THE HANDBOOK FOR HOSPITAL PLANNING AND DESIGNING

THE HANDBOOK FOR HOSPITAL PLANNING AND DESIGNING  

Best Healthcare Planning Firm in India

INTRODUCTION

Planning and designing hospital is a complex and multifaceted process that requires careful consideration of various factors to ensure the delivery of high-quality patient care while optimizing operational efficiency. Hospitals and other healthcare facilities are designed with the help of healthcare architects, who have a crucial and varied role to play. Due to the special and complex requirements of healthcare facilities, their participation is essential. Task of the architects before construction of a hospital are to determine the broad requirement for the hospital system. The system should be able to provide reasonably effective services to patients. Further, workloads and the required activities of any healthcare institution are never predictable in detail. Architects, therefore, must recognize the two main problems, expansion and flexibility to keep pace with the rapidly developing technology in medical sciences.  Physical planning must allow for future expansions in all major functional areas of the hospital and for internal adjustments in the use of space to desired degree of changes must be feasible. Functionally a hospital has six major facility zones:

1. Accident and Emergency.
2. Ambulatory Care (outpatients department).
3. Diagnostic and Therapeutic Facility
4. In-Patient (Nursing Care) Units.
5. Administration Department and Business.
6. Hospital Engineering Services.

Each of the functional components needs to be placed appropriately based on their interdependence but with the shortest possible travel to achieve efficiency. These facilities do require their independent access and related parking lots.

However, for reasons of overall control and security, entries and exits are to be kept to a minimum.

1. Emergency Department is an independent unit to function round the clock like a mini hospital. Entry to this department has to be prominent and self-guided so that a very minimum time is lost in giving immediate treatment to casualty and emergent cases arriving in the hospital.
2. Ambulatory care unit has to perform three main functions:

• To diagnose and treat patients at an early stage.
• Follow up treatment after discharge from the hospital and
• To institute health education programme to educate the public in environmental hygiene.

The outpatient department in a hospital has a very important role in health care delivery. A well-organized and well-equipped outpatient department can play a key role in reducing the load on the inpatient beds and saving a lot of time and expenditure. The emphasis is now more on outpatient facilities, which are likely to increase substantially, thereby reducing the load of inpatients and the cost of hospital projects as a whole.

Facilities of this unit are termed as:

• Clinics for various medical and surgical disciplines.
• Supporting facilities like laboratory, injection rooms, etc.
• Pharmacy and Blood Bank.

Diagnostic and therapeutic facilities include:

1. The radio-diagnostic and imaging department,
2. Clinical pathology as diagnostic facilities
3. Radiotherapy, operation theatres, rehabilitation and physiotherapy as therapeutic areas are to serve in common to outpatient department and inpatient nursing care units.

These facilities should be placed at different levels accordingly, taking into account their functional use and the degree of necessity for dependent departments. Diagnostic and imaging units generally deal with radiography and fluoroscopy, ultrasound, nuclear medicine, CAT scans, etc.

This technique is rapidly developing and should be designed with the future scope of expansion in mind. Laboratories are concerned with the analysis of diseased tissue, fluids, and other elements in the body. This department may comprise activities like biochemistry, microbiology, clinical pathology, hematology, histology, cytology, and serology.

Other activities connected with the department are mortuary and autopsy. Radiography involves the treatment of different types of radiation, from superficial therapy to megavoltage therapy.

The size of the department depends on the load, scope of work, and type of equipment employed. High levels of radiation, protective measures, and air conditioning for the efficient functioning of the electronic equipment are the essential design requirements for the department.

Operation theatre is technically a therapeutic aid in which a team of surgeons, anesthesiologists, nurses, and sometimes pathologists and radiologists operate on or care for patients.

• Location of the department should be decided on factors like quiet environment, noise- free atmosphere, conditions free from contamination and possible cross infection and convenient relationship to surgical wards, intensive care unit, radiology, pathology, blood bank and central sterile service department.
• Understanding of medical and surgical needs of the patient during surgical procedures and the role of environment, sterilization and aseptic techniques in the control of nosocomial infections have led to the development of modern concept of zoning namely protective, clean, sterile and disposal zones in operation theatre design.
• Filtration and recirculation of conditioned air and scavenging of expired anesthetic gases have further enhanced the safety and comfort of the patients and surgical team.

The Rehabilitation and Physiotherapy Department provides treatment facilities to patients suffering from crippling diseases and disabilities.  These facilities are classified as physical and electrotherapy, hydrotherapy, occupational therapy and exercises.

In-patient Nursing Care Units (Wards)

• In-patient nursing care units (wards) occupy the maximum share of hospital space. Concept of providing this facility is fast changing due to policy of early ambulation and in fact only a few patients really need to be on bed.
• Nursing care is broadly classified into general wards, specialty-wise wards and intensive care units. Basic consideration in placing wards is to ensure sufficient nursing care, segregating patients according to three categories, locating them according to the needs of the treatment in respective medical discipline and controlling cross infection.
• Specialty-wise wards, however, should be located closer to their respective outpatient clinics to act as self-contained centers. In planning a ward, the aim should be to minimize the work of the nursing staff and provide basic amenities to the patients within the unit.
• Ward pattern has undergone a radical change from Nightingale ward to Riggs ward.

Many  variations  and modifications  of  the  concept  are  meeting  specific socio-medical requirements  while  attempting  to enhance the efficiency of nurse-patients interaction, observability,  lighting  and  other  physical  requirements,  replenishment  system  for  supply  of  diet medical  and  surgical  supplies,  linen  and  other materials  at  the  doorstep  of  nursing  activity  have further  relieved  the  nursing  staff  on  non-nursing functions to attend patient centered activities.

Norms In-patient Department

In-patient care is not only for admitting patients who cannot be treated outside the hospital, but also for training doctors and paramedical staff.

In-patients are likely to fall into one of five broad cares grouping in the proportions shown.

Intensive Medical Care Where continuous medical and nursing observation and mechanical assistance is necessary to maintain life one percent.

1. Intensive nursing care is where patients are unable to leave their beds and where continuous nursing, observation, and physical assistance are needed, with a 20-25 percent increase in the number of patients.
2. Medium Nursing Care allows patients to leave their beds for short periods (up to four hours) each day with assistance from 20-25 percent.
3. Low nursing care where patients are able to leave their beds for more than four hours per day, requiring minimal assistance of 20-30 percent.
4. Self-care patients leading an apparently normal life while in hospital for observation represent 5-10 percent.

Out-patient Department “Ambulatory Care” is the medical care provided to patients who are not confined to bed.

It can be provided at a general practitioner’s or specialist’s practice premises or at a health post, health center, or hospital.  The functions of outpatient services of a hospital are to provide diagnostic, curative, preventive, and rehabilitative service on an ambulatory basis to the community.

The extent of these functions established by the individual hospital will vary depending on the hospital’s aim, expectations of the community, and political will. The scope and form are undergoing dramatic change.

If it functions well, it can reduce pressure on inpatient care, which can be achieved by increasing diagnostic and treatment services.

Planning is a dynamic process and necessary for orderly development. It can be carried out at many levels of detail and in many timeframes.

To assure a smooth, orderly project the first step in the planning process is to establish a schedule for the entire project:

• Preplanning schedule.
• Determination of community need for healthcare.
• Evolution of existing conditions.
• Demographic survey of the community.
• Statement of goals and objectives related to community needs.
• Capital financing plan.
• Operational programme to meet goals and objectives.
• Master development plan as a framework, including gross departmental area allocation.
• Schematic plans, and construction staging.
• Cost analysis.
• Detailed space programme of first stage for construction.
• Equipment list.
• Design of first stage.
• Construction of first stage.
• Evaluation of operation and feedback.

The departments responsible for each group’s successful interaction are the foundation of the hospital’s work.

• Each separate department needs its own identity and within it, its own map, its own private and public space as well as own front door.
• The design must allow the identity of many families which form its work force to be identifiable, physically, from inside the complex.
• 0 beds -10 acres, 100 beds 15-20 acres, 200 beds 20-25 acres, 500 beds 55-70acres, 700 beds 80-90 acres, 1000 beds 90-100 acres. Hospital design must have flexibility, to adopt change and its concern should be the quality of medical care and the improvement of its standards.
• It is accepted that planning and proper programming is essential to strengthen the health care facilities.
• Every country should accept it as its responsibility to design and implement changes that enhance the performance of the total health service delivery system in a balanced and integrated manner, because hospital is a complex organization.
• The idea of planning is to prevent the haphazard mushrooming up of structure, to prevent fragmentation of function and to promote logical flow of patient, staff and equipment and to attain a fair degree of uniformity and standardization.
• The implementation of a health care facility project could be regarded as a sequence of phases.
• Formulation consists in establishing the need for a facility; in making sure that its erection would be in accordance with stated policies and priorities, in ascertaining that the resources (money and manpower) necessary for its realization and operation are available or will be available when needed.
• At the end, formation of planning team should be made.

SITE SELECTION

It is important for hospital building. It must have the following characteristics:

• Easy approach by people
• Enough land availability
• Sub-soil water must be deep
• Sufficient supply of water and electricity.

When selecting the site, one must keep in mind that any further expansion in the size of land required will be as follows:

• Single storey
• Double storey
• 3-5 stories
• 4-6 stories
• 6-9 stories.
• Basement is possible if the sub-soil water is below 25 feet in mid monsoon time

The need for a good hospital design not only indicates impeccable infrastructure, but also a step towards healing and wellbeing. Hence, hospital design is an extremely crucial aspect. Here are the things to be taken into consideration while designing a hospital:

Preparation of architect brief 

After obtaining requirements of clinical and nursing departments supportive service, administrative and business and utility services, a general outline of requirements is prepared to provide the client with an appraisal and recommendation, so that it can be ensured that the project is functionally, technically and financially feasible. The client’s task is to establish a project management organization that can develop the project brief by taking into account and analyzing all important factors.

Design Plan 

While designing different zones, there is a need to establish relationship between activities and space in a health centre.

Circulation area such as corridors, entrance halls, staircase, etc. in the hospital building should not be less than 30 percent of the total area of the building.

Basic circulation pattern depends upon land availability, and environmental circumstances, however, it may be any one of the following:

• Radial-linear
• Tree-shaped or dendritic-grid.

The other relevant details need to be kept in mind are as follows:

• Water Supply

About 300-500 liters of water per bed per day (excluding water for gardening) is to be catered for Water supply should be preferably from two sources. Reserve water for 7 days if from a single source and 2 days if from two sources.

• Electricity

Electricity supply should be from 2 grid/3 grid (source).  In addition, generator supply for certain essential areas should be catered for even for more essential equipment there should be provision for uninterrupted electric supply.  Requirement for the hospital is 1 kWh per bed per day.

• Sanitary Requirements

Toilet for an individual room (single or two beds) in a ward unit shall be 3.5m2 comprising a bath, a wash and WC.

Toilet common to serve two such rooms shall be 5.25m to comprise a bath, a WC in a separate cubicle and a wash basin.

For a multiple bedded ward unit, requirement of fitments is given below:

Biomedical waste (soiled, semi-soiled and liquid) amounts to 2 kg per bed per day.

The hospital drainage should be connected to the main town drainage system.

A sewage treatment plant is desirable for a large teaching general hospital.

Certain General Parameters

The Hospital Space Module is taken as 3.5 sq.m. This space is enough to accommodate a toilet comprising a WC, wash basin and a shower. 7 sq.m is enough for the routine hospital bed, and 14 sq.m will be required for each bed in the Intensive care unit.

1. Hospital Engineering Grid is taken as 1.6 m one and a half grid i.e. 2.4 m is the desired width of a corridor. Width of door, window etc. can also be expressed in the form of a grid.
2. Plinth area

With all constraints the recommended area per bed is 75 sq.m. Whereas in developed countries it is 150 sq.m.

Floor height

The height of all the room in the hospital should not be less than 3 m and not more than 3.65m.

1. Head room

The minimum height under the beams, fans, lights and other fixture on the ceiling should not be less than 2.6m. measured vertically from the floor.

2. Dado

It should be generally up to a height of 1.2 m. In bathroom up to 2 m. and in operating and delivery room dado should be the complete floor height.

3. Door

The minimum width of doors should not be less than 1.6 m. and height 2.1 m.

Ventilation – There should be sufficient ventilation in hospital. As far as possible, there should be cross ventilation thus size of window should be 20 percent of the floor area.

Exhaust fans should be provided as per following scales.

• Operation theatres and delivery suites – 20 air changes per hour.
• Radiography room, Radiotherapy room – 08 air changes per hour.

1. The traction system of the hospital may be divided into two parts extramural and intramural. The extramural system is the ambulance service. The intramural system includes ramps, lifts, conveyor belts, and dumb waiters and trolleys etc.
2. Lifts (automatic control) with speed of 0.36 m and 0.75 per second for hospitals of two or more stories.

Fire protection – In a high-rise building the following systems should be provided:

• Fire safety system
• Fire detection system
• Fire alarm system
• Firefighting system

Design Competition

If the hospital is big, a tender can be introduced to invite the architects for a design competition and a rate. A group of users and experts can choose the best design and rates, etc. Construction by Contractor A project like a hospital has to be contracted only at a reasonable price with a reputed contractor.

A tender has to be issued by the engineering department with full and complete specifications stating type of work, the accepting cost, period of completion, etc. The planning team should take a decision regarding allotment of work. Proper control of construction must be exercised by management.

Control

• Control is an integral part of the project management process.  It aims at regular measurement of achievement and monitoring by comparison with planned progress.  When deviations from planned progress occur, plans may have to be changed.
• Time is very important, and the control process should aim at early discovery of any departure from the planned course so that adjustment can be in time to be effective.
• Control information provides a basis for management decisions, and the following requirement should be satisfied by an effective control system. It should draw immediate attention to significant deviations from what is expected. It should focus on the exception rather than the rule. True and meaningful comparisons can be made possible.
• The information should indicate in due time what corrective action is necessary and by whom, the action should be taken.  It should also, as far as possible, indicate what consequences any deviation from the plan is likely to have on any other planned activities, especially the time-schedule, in order to help the project manager to modify his plans accordingly.
• Control information should be expressed in a simple form so that it is readily understood by those who have to make use of it.
• Key areas of control must be chosen with care so that the results of control are worth the time and effect expended.
• Working with a qualified external planning team and following the guidelines of reasonable schedule, the institutions role in the process is to review, comment, and make timely decisions on the work or recommendations of the external team that is made up of health care consultants, architects/engineers, construction managers, and other consultants and advisors.
• This review-and response interaction among the various parties may require administrative and board decisions before the next phase of activity can begin.

The success of a project depends largely on getting everything set up correctly: choosing an appropriate process, selecting appropriate team members, and doing the groundwork, so a team will know what the project is all about.

The following activities must be incorporated into every step of project:

• Maintain communication
• Fix obvious problems
• Look upstream
• Document progress and problems
• Monitor changes. Teams must spend time in the early stages of their project planning how the project will unfold. Planning is the heart of using a scientific approach to quality improvement.

MARKET SURVEY – HEALTHCARE IN INDIA

Healthcare in India is in a developing stage and requires a radical policy shift at the government level to implement changes and address the challenges of the future. Under the umbrella of health care providers are outpatient set-ups, nursing homes, hospitals, medical colleges, health spas, diagnostic centers, ayurvedic and naturopathy centers, hospices, old age homes and more. Most of these institutions will have varied needs, which will differ vastly in terms of their planning needs.

Health care provision in India is different in rural and semi urban settings where it is more unorganized to today’s super specialty centers where it more institutionalized. The mechanisms for funding are fast changing to the private sector involvement thereby pushing up the cost of both setting up hospitals as well as availing health care in these hospitals. The lowering of interest rates over the years has no doubt helped the cause of the private sector wherein more entrepreneurs are coming forward to set up hospitals as it has become affordable to take loans and repay them. The rapid growth of the insurance sector is equally helping the community to face the problem of spiralling health care costs.

Stakeholders

There are innumerable stakeholders in the health care delivery domain including the government, philanthropic trusts, educational institutions, corporate sector, insurance companies, bio-medical vendors, architects, construction companies, patients, relatives, the pharmaceutical industry, professionals like doctors and other para-medical staff, and the funding agencies The industry’s growth will be beneficial to many in the population due to its wide range of stakeholders. The hospital ownership pattern can be basically three types:

1. Government owned - central / state / district / autonomous like army, railways etc
2. Not for Profit – Managed by Trusts / Societies
3. For Profit – Corporate Sector

PROJECT CONCEPTUALIZATION

The first step in hospital planning is to freeze the project concept in terms of:

• Identification of the market needs and deriving the appropriate size of the project
• Determining the possibility of getting skilled manpower

All the above factors have a bearing on the project cost and its viability in the future. This process helps understand the need of the community that will be served by the hospital in the given location. For doing this, one needs to undertake a detailed Market Survey by collecting secondary data from various sources like the internet, libraries, media publications, newspaper archives, ministry of health and district health departments records etc. Unfortunately, India does not have a reliable mechanism for capturing health related data especially in the private sector. One also needs to undertake primary data search by conducting interviews with households, practicing doctors and visiting existing institutions. There can be three types of surveys required:

Household Survey

This is essentially done to understand the health care seeking behavior pattern of the community as a whole. Sampling techniques are used to map the statistically significant number of households. The basic information which should be collected and analyzed is as follows:

1. Demographic details of the family
2. Education & Income details
3. Disease profile in last three years
4. Choice of health care provider for minor & major ailments with reasons
5. Method of payment for availing healthcare
6. Their opinion on deficiency in health care market
7. Critical success factor for the proposed project

Doctor’s Survey

Medical professionals are usually the best judge of deficiencies in the medical market and should be carefully interviewed to determine a successful project approach in the geographic services field. The sample of physicians surveyed should include specialists in all medical and surgical departments, including specialists in diagnostic departments such as laboratory, imaging, and physical therapy. Basic information Laboratory, image processing, physical therapy, etc. Collected and analyzed when:

• Personal details on specialty, qualification, experience etc
• Area of practice and hospital attachments
• Patients seen and their drainage area
• Referrals to other hospitals/diagnostic centers with reasons for referring
• Views on deficiency in health care market and solutions for same
• Patient’s capability to pay
• Critical success factors for a hospital project in the service area

Institutional Survey

Getting basic feedback on the competitors in the primary service area, which is within a 5-10 km radius, would be important to assess the strengths and weaknesses of major players. For national centers of excellence, however, the catchment area could be much larger, maybe the whole country, like Tata Memorial Hospital in Mumbai. One would also need to know the productivity, tariffs, salary structure etc, which will help with preparation of the feasibility report. The important information to be collected would be as:

• Ownership with historical growth pattern
• Service Mix (diagnostic, therapeutic, medical, surgical, support services)
• Bed mix
• Productivity of major services
• Tariffs of major services
• Bed to manpower ratio
• Technology level
• Annual revenue/expense in last 2-3 years to understand growth pattern

DATA ANALYSIS

The data collected through secondary and primary sources is then analyzed to arrive at a facility mix for the proposed project. It will also determine the scale of the project in terms of its bed size. In case it identifies some atypical need like cancer treatment, it would perhaps need more research to understand the profitability of such a capital-intensive specialty. The end result should give definitive information on the following:

Specialties to be practiced in the proposed project

1. Number of OPD rooms
2. Bed mix with break up
3. Number of operation theatres
4. Diagnostic service
5. Blood bank
6. Support services

In case the project is to be developed in phases the facilities to be phased should be clearly identified as the engineering services and areas for the phased development will have to be accordingly planned.

DETAILED PROJECT REPORT / FINANCIAL FEASIBILITY

After finalizing the project concept in terms of its facilities and size, the next important step is to analyse its financial viability. This will also help the promoter in planning the means of financing the project based on its profitability and capability of servicing the debt proportion.

The first step of the feasibility process is to identify the cost of the project in a realistic manner. This is done by way of producing a detailed project report (DPR). Many projects have failed midway through the construction process because it was identified that the cost overrun would be more than 50% of the estimated budget.

Hospital buildings are very complex in terms of their engineering needs and hence specialized agencies are required to plan these and identify the cost. The cost of the project should be broken down under the following heads:

1. Civil Works including RCC, masonry, doors, windows, interior, and facade treatment
2. Electrical Work
3. Plumbing & Fire Fighting
4. Air Conditioning
5. Landscape & Site Development
6. Elevators
7. Medical Equipment Broken Down Under Departmental Heads
8. Non-Medical Equipment Like Kitchen, Laundry, Computer Hardware & Software Etc
9. Hospital Furniture and Fixtures
10. Professional Fees
11. Pre-Operative Expenses
12. Municipal Taxes & Deposit
13. Interest During Construction
14. Contingency

The estimates for all the above should be compiled meticulously after detailed discussions with experts and undertaking adequate research. Financial institutions also require sufficient back up data to accept the costs before accepting the project for funding.

INCOME ASSUMPTIONS

After compiling the project cost, the next important step is to ascertain the income from the project from various heads. Whilst doing this, one would rely heavily on institutional market research to understand the industry benchmarks for making assumptions. Income assumptions will need to be made for the following income heads:

1. Room rents for all categories of beds like general ward, twin/single rooms, ICU, NICU etc.
2. Departmental income for diagnostic services
3. OPD & IPD Consultations
4. Surgical Operations (Major and Day Care Interventions)
5. Health Check Schemes
6. Pharmacy
7. Emergency
8. Deliveries
9. Blood Bank
10. Emergency
11. Any specialty service like LINAEC, IVF, Angioplasty, Minimal Invasive Surgery, Organ Transplant etc. will need to be separately assessed

EXPENSE ASSUMPTIONS

The next important step is to compute all the important expenditure heads for the project operations. These heads would include the following:

1. Salaries and wages – these should be computed on a cost to company basis and should take into a staffing pattern inclusive of those for leaves, contract labours etc.
2. Departmental expenses in terms of consumables. This could be arrived as percentage expense to the departmental income by taking industry benchmarks
3. Professional fee payable to doctors for rendering clinical services. This would differ from assuming a flat salary to incentive-based remuneration. Again, industry benchmarks will have to be followed for same. Some hospitals have a mix of both the options
4. Energy costs in terms of electricity, water, medical gases, generator
5. Food expenses for patients and staff
6. Laundry & linen expenses for patients and staff
7. Housekeeping expenses can be calculated on a per sq. ft basis for the building
8. Stationery expense
9. Telecommunication
10. Conveyance and car maintenance
11. Marketing expenses
12. Repairs and maintenance
13. Insurance, Legal and Audit charges
14. Miscellaneous expenses
15. Depreciation
16. Interest cost for loans taken
17. Taxes for corporate hospital

FINANCIAL STATEMENTS

After computing the income and expense statements as mentioned above, one arrives at the various financials, such as the Profit & Loss statement, Balance Sheet, Cash Flow, and Break-Even Analysis. After computing these statements, once we can undertake sensitivity analysis by subjecting the project assumptions to certain changes and evaluating the impact on profitability, like:

• Change in debt to equity ratio
• Change in interest rates on the loan taken
• Change in capacity utilization over the five-year period
• Effect of cost escalation

FUNCTIONAL & SPACE PROGRAMS

Once you have agreement on a capital investment strategy and a facility mix (derived from the detailed project report), it is time to undertake programming. The detailed project report (DPR) may have been done for a long-range planning strategy, a short-term need or maybe both. The functional program and the space program are to be prepared for the short-term project or for phases of a longer-term project for which planning has already been done in totality, like a teaching hospital. It serves as a common policy document which outlines the parameters and vision of the project for all the members of the planning and design team. It should also contain all the necessary information for the architectural design team to commence conceptual and schematic design. The components of the functional and space program for each department of the proposed healthcare facility can read as follows:

• Listing of planning assumptions
• An assessment of the situation on the ground (as existing)
• The planning objectives and a vision for the future
• Existing and proposed workloads
• Proposed time of operation
• Existing and proposed staffing
• Operational and support systems assumptions
• Equipment list for the proposed department  

Functional adjacencies and access requirements of the various departments

The space program consists of a list of the various spaces in the department in square feet and meters.

The space program provides a list of all rooms or areas required for each function and the total area required for the function. The above approach flows from the functional requirements. This document defines the functional requirements of the project in keeping with the facility & service mix brief provided by the clients. These functional requirements are defined in terms of the following parameters:

• The services accommodated,
• The potential workload, &
• The key operational premises

ROOM DATA SHEETS

The room data sheets are an extension of the space program. Usually confined to an A3 sheet, it can contain a plan of the room, minimum dimension of the space, a list of major items of medical or other equipment to be housed within that space, and any unique temperature, humidity, lighting etc. conditions.

Without the plan, the same information can be given could an Excel sheet, and the plan can be added after schematic design is done to complete the sheet. At this stage, the room data sheets could only be generic to help the non-healthcare architect plan the furniture, fixture and equipment plan (FFE).

For the room data sheets to be of optimal use, they would need to be prepared after the FFE is in place.

ZONING

Zoning of a site is a concept every architect is familiar with, so I will just give a brief description for the benefit of my healthcare professional readers. On a site that has multiple usages by which I mean buildings housing differing kinds of functions it is useful at the onset of design to block out appropriate areas that each usage will occupy. This is done by considering the following factors:

• The functional and spatial relationships between the various buildings/usages.
• The topography of the site.
• The vehicular and pedestrian circulation connections between the buildings.
• Any special site features such as trees, existing buildings, water bodies, HT lines etc.
• Orientation of the buildings with respect to sunlight and prevailing winds

In the conceptualization, design, construction and commissioning of any successfully run HealthCare facility project, the services of some or all of the following types of consultants will be required-

1. Hospital Consultant/Facility Planner
2. Consulting Architect / Architect
3. Municipal Architect / Local Architect
4. Structural Consultant / MEP (Mechanical, Electrical, Plumbing) Consultants
5. Project Management Consultants
6. Lighting Consultant
7. Networking Consultant
8. Safety/Security Consultant
9. Fire Safety Consultant
10. Logistics Consultant
11. Acoustic Consultant
12. Quantity Surveyors
13. Public Health Engineering Consultant
14. Environment Clearance Consultant
15. Bio-Medical Waste Consultant
16. Infection Control Risk Assessor
17. Kitchen Design Consultant
18. Laundry Design Consultant
19. Audio-Visual Coordinator
20. Chartered Accountant
21. Geo-Technologist
22. Land Surveyor
23. Landscape Architect
24. Interior Design Consultant / Graphic Designer
25. Bio-Medical Engineer / Medical Equipment Consultant
26. The Client / Client’s Representative
27. Hospital Administrator / CEO of Proposed Facility
28. User Groups

Enumerated below are the agencies who would be collectively involved in the construction of the hospital:

1. Excavation contractor
2. Civil contractor
3. Plumbing
4. Firefighting
5. Electrical
6. HVAC
7. Elevator
8. MGPS
9. Pneumatic Tubes
10. Nurse Call
11. IBMS
12. Hard Flooring & Dado
13. Casework, millwork
14. False Ceiling
15. Painting
16. Wall coverings
17. Crash guards / corner guards
18. Doors
19. Windows
20. Loose furniture
21. Artworks
22. Façade works
23. Landscape
24. Signage
25. IV tracks, curtains
26. Steel storage
27. Medical furniture
28. Display screens
29. Equipment – medical, non-medical
30. Low voltage applications – access control, CCTV, RFID

THE PROCEDURE FOR HOSPITAL SET UP IN INDIA

• Registration under the clinical establishment act, 2017

This act was enacted by the central government and is being adopted by the states of India. It needs a one-time registration for a premise to be operated as a hospital. The registration must be done by the respective state government that has adopted this act. For registration, hospitals should fulfill the minimum requirement under the category in which they fall. Each state has described the procedure of registration of the hospitals that fall within their territory.

• Registration under companies’ Act, 2013

This act is applicable when the hospital established it under the ownership of a corporation. The act needs the corporation to be registered and fulfils the requirements of incorporation like memorandum of association, articles of association, capital structure formation, securities allotment, account audits, etc.

• Director Index No (DIN NO) for each director

This comes under the Ministry of Corporate Affairs, Government of India. It is a compulsory registration required for each director who wants to be a part of a corporation. It is a onetime registration for directors.

• Registration under societies registration act, 2001

In case the hospital is being established under the ownership of society, the society registration act is required.

• Locations of the Hospital

This is required to be chosen well, because if there are already some hospitals in the locality, then it would be difficult to get in patients. Also, the hospital must be set up in an area that has a good transportation facility or is close to a railway station. One must look for non-agricultural land particularly designed for hospitals. All the electricity supply, as well as the water supply, should be easily available and that is required to be checked before purchasing any land for the hospital set up.

• Facilities Offered

The facilities offered by the hospital should be decided by the management depending on the locality of the hospital. It might be generalized into pathology, ICU treatment; orthopedic, as well as other specialized services should be specified. Also, the facilities linked to electricity, AC rooms, water, hygiene maintenance, etc, should be checked before providing any specialized services.

Permits

• Land and construction

A hospital could be set up only on no- agricultural land that could be used. The numerous approvals, as well as permissions required from the local authority and the government should be obtained before starting any hospital.

• Electricity and water

A hospital needs approximately 100 liters of water per bed each day. The water requirement for the various hospitals would be different from project to project based on whether the hospital is a primary, specialized hospital, etc. The concerned municipal authority’s permission should be obtained to make the water and electricity facilities available.

Sewage

Well planned sanitary measures for disposal of waste as well as a drainage system which includes tanks, pipelines, etc. and permission from the local authorities should be obtained.

• Biomedical Waste

The large hospitals must have an incinerator for disposal of bio-disposal waste, for instance, body parts or tissues. A smaller hospital is not able to afford such a cost and it needs minimal space and additional machinery installations, which are expensive for a small hospital set up. The Municipal corporation’s permission would also be required for such disposal of waste and it must not be harmful to the people living in a nearby location.

• Fire and Health License

Approval of the Fire Department is required for a large hospital as well as a Health certificate from the local authority after installation of all the beds and equipment within the hospital. A NOC from the Fire department should also be required for small hospitals and it would be the responsibility of the hospital management to prove that the hospital would not cause any harm or loss of life and needs to be procured from the local municipal council.

REGULATIONS RELATING TO EMPLOYMENT OF STAFF

• Employment of employees (Doctors, Nurses, Pharmacists) only after proper credentialing
• Prevention of sexual harassment of women employees at the workplace
• Responsibility of the employer for the safety of workforces
• Rules governing the employment of staff
• Immunization / other measures for the protection of staff from Occupational Health hazards.

SIGN BOARDS
Rules for the size, contents as well as the correct place for signboards (IMC Regulations 2002)

• Information that requires be displayed at the Hospital are:

1. Certificate of registration of hospital with the municipal authorities
2. IMC/SMC registration certificate (IMC Regulations, 2002)
3. Charges for consultation as well as other procedures/services (IMC Regulations 2002)
4. Clinic timings, closed days

• FSSAI license for operating a kitchen

The FSSAI license comes from the Food Safety and Standards Authority of India under the Ministry of Health and Family Welfare, Government of India. The license is necessary if the hospital runs an in-house kitchen for the patients as well as attendants.

• Permit to store LPG cylinder

If the hospital store has an LPG cylinder in large quantities for use in the hospital’s kitchen or hospital purposes, the hospital must have a permit from the Controller of Explosives under the Petroleum act, 1934.

• Pharmacy registration for medical shop

This comes under the Office of the Drug Controller. There are different licenses for medical shops attached to hospitals (IP) and standalone medical shops. There are minimum requirements for the registration like the minimum size of the shop (250 – 300 ft) as well as requirements of Air conditioner and Refrigerator. This license is valid for 5 years.

• Trademark registration

The Indian Trademarks Act 1999 is not a mandatory activity and is essential only if the hospital wants to trademark its logo or name.

• Vehicle registration for ambulances

The ambulance bought by the hospital must be registered with the RTO, the Transport Department, and the state government.

• Arms licenses under arms act 1959

If arms are possessed by the hospital or its employees (for example by security guards), a license for the same should be available.

PLANNING THE HOSPITAL INFRASTRUCTURE

One must take care of these things:

• Qualifications of Doctors as well as their registration numbers
• Working hours for Nurses as well as their shift timings
• Medical equipment as well as instruments purchased
• Computers as well as other hardware devices set up
• Engineers as well as staffs required for maintenance, plumbing, medical gas pipelines, air conditioning, etc.

LICENSE REQUIRED

1. Regulations Building Permit and Licenses (From the Municipality)
2. No objection certificate from the Chief Fire Officer “License under Bio-Medical Management and Handling Rules, 1998.
3. No objection certificate under Pollution Control Act.
4. Narcotics and Psychotropic substances Act, 1985
5. Vehicle Registration Certificates (For all hospital vehicles.)
6. Atomic energy regulatory body approvals (For the structural facility of radiology dept, TLD badges, etc)
7. Boilers Act, 1923(If applicable)
8. MTP Act, 1971 (MTP stands for Medical termination of pregnancy. To be displayed in the Gynaec and Obs department)
9. License for the Blood Bank (To be displayed in the Blood Bank)
10. Transplantation of Human Organs Act 1994(If applicable)
11. PNDT Act, 1996 (PNDT stands for Prenatal diagnostics test. To be displayed in the Radiology department that this is followed
12. Dentist Regulations, 1976
13. Drugs & Cosmetics Act, 1940
14. Electricity Act, 1998
15. ESI Act, 1948 (For contract employees)
16. Environment Protection Act, 1986
17. Fatal Accidents Act 1855
18. Guardians and Wards Act, 1890
19. Indian Lunacy Act, 1912 (Applicable only if a Psychiatry dept is there in the hospital)
20. Indian Nursing Council Act 1947 (Whether nurses are registered with NCI).
21. Pharmacists registered with Pharmacy Council of India.
22. Insecticides Act, 1968
23. Lepers Act Maternity Benefit Act, 1961
24. Minimum wages act, 1948 (For contract employees)
25. Pharmacy Act, 1948
26. SC and ST Act, 1989
27. Protection of Human Rights Act, 1993
28. Registration of Births and Deaths Act, 1969
29. Urban Land Act, 1976
30. Right to Information Act 2005

The registration for transplantation of human organ Act, 1994 (in case the hospital varies out human organ transplantation or organ harvesting, it shall be registered under this Act) Excise permit to store spirit (to store spirit beyond a certain quantity, the hospital must obtain a permit from state excise department). Multiple medical laws along with ethics are required to be followed at every step. A set of rules and eligibility criteria were put forth by our government for hospitals, which offer services for central government health scheme beneficiaries.

HOSPITAL PROJECT COMMISSIONING

Unlike most other buildings, health facilities are complex buildings incorporating multiple clinical disciplines. They need to be planned and designed to accommodate various functions that have to strictly follow laid down operational policies. It is not just the building but other asset classes such as MEP and HVAC services that follow strict design norms, not to mention the medical devices that can often cost as much as or more than the building itself. Establishing the facilities under these circumstances is just half the task. Hospitals, by and large are complex, expensive to operate and maintain. It is therefore essential to synchronize the commissioning and hand over in a seamless manner so as to minimize any problems in future.

The commissioning team would prepare a project implementation plan / program based on the objectives of the project promoters, the nature of the hospital, timelines for commissioning the facility, the various assets and services that need to be incorporated, the building plans, etc.

The major categories of systems to be commissioned would be:

1. Building envelope
2. Safety systems
3. MEP systems
4. HVAC systems
5. Medical Gas Pipeline Systems (MGPS)
6. Nurse Call Systems (NCS)
7. Pneumatic Tube Systems (PTS)
8. Fire protection and alarm systems
9. Information technology
10. Vertical transports
11. Material handling
12. Interiors including lighting, furniture and finishes
13. Landscapes
14. Exterior lighting

It is important to write and execute policies and protocols and SOPs to ensure that the skill sets for clinical and managerial areas are maintained to achieve complete patient care. Some more aspects covered under commissioning assistance are:

Human Resource

• Structuring of Organizational Chart
• Distribution of Staffs in various grades
• Salary structuring grade-wise

 

Manpower Planning

• Job Description of all the employees
• Employee Manual

Training Modules

• Induction Program
• Basic etiquette for Housekeeping, Nurses & Ward boys
• Communication etiquette for front office staffs
• Code of conduct
• Grooming
• Basic Etiquette for Housekeeping, Nurses & Ward boys

Information System (IT) Management:

• Evaluation Program
• IT Integration & Planning
• Module Selection
• Technology Evaluation And Finalization
• Selection of It Hardware
• Implementation of IT
• Assistance of Data Masters
• Website Framework
• Integration With HIS
• Mobile App Framework
• Security Guidelines For IT
• BMS (Building Management System)
• Public Address System
• EPBX
• CCTV
• Queue System
• Nurse Call Integration With His
• E- ICU Management
• Integration of Various Medical Equipment’s With His

Operations Management:

• Induction Program
• Workflow Management
• Departmental Flow chart
• SOP’s of Every Department As Per NABH
• Tariff Design 

Marketing Management:

• Template for Monthly Marketing
• Yearly Marketing calendar
• Template for Travel plan for Marketing executives
• Health check-up plan
• Internal Marketing 

Branding Activities

• Brand identity: Logo letterhead visiting cards, envelops etc.
• Creation of LinkedIn, Facebook, Twitter and various other social media accounts
• Brochure Design
• Signage Program
• Stationary Program
• Finalization of Linen
• Ambulance Design
• Hoarding Design

Marketing and Branding are the final steps when it comes to planning any hospital which is important for two main things-

1. Create awareness regarding the new facility
2. Put the hospital on the map

CONCLUSION 

Architectural planning and design of applicable healthcare/hospital facilities requires a holistic yet focused approach and proper understanding of population, healthcare demographics, quality, patient preferences, evidence-based outcomes, medical technology, available healthcare professionals, etc. to be able to give birth to a truly effective healthcare facility.

It is a superficial macro-level study. For more details, kindly contact us on  hospaccx.india@gmail.com or log on to www.hospaccxconsulting.com

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