ACEDEMIC INTERACTION

HOSPITAL PLANNING AND DESIGN

PRESENTED BY DR VIDIT KHANDELWAL PG STUDENT COMMUNITY MEDICINE

INTRODUCTIONThe picture regarding medial care services in developing countries including India can be descdbed as chaotic.

Hospital beds are inadequate,

Hospitals are located far away from the communities which need them, Most crowded in towns and cities,

Heavily biased in favors of urban populations.

The average national population ratio is less than 0.7 beds per 1000 population, it is as high as 2.5 beds per 1 000 population in metropolitan centres like Delhi and Mumbai and as low as one bed per 3700 to 14000 population in rural areas in India.

 Unequal distribution of health services. Specialist services are concentrated in urban centres, and there is duplication of services in many others. Essential. hospital service required for the community can be met most

economically only with adequate thought given to planning, design,

construction and operation of health care facilities.

Even where financial resources are adequate, best use of resources will
only be made when sufficient thought is given to planning.

GUIDING PRINCIPAL IN PLANNING

Patient care of high quality Effective community orientation Economic viability Orderly planning Sound architectural plan

REGIONALISATION OF HOSPITAL SERVICES

Regionalisation is a system of technical and administrative decentralisation by establishment of "levels of care" which range from

primary health centre at the community level, to general hospital and

specialized polyclinics at the intermediate level, and culminating in higher medical centers where the practice of all specialties is carried out with

teaching and research as major concerns.

The relationship between organisational scale on one hand and the

effectiveness and efficiency on the other, influences indirectly their

numbers and location

Levels of medical care-

STAGING OF HOSPITAL PROJECT

ASSESMENT OF THE EXTENT OF NEED FOR THE HOSPITAL SERVICES

Two methods (1) Imperical method - Applices the norms of the past and rules of thumb to the problem, with appropriate modifications to suit local conditions.

(2) Analytical method - makes a more fundamental, systematic approach to the problem"
The emperical method hinders evolution of new solutions while as the analytical method lacks the controlling elements of the "norms".

Relationship between Demand and Need

1. Demand for hospital services can be estimated by studying statistical returns of current usage and morbidity statistics. For ex.

Prevelance and type of diseases

Measurement of death rate, birth rate ,MMR, IMR etc Demographic profile Socio economic structure Hosiptal statistics

2. Measurement of need for hospital services takes account of a more positive approach by aiming at a quatitative estimation of the amount of illness in the community which would require hospital services.

FACTOR INFLUENCING HOSPITAL UTILISATION

Hospital bed availability Population coverage and bed distribution Age profile of population Availability of other medical services Method of payment of hospital services

Availability of qualified medical manpower

Family system Morbidity pattern Hospital bottlenecks Internal organization Public attitudes

Hospital size
How big in term of number of beds, should a hospital

be ?
Hospital should have atleast 100 beds. A hospital of 200 to 400 beds enables adequate

deparment of general surgery, medicine ,paeditrics,OBG, ENT etc.

Bed capacity of a hospital is calculated on the basis of beds assigned exclusively for inpatient care.

However, beds in the following areas do not form a part of the bed count.
1 . Bassinets and incubators in the maternity suite 2., Labour rooms 3. Casualty/emergency department 4. Recovery room 5. Any other which are not equipped and staffed for overnight use.

SITE
Site should be large enough to enable future expansion and growth. The social function of the hospital demands that a hospital should be situated in the heart of society. Defining catchment areas in large cities is a first step in deciding the location, subject to availability of suitable sites. ln crowed localities seldom will there be a building site of the usually accepted avereage (2.5 to 5 acres per 100 beds) available in a central place.

Land Requirements
Determining the requirement of land depends upon many factors. ln rural and semi-urban areas, plentiful land may be available permitting the hospital to grow horizontally. However, in urban areas there will always be great premium on land and the only available avenue will be a vertical growth. Site cover percentage = Total ground floor area of all buildings x 100 Total area of site available The degree of crowding on a site is considered in terms of floor area ratio (FAR). lt is the ratio of the total covered area on all floors of a building to the total area of the site.

FAR- RURAL AND SEMIURBAN- 0.5 to 1 or LESS URBAN - 0.5 to 1.5

PUBLIC UTILITIES
Water - The national building code of the lSl suggests 455 litres of water per consumer day (LPCD) for hospitals up to 100 beds and 340 LPCD for hospitals of 100 beds and over.s For planning purposes, the overall requirement of water in hospitals is estimated at about 300 to 400 litres per bed per day. Sewage DisposalSolid waste from hospitals is approximately 1 kg per bed per day. Liquid effluents will be about the same as the hospital's requirement of water i.e. between 300 to 400 litres per bed per day. Power - Requirement of electric power is approximately 1 kW on a per bed per day basis. This includes the needs of all departments and services including power requirement of X-ray department, operation theatres laboratories, central sterile supply department, laundry, and kitchen.

DISTANCES, COMPACTNESS, PARKING LANDSCAPING AND VISUAL IMPACT

Distances Distances must be minimised for all movements of patients, medical, nursing and other staff and for supplies, aiming at minimum of time and motion the routes which the patients will have to take on stretchers, wheelchairs or on foot from their wards to the radiographic department, laboratory should be short. Compactness Functional efficiency and economy depend also on the compactness . Horizontal development demands more land involving extra costs in development and installation of services, roads, water supply, sewage, electric lines and so on. From this angle, multi-storeyed constructions has the advantage of being convenient because of compactness.

Parking
For each inpatient bed there is likely to be at least one visitor a day. For each inpatient bed, there will be about 3 outpatients. One car parking space per two beds is desirable in metropolitan towns, lesser in smaller urban areas whiles much less in semi urban and rural areas. Employees and staff parking areas are preferably separated from Public Parking.

Landscaping
The psychological effect of the visual impact of attractive grounds, buildings and surroundings on patients, visitors and staff cannot be underestimated . Deft use of sloping sites can be rnade by the architect for car parking, refuse disposal, and recreational activities.

HOSPITAL DISTRIBUTION AND RELATIONSHIPS OF DEPARTMENTS

HOSPITAL STORES The various items of stores-rations and vegetables, linen, drugs and dressings and laboratory supplies can be kept in the respective storage areas in the kitchen, laundry, pharmacy and laboratory respectively. When the bulk of these goods is high, it is necessary to design a central place as hospital store. CSSD Central sterile supply department (CSSD) mostly serves the operation theatres, but its other users include the emergency and casualty department, the wards, and maternity suite and should be so sited as to be central to all these

HOSPITAL KITCHEN It will have to be located taking into consideration the prevailing wind direction so that smoke and kitchen odours are not constantly wafted to patient care areas. The best site for a kitchen is at the ground level.

Laundry Mechanical lanundries are becoming popular with larger hospitals, Used linen from wards, operation theatres and delivery suites may be infected, and therefore needs careful handling at an area remote from all other clinical and supportive services departments..

There are some more points that remain to be considered for zonal distribution at this stage.They are as follows
1. Size and location of water storage - Storage capacity should be at least three times the total daily requirement. 2. Location of the hospital incinerator 3. Boiler house for supply of steam to laundry, CSSD and kitchen. 4. Garages for ambulances and staff vehicles. 5. Mortuary for storage of dead bodies, and post mortem room. 6. Residential campus for specialists, residents, nurses and other essential staff. 7. A "community centre" with grocery and fruit shop, barber's shop, newspaper and bookstall, chemist shop, and a community hall. 8. Dharmshala for attendants and relatives of the patients to stay.

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GROSS SPACE REQUIREMENTMinimum 700 to 900 square feet per bed. In some densely populated urban centres in adanced countries, the average floor space per bed in hospitals constructed in the 60s was 55 to 60 m2 (550 to 600 square feet). The current ratio of floor space occupied by wards, outpatient department, diagnostic and therapeutic services, administrative services and services departments is, shown in Table Table Distribution of floor space by wards and departments
WARDS OPD DIAGNOSTIC/ THERAPEUTIC ADM SERVICE DEPT.

37-45 %

12-18 %

18-22 %

8-12 %

15-20 %

Each unit must get essential space for the determined volume of service, for the specified numbers and categories of workers, for working room, for placement of equipment and furniture and for storage of supplies. Approximate breakdown of hospital space is given in Table

Add walls, partitions: 95-125 sq ft

Gross total area (Building gross): 780 -1005 sq ft (72.50 to 93.46 sq mtr) A building gross square footage figure includes everything within a building's perimeter, viz. stairs, corridors ducts, wall thicknesses and mechanical areas. Taking the liberal figures of 1000 sq feet per bed the land requirement for a 5OO-bedded hospital would be as follows. 1. At floor area ratio of 0.5 to 1:about 22 acres 2. At floor area ratio of 1.5 to 1:about 6 acres 3. At floor area ratio of 2 to 1:about 6 acres. lndian Standards lnstitution in their standard lS 10905 Part-l have recommended an area of one hectare for every 25 beds.

Bed distribution It has been generally found that about 165 out of every thousand
population will be hospitalised for an average of about seven days each. The number of beds necessary to care for this number will be about 3 to 4 per thousand population. beds required for a given population in a given region is calculated by the following formulae:

Bed: population = A x S x 100 365 x PO

where, A = number of inpatient admissions' per thousand population per year S = average length of stay (ALS) PO = percentage occupancy. It must be realised that this method is useful in areas in which reasonably satisfactory hospital coverage facilities are in existence and accurate statistlcs are available.

There is no universally accepted formula on the breakdown of beds into various disciplines. However, as a starting point of the exercise, the following distribution is suggested for a general hospital is shown in table-

Table- % of distribution of beds

EQUIPPING A HOSPITAL
The mechanical and electrical installations and the plant and equipment component in a modern general hospital has been estimated to cost about 40 per cent of for entire hospital project out of which about half 20 %) is required for medical equipment(s). Hospital equipment covers a broad range of items necessary for functioning of all the services' Various ways of classifying the equipment in hospitals can be Used . However, for universal application the equipment in the hospital can be classified as: i. Physical Plant' ii. Hospital furniture and appliances, iii. General purpose furniture and appliances' and iv. Therapeutic and diagnostic equipment

Physical plant

Lifts Refrigeration and air-conditioning Fixed sterilizers ,incinerators Boilers ,Pumps Kitchen equipment Mechanical laundry Central oxygen, suction Generator Beds ,Stretchers .Trolleys Wheelchairs Bedside lockers Dressing drums Kitchen utensils Bedside lamps Movable screens Hand wash stands Operation tables Instrument trolleys Bedpans Waste bins Hospital linen

Hospital furniture and appliances

General purpose furniture and appliances

Intercom sets Typewriters Calculators ,Cash registers Filing systems Electronic exchange Computer ,Office furniture Crockery and cutlery Surgical instruments BP instruments ,Suction machines Rehabilitation department equipment Physiotherapy department equipment Sterilisers Glassware washers Voltage stabilisers ,Refrigerators Chemical analysers-microscopes Short-way diathermy machines ElectriC cautery machine Defibrillators X-ray machines ,Monitoring equipment Respirators ,Incubators

Diagnostic and therapeutic equipment

CONSTRUCTION AND COMMISSIONING Construction Working drawings and specifications are prepared by the architect to provide to the contractor a detail picture of the work to be done, materials and methods to be used and responsibilities to be assumed for the project. The contractor usually subcontracts various parts of the work to other contractors, each a specialist in a particular line of work.

Phasing
Few projects can be taken to the stage of completion without recourse to breaking it into phases. This is necessitated because of following factors. 1. The necessity to bring facilities into use quickly asfor operational reasons 2. The neceosity to split a major project into smaller units of building work 3. The necessity of having oertain departmonts ready before others 4. Local priorities for introducing services 5. Limitation-on availability of capital funds.

Commissioning
The hospital is ready to be commissioned when its building is ready, all equipment has been installed, and the staff and manpower engaged. The plant and machinery should have undergone many test runs before this, and the therapeutic and diagnostic equipment should have also been tested. The medical staff and other paramedical personnel should have been positioned a few weeks in advance.

Scheduling the Sequence of Services

Some services of the hospital will require to be ready while others have still ample time. For example CSSD requires lengthy trial runs and bacteriological checks, installation and calibration of x-ray machinery is lengthy job. The sequence of opening the departments should be planned carefully. The following grouping of services into four categories is suggested (Table).

SHAKE-DOWN PERIOD
A well-planned hospital passes from the construction stage to the commissioning stage with a smooth transition if adequate thought has gone into aspect planning, equipment and staffing The period from the time of commissioning of the hospital till it settles

down into a satisfactorily functioning entity is the "shake-down period". lt is

the period during which it experiences its teething troubles.

This period will be shorter if adequate time and thought have been
devoted to planning and execution and can last from a few months to a few years.

EPILOGUE
"Talking about hospital planning is like talking about swimming. One can derive some principles and postulations, and give advice. But, in the final analysis, the only way to achieve proficiency is to jump in and do it".

REFERENCES
1. Mc Giboni J R: Principles of Hospital Administration GP Putnam's Sons: New York,1969. 2. Donabedian A: Volume, quality and regionalisation of health care services. Medical Care22 (2) m:1984.

3. Kleczowski BM, PibouleauR: Approachesto Planning and Design of Health Care Facilities
in Developing Areas. 3:WHO Geneva, 1979. 4. Starling AE: World Hospltals XXll (2) 1986 5- National Buitding Code. lndian Standards lnstitution New Delhi, 1984. 6-Weeks John: Hospitals-more like villages. World Hospitals XXll (3): 1 986. 7- Recommendation s f o r Basi c Req u i re ments of G ene ral Hospitat Buitdings (lS: 10905 Part 1 to 3). Lndian Standards lnstitution, New Delhi, 1985.

8- Scales of Accommodation for A,rmed Forces Hospital 1983. DGAFMS,

Ministry of Defence, Government of lndia New Delhi, 1983 9- Millard G; Commissioning Hospital Buildings. King Edward Hospital Fund, London,l 981 .