Ward Management & Administration for Nurses Manjubala Dash
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IntroductionCHAPTER 1

In ancient times the word ‘Hospital’ had a use of wide sense. There were several treatises contained account of hospitals and of ‘attendants’ called nurses. They give details of attributes of a good nurse. Notable among these are Charaka Samhita, Ashtanga Hridaya and the writings of Sushruta. Emperor Ashoka, built many hospitals and employed nurses. As per their writings, the nurse of those days should be proficient in cooking, caring for bed patients and in other nursing procedures. It is clear that nursing schools were existed even in those days.
An organizing training for nurses in India can be said to have started in 1854 with the opening of a school for midwives at Madras. Soon schools for nurses, training were opened in Calcutta in 1859 and in Madras in 1871. To cater to the demands of the army during the World War, Lady Reading Health School was opened in Delhi in 1918 to train nurses. Training male nurses was also started during the early period of this century. In succeeding years, nursing schools were opened all over the country in collaboration with the government and private hospitals. These schools were followed the systems, which were in use in Western Countries at that time.
There are two accepted types of organizations in nursing services, both running parallel. They are line and functional organizations. In the line organization the chief of nursing, normally called matron or the nursing superintendent, is responsible for the recruitment, appointment, training and allotment of nurses to various areas and for overall supervision of their activities, she is incharge of the whole department and its personnel complement. In the functional organization, the nurse takes order from the clinician so far the medical care of the patient is concerned. The clinician however is not authorized to act in the line organizational manner. If a nurse does not perform her duties, the clinician should refer the matter to the Chief Nursing Officer.2
Effective coordination and cooperation should be ensured for proper functioning of this dual authority. Normally there is no conflict, but controversy exists, whether the nurse should be counted upon as an assistant to the clinician or from her background and training should plan nursing care independently within the frame work of the clinician's policy. More and more emphasis is laid on the coordinating member of the team, coordinating the orders of the clinicians and the work of the other services to achieve efficient patient care.
HOSPITAL AND HOSPITAL PLANNING
A hospital is a complex organization and has all the attributes of an organization. But there are many features of management and administration, which are not visible in many other organizations and systems.
A hospital provides personalized and individualized care; each person is unique, even when there are many persons suffering from the same diseases.
  • Must be highly responsible to the expectations of the individual, the family and the community
  • Must be involved in primary health care and community health even when providing secondary and tertiary care
  • Must cope with emergency care; management of crisis (accidents’ and emergencies) is an integral part of management of hospital
  • Cannot make mistakes, which may end up with loss of life or life-long disability or chronic disease
  • Has teamed of professionals who expect and demand freedom for decision-making and action
  • Has difficulties to evaluate its functioning with ill-defined objectives and outcomes
  • Has difficulty in providing individual rewards or punishments
  • Find it difficult to evaluate its functioning with ill-defined objectives and outcomes.
The hospital is an integral part of a social and medical organization the function of which is to provide for the population complete health care, both curative and preventive and whose out-patient services reach out to the family and its home environment.3
The hospital is also a center for training of health workers and for biosocial research World Health Organization (WHO).
The primary function of a hospital is the provision of medical care to a community. A hospital, however has two other important roles to fulfill—to be a center for the education of all types of health workers, doctors, nurses, midwives and technicians and for the health education of the public to be a center for research. The hospital's appearance is impressive and its work is dramatic.
In India, as all over the world hospitals are the key health care delivery institutions, significant progress has been made since independence in the establishment hospitals and improving their efficiency and operations.
A vital function of the hospital is the prevention of disease and the promotion of health. The hospital is to render to the community a high quality of service on a broad scale, competent personnel, good facilities.
  1. Hospitals should look after the total care and not merely in episodic care, when the patient seeks relief for the acute condition.
  2. Hospitals should become health centers, instead of being only providers of acute and episodic care, when patients come for treatment of diseases.
  3. Hospitals should provide facilities for health education of patients, relatives and public. There is need for all hospital staff to be involved in health education.
  4. Hospitals should become cost-conscious and generate as much fund as possible for the running of the institution.
  5. The hospital must provide low cost effective care. The manpower and equipment must be optimally utilized. Pilferage, which is fairly large in many hospitals should be checked.
  6. Hospital should ensure community participation by having effective and representative committees.
  7. Hospital should incorporate tried methods of treatment in indigenous systems and yoga, wherever possible.
  8. Hospital should function as centers for rehabilitation the departments of physical, medicine and rehabilitation should be improved with vocational and occupational training and efforts must be made to rehabilitate the persons in the community.4
 
DEFINITION OF HOSPITAL
The word ‘Hospital’ is derived from the Latin word Hospitals, which comes from hospes, which means a host. The English word Hospitale, comes from the French word Hospitale, as do the word ‘hostel’ and ‘hotel’ all derived from Latin.
Hospital means, an establishment for temporary occupation by the sick and the injured.
Today hospital means an institution, in which sick or injured persons are treated. A hospital differs from dispensary.
A hospital being primarily an institution, where inpatients are received and treated, while the main purpose of a dispensary is distribution of medicine and administration of outdoor relief.
According to Steadman medical dictionary, it is defined as an institution for the care, cure and treatment of the sick and wounded for the study of diseases and for the training of doctors and nurses.
According to Blackstone, Hospital is an institution for medical treatment facility primarily intended, appropriately staffed and equipped to provide diagnostic and therapeutic services in general medicine and surgery or in some circumscribed fields of restorative medical care together with bed care, nursing care and dietetic services to patients requiring such care and treatment.
According to the directory of hospitals in India, 1988, a hospital is an institution, which is operated for the medical, surgical and obstetrical care of inpatients and which is treated as a hospital by the central/state government/local body or licensed by the appropriate authority.
A modern hospital is an institution, which possesses adequate accommodation and well-qualified and experienced personnel to provide services of curative, restorative and preventive character of the highest quality.
 
CHANGING ROLE OF HOSPITALS
From its gradual evolution through the 18th and 19th centuries, the hospital both in the Eastern and Western World has come of age only recently during the past 50 years. So the concept of today's hospital contrasting fundamentally from the old idea of a hospital as no more than a place for the treatment of the sick with the wide coverage of every aspect of human welfare as part of health care; i.e. physical, mental and social well-being a reach out to the community 5training of health workers, biosocial research, etc. The health care services have undergone a steady metamorphosis and the role of hospital has changed with the emphasis shifting from:
  • Acute to chronic illness
  • Curative to preventive medicine
  • Restorative to comprehensive medicine
  • In-patient care to outpatient and home care
  • Individual orientation to community orientation
  • Isolated function to area—wise or regional function
  • Tertiary and secondary to primary health care
  • Episodic care to total care.
The important factors, which have lead to the changing role and functions of the hospital are as follows:
  • Expansion of the clientele from the dying, the destitute, the poor and needy to all classes of people
  • Improved economic and social status of the community
  • Control of communicable disease and increase in chronic degenerative diseases
  • Progress in the means of communications and transportation
  • Political obligation of the government to provide comprehensive health care
  • Increasing health awareness
  • Rising standard of living (especially in urban areas) and socio-political awareness (especially in semiurban and rural areas) with the result that people expect better services and facilities in healthcare institutions.
 
PHILOSOPHY OF HOSPITAL
General hospital is committed to assessing and meeting the physical, emotional, spiritual, environmental, social and rehabilitative health needs of the citizens in the region. The worth, dignity and autonomy of individuals (customers, employees and others) are recognized, as is each individual's right to self-direction and responsibility for one's own life. Individual uniqueness will be considered, when assessing the needs and delivering quality care. Educational pursuits, research and public service programs will be used toward innovations and improvement of health care in the region. General hospital personnel will work in collaboration with customers and in partnerships with other organizations to provide cost-effective services.6
 
HOSPITAL PLANNING
Hospital planning depends on the following factors:
  1. About planning.
  2. Complexity of the problem.
  3. Planning comprise.
  4. Factors influencing modern hospitals.
Hospital planning has undergone such a striking changes as does not show any sign of stabilization on the near future, due to this rapid rate of change, the strategies with regard to hospital planning, aimed at ensuring intrinsic quality and efficient performance, seem to get lost in a machine-like character, which typifies our present-day hospitals. Thus there is an urgent need for a change in approach to hospital planning.
Hospitals planned only on the basis of economics, performance, inter-relationship of functions and space standards tend to result in an ‘inanimate’ environment for the patients as well as other users. A sense of numbing, helplessness and near-isolation characterizes hospital experience for a majority of people who use it either as a visitor or a patient. Seen in its correct perspective the environment of such hospitals has no equal in barrenness anywhere in any culture with the solitary exception of the prisoner's cell. Such an environment is described as ‘disintegrated’ or ‘degraded’ because it lacks wholeness. It is incomplete too, as it does not adequately support the wide range of human behavior associated with hospital functioning, it implies patients’ confidence to take care of themselves and thus makes the job of the supporting staff comparatively more difficult. From the Indian context point of view hospital planning should be viewed in the light of:
  • Magnitude of the problem
  • India's limited resources
  • Level of technology in the country.
Analysis of these factors will lead one to the conclusion that health welfare services in India should stay as public services. For a very long time, we will have to cater to very large masses of people. We are still not ripe for specialized referral treatment. Thus the cost reduction in hospital planning should be one of our major objectives. On the one hand it is essential to keep pace with the technological advancements. On the other, technological advancements must be viewed in the light of our own objectives and financial restraints.7
For the last few years, a considerable amount of work has been done on the problems of services in hospital planning. A stage has now come, where hospital planning is by and large a technical problem encompassing a very complex infrastructure.
An important function of a hospital in the Indian context is to cater to very large masses of people by providing comfort conditions for various users. Hospital planning should not be indifferent to the aspirations of these people each of whom serves an important interdependent function.
 
Complexity of the Problem
The planning of a hospital is highly complicated by a variety of quite unrelated factors. Like necessity for providing certain rooms, such as private rooms, wards, operating and other treatment rooms, offices, etc. in the most suitable location with the shortest possible connections and easy inter-communication between the various departments. There should be space for future expansion. All these points must be carefully coordinated. The problem is made still more complicated by the fact that some of these considerations and requirements are quite incompatible. Thus, good economy regard to construction, operation and favorable communications requires a concentrated building structure.
 
Planning Comprise
A hospital is a compromise between various considerations, among which the medico-hygienical factors. Solutions will vary according to the importance placed on one or another of these considerations. That is one of the reasons why hospitals, even of the same type and size, are often quite dissimilar and why it is so difficult to achieve a standardization of even small institutions. The architect, first and foremost, must have the broad view of the problems, regard the whole as a working unit, and differentiate between leading principles and secondary requirements. This involves considerable difficulties for the inexperienced hospital architect. A doctor, for instance may have his own personal idea as to how a certain department should be related to the whole building, which may be well founded in it but may be difficult. Or the requirements for a special department may exclude incorporation into the main structure without ruining the framework. In such cases, individual 8requirements must of course give way to the necessity of creating a functioning institution, in which the main consideration is the cure of patients in the shortest possible time through the coordination of all available means.
A hospital building plan however well worked out from the medical point of view, must also allow a favorable solution of constructional problems. Some experience is necessary to reach a compromise between diverging opinions, without giving up essential medical considerations and other advantages. It is essential to separate the major from the minor issues. However, a good hospital is always a good compromise between a numbers of different points of view.
 
Factors Influencing Modern Hospitals
The factors influencing the modern hospitals are as follows:
  • Medical science
  • Emerging changes
  • Impacting factors.
 
Medical Science
The advance in medical technology impacts on medical science. It was no longer possible for one doctor to master both surgery and internal medicine. A separation was necessary in order to find out the special acute cases. Some large hospitals have this separation for surgery and medicine. Medical science has new discoveries are constantly creating new methods for diagnostics and therapeutics. The individual fields are continuously expanding and each specialty, consequently, becomes gradually more difficult for one person to master. Repeatedly new divisions and subdivisions become necessary. In rapid succession, the following special branches have been separated from general surgery. For example, ENT(ear, nose and throat diseases), ophthalmology (eye diseases), obstetrics and gynecology (maternity and female disease) and orthopedics (surgery of bone and joints), etc. In recent years neurosurgery (surgery of the nervous system, especially of the brain), thoracic surgery (surgery of chest) and plastic surgery (correcting faulty or replacing missing limbs) have branched-off form general surgery. Urology (surgery of urinary ducts), pediatric surgery (for children), and surgery of the hand are also gaining 9recognition as special branches. The remaining, i.e. general branch of surgery is largely abdominal surgery. It has active connections with chemistry and laboratory medicine. It also deals with certain parts of the body rather unrelated disciplines of orthopedics and traumatic surgery.
Like surgery, the internal medicine has become more and more subdivided. Apart from general medicine, one finds among others the following special branches neurology, tuberculosis, dermato-venereology, pediatrics, epidemiology and rheumatology. Similarly, cardiology (the treatment of heart diseases) is another field which due to medical advancement will more and more require the attention of specialists. X-ray diagnostics and therapeutics have become a field for specialists. In large hospitals, X-ray diagnostics are even separated from X-ray therapeutics.
In very big hospitals, this branch may become so large that two independent departments would need to be established, each with its own independent chief.
Medical science plays a vital role in laboratory work at the hospitals. Diagnosis has become more complicated and time-consuming, requiring detailed tests, often taken directly on the patients, the use of new and complicated equipments and the applications of new techniques.
According to the modern technology of medical science, the main special branches are:
  • Biochemistry and morphology, the science of the structure and chemical composition of the organism, including the chemical reactions within these
  • Physiology, the treatment of the process within the organism and the functions of its constituent parts
  • Pathology, the science dealing with changes caused in the tissues by diseases
  • Bacteriology, the science dealing with bacteria
  • Serology, the science dealing with the bloodfluid and its properties.
As the modern science has been developing, it is going on and on, prompted by modern man's curiosity to know more and more about less and less.
Medical science and related health facility planning is an emerging sector of health infrastructure development. Medical technology, health transition, consumers’ expectations, 10epidemiological and demographic changes; all impact provision of health care. The advancement in scientific and technological research has taken the healthcare skills and facilities to a state-of-the-art level.
The improvements in the qualitative aspects of health care, the exponential escalation in the cost of construction of hospitals and resource constraints, offer new challenges in effective utilization and conservation of resources. It is thus, imperative that planning and designing of hospitals is done holistically and scientifically.
 
Emerging Changes
There have been new and emerging issues such as technological advancements, demographic, epidemiological and environmental changes. The epidemiological transition has been form a disease profile, in which communicable diseases and nutrition-related conditions predominated to one, where non-communicable and life style-related diseases, accidents and injuries are the major causes of morbidity and mortality. The consumers are increasingly demanding convenient, reliable and timely services provided in a caring, safe and high quality environment.
 
Impacting Factors
 
Socioeconomic Profile of Community
This aspect has imminent bearing on the space determination and also the expected standards of hospital facilities.
 
Existing Medical Facilities
This will directly impact on the size and type of healthcare facility that is planned.
 
Health Profile of the Region
The varying disease pattern of different regions affects the requirements of the various departments/services.
 
Vernacular Architecture
Vernacular architecture of the local traditional architecture has a major role to play in the planning of medical facilities of that particular region. Local architecture is a result of age-old construction methods, which take into account the climatic conditions, seasonal variations and other aspects with special emphasis on locally available material. While providing the new 11facilities, this aspect should be taken into account so that the built from blends with the local surroundings.
Suitable variations could be made to utilize new materials and the requirements dictated by the emerging technologies and trends.
 
Local Regulations
Governing bodies and the local bodies from region to region have different type of policies/guidelines/rules related with the respective regional planning norms, thus affecting the spatial relationship of health planning.
 
Source of Finance
Government, private, international financing institutions such as the World Bank, WHO and the Asian Development Bank, often may fund various health-care facilities. They have specific guidelines/policies, which influence the normative planning. These have to be complied with, if financial assistance is provided from them.
 
Choice of Technology
This depends on the type of facility being planned for the specific level of healthcare, financial availability, and the type of equipment that are to be provided for the specific hospital or the healthcare unit.
 
Climatic Zones
Design and space parameters are influenced by the type of climatic conditions. The impact of climate in space norm varies in different situations, e.g. a volume of space in a consultants room or a ward in a cold region will have lesser opening and will be compact in nature whereas the same in coastal region will have move window area and open type of planning for cross-ventilation.
 
Key Planning and Design Parameters
The following parameters merit consideration:
  1. A team comprising of medical architect, hospital administrator, hospital engineer, financial expert, health statistician and a social scientist should be formed for the hospital planning.
  2. Data of vital statistics (death and birth rates, infant mortality rates, maternal mortality rates), morbidity, demographic, socio-economic, climatological, geographical, in the area of operation of the healthcare facility should be known and analyzed.12
  3. Regulations, bye-laws and legislative enactments related to healthcare facilities should be meticulously read, analyzed and followed.
  4. Various levels of planning, viz. macro, extramural, micro and intramural merit consideration. Macro planning involves parameters such as demographic and socioeconomic data whereas, microplanning involves aspects such as waiting spaces, number of toilets, etc.
  5. Plan for flexibility, convertibility and expandability, which may be achieved by incorporating a modular approach.
  6. Assessment of needs such as number of beds, specialty wards, and scope of various services, outsourcing and level of specialization should be ascertained.
  7. Estimation of resources and funds, which would enable to plan the various activities including equipment procurement and staff recruitment.
  8. The landscape, facility mix, bed mix, availability of utilities in the vicinity will have to be considered. Considerable inputs from the other agencies like heating ventilation air conditioning (HVAC), electrical plumbing, medical gases and inputs from equipment vendors especially in specialty areas like magnetic resonance imaging (MRI), computerized tomography (CT) scan, linear accelerators, catch labs, operation theaters will be essential to finalize the working plan of the hospital.
  9. Hospital infection: To maintain asepsis in a hospital, due care in planning, designing and detailing is required in terms of right location and choosing the right materials and specifications. This acts as a preventive measure against infection to the patient.
  10. In the planning process location of various departments has a very important role to play. All the departments are the ‘activities’ of the hospital and an architect's role is to rightly identify the ‘activity’ and ‘activity sequence’ in working out a functional program of spaces. As has been appropriately commented by Emerson Goble, “separate all departments yet keep them close to each other; separate types of traffic yet save steps to everybody. That is all there is to hospital planning.”
  11. All elements of progressive patient care, viz. intensive care, intermediate care, self-care and ambulatory care must receive due consideration.13
  12. Patient being the main focus, protection of the patient is the primary rule. Planning and designing must provide a safe comfortable and healthy environment to the patient. Patients want a built environment that:
    • Promotes connections to staff
    • Is conducive to well-being
    • Is convenient and accessible
    • Is confidential and private
    • Is caring for family
    • Facilitates connection to the outside world
    • Is safe and secure
    • Has easy way finding.
  13. High quality of health care may be achieved only if the hospital design is efficient, functional and economical.
  14. Factors such as travel time and travel distance by the users must be considered while planning.
  15. The functional circulation with the shortest possible traffic route helps in economizing construction costs. Also, segregation of dissimilar activities such as movement of dirty utility and clean utility, quiet and noisy activity, different types of patients and traffic, both inside and outside of the building is an aid in economizing construction costs.
  16. The main circulation and utility distribution systems in a hospital are similar to those of a small city. With the added complication of conceiving these in a three dimensional structure, maintaining a rectilinear pattern provides the greatest amount of flexibility.
  17. There is a greater need to be cognizant of the blend of technology and human behavior by promoting development of landscapes, gardens, which are proportionate to the scale of the building and the population.
  18. Utilization of natural light, good illumination and better appearance has a theoretical healing potential. Building, ventilation, external and internal appearance, internal and external traffic patterns, energy efficiency, orientation are very important points to be considered while designing an effective healthcare environment.
  19. Use of eco-friendly materials should be encouraged.
The essentials of master planning, space programing and feasibility report are enumerated in the following respectively.14
 
Master Plan
Master plan diagrams and drawings should be prepared for all logical options (Fig. 1.1). A master plan diagram or drawings is typically a simplified plan showing the following:
  • Overall site or section of site relating to the development
  • Departmental boundaries for each level related to the developmen
  • Major entry and exit points to the site and the relevant departments
  • Vertical transport including stairs, lifts and escalaters
  • Main interdepartmental corridors (arterial corridors)
  • Location of critical activity zones with departments but without full detail
  • Likely future site development
  • Areas set aside for future growth and change
  • Appropriate way finding
  • Service master plan showing the engineering impact, plant locations, availability of services and future demand.
zoom view
Fig. 1.1: A flow chart of the process of planning and designing of hospitals from inception to commissioning
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A minimum of three options should be provided to the design maker along with master plan diagram, a report containing the following should be made available for decision making:
  • Project decision
  • Outline brief
  • Opportunities and constraints
  • Options considered
  • Evaluation criteria
  • Evaluation of the options including cost impact (if any)
  • Recommended option
  • Executive summary and recommendation.
Depending on the nature of the project, the exact deliverables for a master plan can be fine tuned
 
Space Programing
  1. Space programing is a process, in which the specific requirements of a department are identified including such elements as specific room requirements and dimensions, description of the departments, operations and unique functional requirements.
  2. Department's space table is developed to identify the specific rooms and spaces. Space tables are organized by room/space type and function and include the net square feet (NSF) requirement for each room a total NSF is estimated for all rooms constituting the departments.
  3. Circulation/conversion factors average 30% to 40% for most inpatient departments. Once the conversion factor is applied to total department NSF, a department gross square footage summary (GSFS) is obtained.
  4. Total building gross square footage (BGSF) is calculated for the entire building, consisting of structure, mechanical/electrical and circulation factor, with a typical of conversion factor of 25 percent added to the total GSFS of all departments.
Note: For calculation of dimensions m/cm/mm may be utilized instead of feet.
 
Hospital Project Feasibility Report
Hospital project feasibility report should deliberate the following:
  • View of health scenario at national, regional and local levels
  • Data such as vital statistics (birth and death rates, infant mortality rates, maternal mortality rates), morbidity rates, 16demographic, socioeconomic, climate and geographical data should be tabulated and analyzed
  • Health needs assessment of the catchments areas
  • Site/location of the proposed healthcare facility
  • Type of healthcare facility—primary/secondary/tertiary; number of beds planned for the facility of construction, equipment, staffing and maintenance, etc.
  • Approximate costs and sources of funding.
 
Design and Architect Brief Components (Fig. 1.2)
 
Architect Brief
Architect brief is a written document, which explains the operational policies, types of services to be provided, inter-relationships and interdependency of each facility. It is written expression of the client's need as expressed in consultation with various professionals including the architect and engineers.
 
Content of an Architect's Brief
Content of an architect's brief should include mission of the healthcare facilities, philosophy of service, development plans and organization.
 
Site Information
Site information should include:
  • Bearings, boundaries, topography and surface area
  • Landmarks
  • Existing utilities
  • Nearest city, airport/port
  • Weather.
 
Functional Content
Sizes function and content of departments. It should include the number of beds in wards, number of operation theaters (OTs), etc. It should also include:
  • Bed and facility mix proposed for the facility
  • Major equipment planned
  • Intramural and extramural communications
  • Work and traffic flows.17
zoom view
Fig. 1.2: Design of the hospital (OPD = outpatient department, IPD = inpatient department, OT = operation theater)
 
Workload
Workload should specify timings of various departments as well as peak periods of work.
 
Staffing
Staffing should include number and type of staff.
 
Equipment
The type of medical equipment and quantity should be enumerated.
 
Policies and Procedures
Policies and procedures should include process and procedures related to:
  • Patient and staff movement
  • Supply delivery
  • Services—laundry, central sterile supply department (CSSD), catering, etc.
  • Fire protection
  • Mains and standby electrical supply18
  • Lighting
  • Infection control
  • Future expansion plans.
 
Schedule of Accommodation
Schedule of accommodation should include functional and behavioral spaces, list of all norms and spaces in each department, and activities performed. Functional relationship between departments and between rooms within a department.
 
Zoning
Zoning specifies grouping of departments.
 
Financial Aspects
Financial aspects should include:
  • Construction costs
  • Project management services costs
  • Equipment costs
  • Furniture costs
  • Sources of fund should also be enumerated.
 
Details of Detailed Project Report
Detailed project report (DPR) consists of following:
  • Background of the project
  • Constraints/limitations
  • Financial statement (cash flow)
  • Labor deployment (man hours)
  • Material management
  • Local regulations
  • All detail drawings such as:
    • Architectural working drawings
    • Structural drawings
    • Plumbing and drainage drawings
    • Fire detection and fire fighting
    • Medical gases and equipments
    • HVAC
    • Electrical and mechanical drawings
    • Waste management
    • Landscaping19
    • Bulk services
    • Interior design, furniture furnishing.
  • Detail estimate of the project
  • List of medical equipments and specifications
  • Man power requirements
  • Running, maintenance and operational cost
  • Budgetary projection.
 
Best Practices in Medical Architecture
Best practices in medical architecture:
  1. Design must follow function.
  2. Should be a multi disciplinary team approach to ensure holistic and scientific planning and designing.
  3. Utilization of space must be optimized. There should be economy in utilization of space and materials without sacrificing functional efficiency.
  4. Patient focused architecture should be planned and designed. The facility must provide a safe, comfortable and human environment, which will be a catalyst for healing. It should facilitate high quality of care and access in a setting; this is supportive of human relationships during time of anxiety fear and helplessness.
  5. Barrier free environment should be planned and designed for access and usage by the disabled.
  6. Green concept, i.e. incorporation of excellent practices that result in environment protection, water conservation and energy efficiency, usage of recycled products and use of renewable energy should be put to practice.
  7. Need lead planning must be planned along with resource lead planning. The planning and designing should be realistic and achievable within the time frame and available resources.
  8. Healing and life enhancing designs must be advocated.
    1. It should be conclusive to the needs of the seekers and providers of healthcare. It should provide an ideal patient encounter wherein care givers, technology and patients are brought together effectively.
    2. Primeval forces of nature, i.e. light, sun, water and air should be maximally utilized.
    3. The design should facilitate easy and safe movement of people and materials.20
    4. It should be able to provide services when most needed such as in disaster and earthquake situations.
    5. The facility should correlate to the real needs of the community.
    6. The healthcare building should respond to the local climate and the characteristics of the region. The use of local skills, materials and natural resources should be made.
    7. Planning must incorporate flexibility and expandability. Modular approaches and universal usage should be optimally utilized.
    8. Effort should be made to provide best facilities for preparation of life, protection of life and quality of life.
    9. The design should ensure easy and cost effective maintenance.
    10. It should be designed to provide continuum of care.
  9. It should provide seamless integration of clinical requirement with building planning and designing issues. There should be a harmonious convergence of the clinical, administrative and hospitality dimensions in healthcare.
  10. The hospital buildings being constructed at present should be able to fulfill the requirements of the future. The medical architecture should put into practice the golden architectural principles of indeterminacy and enable a building to grow with order and change with calm.
  11. The spaces should be provided for functional as well as behavioral requirements. Anthropometric inputs should be maximally utilized.
 
Expression of Interest
Expression of interest (EOI) is the first stage of pre-qualifying the consultant/vendor through advertisement in local newspapers or through internet. It should contain the following information:
  • Brief description of project
  • Salient features
  • Approx project cost
  • Conditions for pre qualification.
 
Request for Proposal
Request for proposal (RFP) is a document describing details of the project prepared by the client for the organizations, who are 21short listed through EOI. This document consists of detail project requirement in terms of:
  • Background of the project
  • Architect's brief
  • Best practices in medical architecture
  • Constraints/limitations
  • Methodology and time frame for execution of project
  • Contract conditions
  • Local regulations.
 
Anthropometric Aspects
The dimension of the human body (anthropometry) dictates the size of the bed, the floor space per bed, the width of the doors, the size of accommodation for patients and any dimensions in other departments, such as the height of laboratory or kitchen platform, the dimension of operating and diagnostic table, etc. Average dimensions and clearances required for the human and anthropometric study of movement in passages and waiting.
 
Area/Bed Space
The number of hospital beds required is one of the important information needed in healthcare planning.
The actual area required by a hospital bed is 2 m2. However, the area required for each bed in a ward, where space must be allowed for nursing and general circulation, amounts to about 6 m2. For each nursing unit of 20 to 30 beds, other facilities such as toilets, shower, pantry, duty room, examination room, storage and utilities must be included, thus bringing the total floor area per bed required in the inpatient department to 8 m2. When other essentials for inpatients are added, such as outpatient department, laboratory, imaging and support services viz. kitchen, laundry, CSSD, stores are taken into consideration the total floor area required per bed increases to approximately 70 m2.
These figures vary according to the site and the facilities provided.
 
Site
Site profile varies from region to region and place to place. A hilly terrain will have a different type of circulation pattern than a flat terrain.
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zoom view
Fig. 1.3: Site of the ward
In a coastal region, courtyard planning is preferred for cross-ventilation as against compact building in desert or cold region thus affecting the normative planning.
The sustainable design does not visualize boundaries in the traditional manner; instead, it is more global and encompasses both ecosystem and community. Sustainability lies in analyzing local, regional and global conditions, which influence the shape of the site. The hospital building must have easy approach, enough land availability, sufficient supply of water and electricity (Fig. 1.3).
 
Stack Diagram
Stack diagram shows the distribution of the facilities in the various floors and their vertical distribution with each other. The main points to be noted are:
  • Outpatient department (OPD) located vertically above the main entrance
  • CSSD is located vertically below the OT
  • Emergency department is located vertically below the OT complex and birthing center.
The stacking provides for quick vertical connectivity through use of lifts. A stack diagram for a hospital is as follows:
Approximate costs related to construction of hospital are:
Cost per bed (excluding cost of land)
General bed
5 to 10 lacs
Speciality bed
15 to 20 lacs23
Superspeciality bed
40 to 50 lacs
Development of land includes topographical Survey, site clearance, landscaping, horticulture, Compound wall fencing, internal road, soil and storm water drainage.
1% to 5% of total project cost
Cost of civil construction includes:
Cost of hospital building
Costs of residential building
35% to 45% of total project cost
Cost of hospital building utility-services
Equipment (communications, electric substation, generators, uninterruptible power supply (UPS) and allied electric services, fire protection services, heating ventilation and air conditioning (HVAC), lifts, escalators, signage, waste management, interiors, furniture and fittings)
15% to 20% of cost of construction
Cost of hospital equipment
45% to 55% of project cost
Consultancy charges
7% to 10% of total project cost
Some of the value added services are:
  • May I help you, information kiosks, guide maps, layout plans, touch screen
  • Communication facilities
    • STD, ISD, fax, cyber café, post office
  • Furnished waiting areas
  • Vehicle parking
  • Intelligent-building
  • Snacks bars, cafeteria
  • Prayer room/facilities
  • Banking/ATM facilities
  • Flower shop/fruit shop/book store
  • Fitness/wellness center
The project cost varies depending on the types of hospital, technology planned and the location. Approximate land area requirement is shown in Box 1.1.
 
Water
Water conservation and reutilization by rainwater harvesting should be ensured. Landscape, which requires minimum irrigation should be designed.
24
Recycling water to support the entire mechanical and horticultural requirements should be planned. Approximately 500 liters of water per day are required excluding requirement of water for fire fighting, gardening and steam.
 
Energy Efficiency
The building should be designed for energy efficiency. Use of solar and wind energy should be optimally utilized.
 
Indoor Air Quality
Indoor air quality has a direct relation to the occupant health and productivity as well as to energy conservation. The comfort level of interior environment should be achieved through energy, efficient lighting and ventilation system.
 
Plumbing
Water supply and drainage system has directed bearing on control of hospital infection. Hence, selection of piping material made out of polyethylene is recommended.25
 
Flooring
Flooring is one of the most important component of buildings, especially that of healthcare facilities. The various factors, which must be taken while selecting flooring in healthcare facilities are as follows:
  • It should provide a safe, comfortable surface for use by patients, staff and visitors
  • It should facilitate cleaning; covered skirting should be done to prevent dirt/dust accumulation
  • Floor loading capacity should be appropriate to the human traffic and equipment utilized in the facility
  • Floor should be non-slippery when wet
  • Laboratory flooring should be abrasion, acid and alkali resistant
  • Antistatic flooring is required in operating units where flammable anesthetic agents are used
  • The flooring should be conductive to movement of objects such as trolleys and wheelchairs
  • The flooring should minimize noise generation
  • Insulative flooring has a resistance to ground > 109 ohms (barrier against the passage of currents)
  • Static dissipative means that the resistance to ground is between 106 and 109 ohms
  • Conductive, where the resistance to ground is <106 ohms
  • Static dissipative and conductive flooring need a special laying (with copper foils and conductive adhesive)
  • Antistatic (Din 54345-AATCC 134) means during walk on a floor, the electrostatic-charge due to treading is less than 2,000 volts (=2 kV), which is the human perceptible limit.
 
Surface Materials
  • Fixtures and fittings should be designed to facilitate easy cleaning and discourage accumulation of dust
  • Horizontal, textured or moisture retaining surfaces should be avoided
  • Inaccessible areas, where dust and moisture would accumulate should be avoided.
  • Surfaces should be smooth, impervious and easily cleaned. There should be of seamless materials in high risk clinical areas such as operating units, intensive care units (ICUs) and obstetric units.26
 
Wall and Cellings
  • Wall materials in areas such as operating units should be impervious, joint less, non-absorbent and easily cleaned
  • X-ray view box, electrical plugs/switches should be flush with the wall surface to facilitate cleaning
  • Walls and floors, situated above ground level of imaging department, must be provisioned with shielding material such as lead, to prevent radiation exposure
  • Corner of the walls should be protected against physical impact by stretchers/trolleys.
 
Doors and Windows
  1. Doorways should be minimum 90 cm, clear opening width to allow easy passage to patients/visitors/staff including those on wheelchairs. A level space of at least 152 cm wide should extend about 45 cm on either side of the doorway for facilitating opening/closing by a wheelchair person.
  2. In pediatric rooms, two sets of doors handles should be provided one at a high-level and one at low-level for use by children. Patient's rooms should have windows having external views and use of natural light should be optimized.
  3. Each window and/or glazed door should have direct glazed area of not less than 15 percent of the floor area of the room.
 
Ramps, Stairs and Lifts
 
Ramps
The gradient of the ramp should be between 1 : 12 and 1 : 20. Pedestrian ramps must have handrails (one at height of 0.9 m and the other at 0.5 m for ease of people in wheel-chairs). The minimum width of ramps should be 1.6 m. To allow easy passage of patients/visitors including those on wheelchairs.
 
Stairs
Recommended height of risers is 0.15 m having 0.30 m treads. It should have level and non-skid surfaces. Handrails should be positioned on both sides of stairs and extend beyond the first and last step to facilitate people with leg braces to pull themselves beyond these points.27
 
Lifts
Passengers lifts are ideally recommended for all healthcare facilities having patient services located on a level other than ground floor. Lifts required for transporting patients on beds and emergency lifts should be capable of accepting hospital beds with emergency equipment and attendants.
Healthcare cannot be separated from the buildings, in which it is delivered. Architectural designs have an important healing process. Requirements of hospitals/departments are changing and will continue to change. Designing should allow indeterminacy, which is an architectural principle enabling buildings to grow with order and change with calm.
 
Planning the Nursing Unit
The nursing unit remains one of the most important elements in a hospital. The basic reason for the hospital existence is the patient and her/his human needs. The personnel's environmental needs must be balanced with those of the patient.
A nurse's main domain is ward unit or nursing unit. Since the patients are lodged and looked after in the ward after admission, it should have adequate physical facilities, human and material resources. A nurse being present for 24 hours of the day is required to coordinate all activities within the ward as well as pool all other resources available in the other departments of the hospital to provide the best kind of hospital care to the patient. Therefore, the nurse automatically assumes the responsibility for its management Box 1.2.
 
Area
The inpatient service area forms approximately one-third of the whole hospital complex.
 
Functions
  1. To render nursing care to all patients.
  2. To provide necessary equipment, drugs and other stores in an organized manner.
  3. Being a temporary home for the patient, it is designed to accommodate all the needs of a patient.28
  4. Training of medical and paramedics.
  5. Conducting research.
 
Inpatient area can be:
  1. General ward: Patients without any special requirement
  2. Specific wards: ICU, critical care unit (CCU), pediatric, maternity, isolation, etc.29
 
Planning and Design of Nursing Unit
Planning and design of nursing unit depend on the following:
  • Community
  • Resource Availability.
Factors to be considered
  1. Policy.
    1. General/specialist hospital.
    2. Bed strength of the hospital.
  2. Physical facilities.
    1. Area : 70 to 79 sq.ft/Bed (7 square meter).
    2. Location.
    3. Size.
    4. Shape.
    5. Ancillary accommodation.
    6. Water and electricity supplies.
    7. Communication.
    8. Air conditioning.
    9. Auxiliary accommodation.
  3. Staffing.
    1. Medical.
    2. Nursing.
    3. Supportive.
Hospitals with less than 200 beds are planned as horizontal, where it saves lot of time in internal movement.
Hospitals with more than 200 beds are planned on vertical expansion, which is cost-effective and convenient for patient movement.
Hospital administration is not easy it is highly complex but it need not produce anxiety neurosis if properly handled. Administration is often tense, it is a process. Things happen in spite of the best rules. Problems do not respect rules and regulations or procedures. Problems which looked small and simple may snowball into extremely difficult issues. Do not tell a problem is difficult, if it was not difficult, it will not be a problem. Do not make premature assumptions. Be open to all suggestions and comments. Do not underestimate the qualities of your hospital or overestimate those of your competitors. There is place for all. The country needs more hospitals and a variety of hospitals, governmental and non-governmental.