable linen loss, damage and pilferage when operating their own laundries with minimum inventories. Consider the consequences of increasing linen inventory sufficiently to contract the laundry out. The extra shipping and handling increases the chance for loss and damage. The number of persons handling the linen is greatly increased as is the percentage of thefts. A possible control problem may result from the inability of come mercial laundries to meet emergenqy linen demands of the hospital. The anxiety of one particular ward not ever knowing whether sufficient linen would be available in case of an emergency was relieved in the following manner. The'ward orderly was assigned the responsibility of 39 swooping down upon the clean linen cart the minute it appeared on the floor, make off with an arm load of linen in addition to the normal allotment and store it in one of the many "rat's nest" on.the ward. The ward was thus assured of a more than adequate supply of linen. The practice of hoarding disrupts linen routing, requires excess linen to be placed in service and distorts the actual linen picture. The average pound of linen per patient per day is increased as is the over- all cost of production. The inherent characteristics of the commercial laundry play havoc with prompt deliveries and are abetted by strikes, traffic, snowstorms and truck and machine breakdowns. Commercial laundry pricepguotations. Quotations from commercial laundries for processing hospital linen are often higher than laundry costs. Prices range from 7 cents to 10 cents a pound in Detroit to an average of 10 cents to 12 cents in.Lansing, Michigan. The following table compares laundry costs of Harper Hospital, Detroit, and those of three commercial laundries. Linen.not requiring ironing is indicated in the per pound column and linen requiring flatwork processing is indicated in the remaining columns.' The commercial laundry's flatwork price is based on finished linen while the hospital per pound cost is based on linen.hefore it was laundered. The lowest commercial quotation for processing a pound of linen was nearly double Harper Hospital‘s cost. These prices were accompanied by stipulations that hospital laundry would.be processed during the regular shift. An.extra shift was termed too costly as was Saturday, Sunday and holiday service. 11,0 Per Uniform Uniform Plant Pound (Short) (Long) Coats Pants Shirts _: A t .07 t .30 each a .30 each i .20 each a .25 each is .17 each cm .30 J40 .20 ”"" """" c .10 .38 .16 .30 .35 .20 Harper * - Hospital .0h13 .265 6 per pound *(59 per cent of lowest commercial quotation) 1 An additional cost is placed on the hospital necessitated by a marked increase in linen inventory to compensate for these non-delivery days. In spite of a commercial lallndryis ability to handle the hospital‘s soiled linen, these limitations would persist. A Detroit hospital reported the return of a proposal stating two commercial laundries would be required to process the entire hospital linen needs. All complexities mentioned before would probably increase sharply if the proposal was accepted. Comercial laundry costs. The American Institute of Laundering published a cost analysis pertaining to commercial laundry operations. From the analysis one can reasonably assume that under normal conditions, a hospital laundry can process its linen for at least one-third less than the commercial firm‘s cost. {the analysis: 1Frank G. Bruesch, "Hospital Laundry Costs Versus Commercial Laundry Prices," Hos itals, 27:12h, Part I, June, 1953. hi Percentage PI‘OdUCtive labor a o o o o o o o o o o o o o 0 37078 Productive supplies . . . . . . . . . . . . . 8.58 Power plant 003133 c o a o o o o o o a o o o o 8033 BUildj—ng overhead 0 a o o o o o o o o o o o o 2 .82 MaCthIery Overhead o o o o o o o o o o o a o o 3 097 IndiI'BCt overhead 0 o o o o o o o o o o o o o 6 o i 8 Total direct laundering cost . . . . . . . 66.26 couéCtion and (131.17er 0 o o o o o o o o o o 18 097 Sales promtion o o o o o o o o o o o o o o o 2091 Office aderJflstration o o o o o o o o o o o 0 11-079 iDirect administrative costs . . . . . . . . . 8.;g Total indirect operating cost ». . . . . . 3h.81 . TOtalCOStooooo00000000101007 Operating 1083 o o o o o o o o o o o 1.007 1 A hospital operated laundry does not have the 3h.81 per cent of indirect operating costs. This is based on the assumption that operating costs are the same for well run hospital and commercial laundries.2 Other areas of new or increased costs that a hospital will experi- ence under a commercial arrangement are trucking for collection and delivery and the loss of tax exempt purchasing power. The economy in substantial volume increases is lost since contracts are generally written for a per pound or per piece cost. Life of the linen is markedly reduced due to the excessive amount of bleach used in commercial laundry operations. The general public seems to be most conscious of linen whiteness so the commercial firm gears its operation toward that end. Hence, bleach being a wonderful.whitening agent is also one of the lJOhnson, 9.2. $0, p. 1.30 3Ibid. h2 foremost causes of excessive loss in fabric strength. The use of excessive harsh detergents is required to remove stains which have been allowed to "set" during transportation and other waiting periods. Hospital operated laundries are able to process the heavily stained linens quicker with special formulae designed to minimize loss of tensile strength. In the case of a 1000 bed hospital following contractual arrange- ments with a commercial laundry, it was found necessary to retain approximately h5 per cent of the original laundry work force in order to handle linen sorting, receiving, delivery to patient floors, bookkeeping, etc.1 I I Two sources of headaches common to commercial and hospital manage- ment stem from contract renewal talks and the control of contaminated linen. Many costly hours can.be spent in contract negotiations reaching an equitable agreement. Special procedures for processing contaminated linen are also costly. Commercial processing of contaminated linen increases the risk of spreading infection throughout the community. St. Barnabas Hospital, Minneapolis cloSed its laundry in preference to a commercial contract due to the age and obsolescence of the hospital laundry machinery. Fourteen months later, St. Barnabas re— activated its own.laundry. 'Working on.the premise that automation is the cheapest method pf production, they installed all new automatic machinery. lhe original decision at St. Barnabas was reversed because 3M81ey,’"lt Pays to Operate Your Own.Institutional Laundry," Hospital.Management, 82:118, October, 1956. h3 in a twelve month period, linen replacement costs skyrocketed to 300 per cent over that of the previous year. Numerous occasions arose where linen was needed but could not be supplied by the commercial firm. The standard of work was declared inadequate for hospital use. Finally the installation of new laundry equipment at the hospital was expected to reduce the cost of linen processing.1 In 195h, Detroit Memorial Hospital was faced with a problem involv- ing the use of obsolete laundry machinery. Replacement of this machinery would cost $100,000 plus another $50,000 for remodeling the laundry plant. The use of obsolete equipment required three times the number of employees normally used in a similar size laundry. It was a depression year and payroll had to be out immediately. Future planning placed the laundry in the hospital‘s front yard because of inadequate area for expansion. The administrator felt community funds should help subsidize professional equipment rather than laundry machinery. The administrator further stated, "Hospitals are well advised to devote their energies as strictly as possible to the job of caring for sick people and not dabble in laundry business and the like." Awarding the laundry business to a commercial firm has resulted in a reported savings 2 of $18,000 annually for this hospital. Linen rental service. Linen rental service is simply a variation of the commercial contract just discussed. It differs from the contract IHallace E. Salovich, "Why we Reopened Our Laundry," Hospital Management, 82:12h, November, 1956. 2FranklinD. Carr; Administrator, Detroit Memorial Hospital, Detroit, Michigan; Letter to the author, March 23, 1959. where hospital owned linen is processed by'a commercial laundry. fUnder the rental system, linen is owned and processed by the commercial firm. The linen rental service eliminates virtually all hospital linen cost worries. A decision to accept the price asked by the rental service to furnish hospital linen leaves only the cost factor of staffing the hospital linen room. A linen rental service contract offers an additional advantage not found under the previously discussed commercial contract. Since the linen used in this system is owned by an outside firm, the hospital is relieved of the responsibility of maintaining a large linen inventory. Relief is also obtained from financing linen replacement and repair costs. A. shortage of investment funds may preclude a hospital laundry expansion. ' The rental service has a definite appeal to a hospital in need of immediate cash. Funds normally earmarked for laundry invest- ments can be used in the area of immediate concern. The need for ready cash in addition to what was termed an extremely equitable contract, was the reason given by one Detroit hospital for Subscribing to the rental system. Many of the disadvantages existing under the hospital owned linen commercial contract are again found to be present in this system in regards to cost, service and control. In addition to these, the fact that a hospital usually has more than 200 different linen items in use, may bring about an inability or hesitation on the part of the linen hS 1 renting firm to accept the order. However, for a relatively carefree linen service, if a hospital is prepared and capable of meeting price demands, the linen rental service is ideal. Summary In this chapter an attempt was made to illustrate how the selection of member hospitals in a centralized area laundry facility is accomp- V lished. Rules and regulations necessary to govern this group plan were suggested. Several existing centralized laundry groups were used to depict the actual workings of such a system. Possible problem areas were also discussed. ‘ The author has also undertaken to follow a line of thought that can be pursued when considering a coimnercial contract to process a hospital’s linen requirements. Some of the pros and cons of hospital is commercial laundry operations were discussed based on actual attempts to employ one or the other and information obtained from present systems now in operation. ‘ The application to a specific hOSpital of the information presented thus far will be considered in Chapter IV. 1Berger, pp. cit. CHAPTER IV APPLICATION OF COI‘ISIDERATIONS TO A SPECIFIC HOSPITAL In an attempt to illustrate how the information presented thus far may be applied to a specific hospital, the author will outline the steps leading up to and the course of action taken by Edward W. Sparrow Hospital, Lansing, Michigan in solving its problem of supplying clean linen for an increased bed capacity. Laundry operation. The bed capacity at Sparrow Hospital during the fall or 1958 totaled 30; adult beds plus so bassinets. Sparrow Hospital consisted of the main building housing 205 beds and two. outlying units of 50 beds each. Each installation processed its own linen needs. Laundry equipmmt, the newest piece being ten years old and some dating back twenty to twenty-five years (example: an open flame heated tumbler), handled approximately 96,000 pounds of linen per month plus an unknown quantity at the units. Labor costs alone totaled 6.9 cents per pound of linen processed. A two shift operation totaling 82 .5 hours per week was required to meet the existing demand for clean linen. Building program. A building expansion program currently in progress was expected to bring the total bed capacity of Sparrow Hospital to approximately mm. This was calculated to produce a weekly demand for L6 h? clean linen of 50,820 pounds based on an average of fifteen pounds per patient per day. Therein lay the problem for administration to solve. How could Sparrow HOSpital best meet this new demand? Should a third shift be added to the present operation plus more equipment? Could present machines and personnel be more efficiently utilized? Should the laundry business be contracted out commercially? Should the services of a linen rental firm be purchased? Or Should the present laundry? plant be expanded and new equipment be purchased and maintain a hospital operated laundry? One by one these alternatives were investigated and discounted until the final decision to expand the laundry plant and purchase new equipment was reached. Supplemental measures. A brief study of laundry repair and maintenance costs indicated that it was only through a very fine effort on the part of the hospital maintenance department that these machines were still running at all. The addition of a third shift would have extended these "relics" beyond their present precarious capacity and would allow no time for even routine or preventive maintenance. Supple- menting the machinery was considered unsound for the same reasons. [Improve efficiengy. The physical layout of the laundry plant was of such a nature that prevented a smooth flow of work. Much back- tracking and crisscrossing was required until a piece of linen ran the entire gauntlet. The fact that all machinery'was manually operated placed an excessive number of personnel in the cramped, poorly lighted 148 inadequately ventilated laundry building thus adding to the confusion and inefficiency of operation. For these reasons, this alternative was determined not feasible. In an effort to avoid the most immediately expensive solution of expanding the laundry building and buying new equipment, the administration next looked to the outside. Commercial contract. In the city of Lansing'Which has a population of approximately 102,000, there are several commercial laundry firms. The firms were approached with the proposition of processing the entire volume of Sparrow Hospital's laundry and asked to quote on their price per pound for the service.’ One firm quoted a cost of 12 cents per pound for finished linen excluding patientts and doctor's gowns-these would cost 25 cents each. Another quotele cents perpound but stated it was not capable of handling the entire load. A.third offered the use of their facilities at a charge per pound of eight cents if the hospital used its own personnel. The addition of second shifts to the laundries was ruled out as being too expensive. Week-end and holiday service was refused too. A quote was also received from a Detroit laundry firm, 85 miles from Lansing, stating they could process the linen for 10 cents per pound. They also refused week-end and holiday service. The high price quotations, the absence of guaranteed, uninterrupted linen service plus the proSpective cost of increased linen.inventory necessary to facilitate the service, were the major factors in deciding against the commercial contract. h9 Linen rental service. Contact was made with a local firm offering complete linen rental service to determine the approximate cost of same and how the figure would be derived. Information was received that the cost of the service would'be computed on a fixed cost per piece basis'gplyt Some representative prices are as follows: sheets-- 18 cents each; draw sheets-~15 cents each; pillow cases-~7 cents each; hand towels-~5 cents each; bed Spreads and blankets-~50 cents each and cubical curtains-20 cents each. A savings of approximately'811.82 during the life of one sheet, should be realized by Sparrow Hospital Operating an on-premise laundry as opposed to the available linen rental service. The $11.82 savings was obtained by using the following'basic figures. 'The average life expectancy of one sheet is eight months.1 The author estimates one sheet will receive 96 washings during the eight months. Therefore, laundering one sheet for eight months will cost the hospital $17.28 under the linen rental service (96 x $.18 - $17.28). The life laundering cost of one sheet at Sparrow Hospital was estimated at $5.h6. The figure was reached by using the projected 8.032 per pound cost of processing linen and the 1.2 percale pound sheet. Thus, $.032 x 1.2 x 96 + $1.77 (cost of one sheet) ' $5.h6. ‘ 'Week-end and holiday service was not deemed feasible by the firm. The firm’s ability to meet emergeney situations without restocking the hospital‘s linen closets was questionable. iStatement by Sam Berger, Whitehouse Linen Company representative, 50 The apparent excessive expense of the rental service plus the uncertainty of service when needed most, overshadowed the enticing prospect of providing as near a care-free linen service as possible. Linen replacement and repair costs were taken into consideration as was the necessity of maintaining a linen handling force within the hospital. Extensive laundry renovation. .Attention was finally directed toward retaining a hospital operated laundry by incorporating a complete plant operation renovation. Two of the major laundry machine manufacturing companies were invited to make proposals for hospital linen require- ments. The ultimate bed capacity was projected and the companies were asked to recommend the amount and type of machinery necessary to do the job in a forty hour work week. The companies were furnished infor- mation on past laundry experience, present cost of supplies and utilities, type patient service rendered and present employee wage rates. Hospital boundary lines were determined beyond which the building could not be expanded without violating city ordinances. Both laundry machine companies submitted blueprints which recomé mended the amount and type of equipment and the most efficient plant layout for the particular situation. Accompanying the blueprints was a book of specifications for each machinery list. One company computed a proposed cost for processing a pound of linen under its particular proposal. Labor, supplies and utilities were considered in this proposal. 51 Upon receipt of the laundry machine company pr0posals, personal visits were made to modern laundry installations to study the various type operations and layouts for comparison basis. Letters of inquiry were sent to institutions where distance prohibited personal visits. Recommendations and blueprints were also solicited from a local architect. Based on the findings, a conclusion was reached by the adminis- tration of Edward W} Sparrow Hospital regarding the amount and type of equipment desired plus what was considered to be the most efficient layout for the machinery. Bids on the equipment list were requested from the two participatinglaundry companies with the contract being awarded the lowest bidder. Likewise, bids were let and a contract awarded to have the laundry plant expanded and renovated. A building permit had previously been obtained from the City of Lansing and construction on the "new" laundry was begun. Although not considered at the time plane'were being made to in- stall a new laundry at Sparrow Hospital, an offer to process the laundry of another area.hospital will be made after sufficient experience is obtained under the new operation. Summary Chapter IV contains 1) the developments leading up to an increased linen demand in a specific hospital, 2) the various approaches used by this hospital to alleviate the situation, 3) the reasons for rejecting possible solutions, and h) the selection of and explanation for embrac- ing the course of action taken. CHAPTER V SUMMARI AND CONCLUSION I. Summary Chapter I contains an account of the hospital‘administration's Changing attitude toward the hospital operated laundry. The problem and purpose of the study were stated. Rebated material was considered in conjunction.with its origin and the author's method of procurement. Unfamiliar terms were defined and presentation of the study was out- lined. In.Chapter II, increased efficiency of the hospital laundry operation was examined as a possible means of meeting increased linen demands. Varying degrees of hospital laundry expansion were discussed along with justifications for each degree. Trends toward the adoption of either hospital or commercial operated laundries were depicted. External sources were considered in Chapter III as a possible means of satisfying hospital linen requirements. Pros and cons concerning a centralized hospital group laundry and commercial laundry service arrangements were revealed. Chapter IV involved the application of the study to a specific hospital that recently underwent a laundry expansion program. 52 53 II. Conclusion Due to the nature of the thesis a decision was made to offer a generalized conclusion rather than record for the reader any specific recommendations. . The author concludes that environmental factors pertinent to a particular hospital will ultimately dictate the most acceptable method of insuring an adequate supply of clean linen. .A method that may be both desirable and feasible to one hospital may prove entirely im- possible for adoption by another. The author feels that the final decision, whether it be in favor of'a commercial arrangement or a continued hospital operated laundry, will be strongly influenced by the l) availability of finances, 2) type of patient service rendered, 3) availability of alternate choices, and h) physical and personnel limitations. BIBLIOGRAPHICAL ENTRIES A. Books Hayes, John H. (ed.). Factors AffectmLthe Cost of Hospital Care. Vol. I of I‘inancinngppital Care in the United States. 3 vols. New York: Blakeston Co. , Inc., 1951;. MacEachern, Malcolm T. Hospital Organization and Management. Chicago: Physician's Record 00., 1957. Troy meerMCMneq Architects and Consultants Data Book. Troy Laundry Machinery Division of American Machine and Metals, Inc. ,East Moline, Illinois: 1957. B. Publications 4 ‘ Munger, C. H. "Commercial Contract vs. Hospital Laundry," Hospital laundry Service. General Notes No. 65. Joliet, Illinois: Arnerican Institute of Laundering, 1953. , Nelson, David T. P. 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