Hospital Planning

A brief note on Hospital Planning for academic and practical purposes of Post Graduate students on Hospital Administration or management.

1. HOSPITAL PLANNING Brig Gen Dr Zulfiquer Ahmed Amin M Phil, MPH, PGD (Health Economics), Advance Course HA (AIIMS, Delhi), MBBS North South University (NSU)

2. Hospital Planning Planning is the forecasting and organizing the activities required to achieve the desired goals. Hospital Planning is deciding in advance the structural and functional components of a hospital that responds to the present needs of the patients, the healthcare workforce and the society, while anticipating the future changes. All successful hospitals, without exception are built on a triad of good planning , good design & construction and good administration .

3. Hospital building differs from other building types in the complex functional relationship between the various parts of the hospital . Apart from providing right environment for patients and care providers , it should also be sensitive to the needs of visitors . It is thus imperative to examine the emerging issues , impacting factors and study the various strategic essentials for planning, designing and construction of a hospital.

4. Efficiency and Cost-Effectiveness An efficient hospital layout should promote staff efficiency by minimizing distance of necessary travel between frequently used spaces; allow visual supervision of patients ; provide an efficient logistics system for supplies and food (and removal of waste); make efficient use of spaces . Flexibility and Expandability Medical needs and modes of treatment will continue to change. Therefore, hospitals should follow modular concepts of space planning and layout ; with well-planned directions for future expansion. Factors to Consider in Hospital Design and Construction

5. Therapeutic Environment Patients and visitors should perceive a hospital as unthreatening, comfortable, and stress-free . The  interior designer  plays a major role in this effort to create a therapeutic environment.  For example, allowing ample natural light , and by providing  views of the outdoors from every patient bed . Cleanliness and Sanitation Hospitals must be easy to clean and maintain . This is facilitated by appropriate, durable finishes for each functional space; careful detailing to avoid dirt-catching and hard-to-clean crevices and joints.

6. Accessibility All areas, both inside and out, should ensure grades are flat enough to allow easy movement and sidewalks and corridors are wide enough for two wheelchairs to pass easily. Security and Safety Hospitals have several particular security concerns, such as protection of patients and staff, hospital property and assets (including drugs). Security and safety must be built into the design with these things in mind. Sustainability Hospitals are heavy users of  energy (380 kwh /sq.mt/year) and water (350-400 L/bed/day) and produce large amounts of waste (1-2 kg/bed/day). Because of this, sustainable design must be considered when designing and building hospitals.

7. Planning involves seven questions: What we expect to do? Why it will be done? Where will it be done? When we expect to do it? Who all are going to do it? How will it be done? Are we looking into changes in future?

8. Strategic Essentials Regionalization Pre-planning consideration Need Assessment Plot Ratio Design flexibility and expandability Fulfill the demand functions Patient-Focused hospital Energy and water conservation Intelligent Building Healing architecture Aesthetic Hospital Architecture Go Green

9. Regionalization of Hospital Regionalization of Hospital refers to establishing an hospital in a defined politico/ administrative/ geographical area with interconnectivity to other hospitals for triage in the same region with a regulatory body. Pre-planning consideration Emerging and strategic issues that influence a hospital’s service and infrastructure requirements like, demographics, epidemiology, healthcare statistics, site conditions, regulatory criteria, technological opportunity, and financial feasibility should be considered before planning for a hospital.

10. Need Assessment It is a systematic method of identifying unmet health and healthcare needs of a population. Plot Ratio/ Floor Area Ratio (FAR) Plot Ratio is the ratio of a building's total floor area (gross floor area) to the size of the piece of land upon which it is built. 2:1 ratio is the highest FAR a hospital can have.

11. Flexibility and Expandability Expandability and Flexibility refers to the ability of the health infrastructure to expand horizontally or vertically as per changing needs of the healthcare. Fulfill Demand Functions of Hospital Demand of healthcare function refers to the quantity, quality, and type of healthcare the consumer wants, which depends on factors like health condition, prices, personal income, and preferences , should be fulfilled. Patient-Focused Hospital A patient-centered hospital creates a home-like environment that not only meets the needs of the patient, but also meets the needs of family members.

12. Energy and water conservation Average energy consumption in a hospital is 1 kw /bed/day, and water consumption is 300-400 liters/bed/day. Healing Architecture : Architecture and design can promote the healing process by giving patients a psychological and physical lift. Intelligent Building : A building that integrates technology and process to create a facility that is safer, and more comfortable for its occupants, and efficient for its owners. Go Green " Go Green ”. Going “Green” means taking measures to become environmentally conscious in making decisions. For hospitals, it mean “ energy saving (20-40%) , better indoor air quality, and water saving (35-40%)."

13. Emerging Issues for Hospital Planning -Epidemiological and demographic changes -Increased expectation of patients -Emphasis on ambulatory care (Day Care) -Enhanced standards -Changing functions of hospitals -Advancements in medical technologies -Concept of outsourcing of hospital utility services

14. Impacting Factors for Hospital -Socio-economic profile of community -Health status profile of the region -Local regulations -Source of finance -Choice of technology -Climatic zone

15. Hospital Designing -The main guideline while designing the hospital is ‘ Form Follows Function ’ . ‘Form follows function’, is a principle associated with modern architecture and industrial design that the purpose of a building should be the starting point for its design. -All architectural and aesthetic design should be secondary in nature. -According to the function of the department, the designing to be made. ‘ Form Follow Function ’: Function is to work with computer. So forms (Facilities), like table and chair should facilitate working with computer . It should not be mere ornamentation.

16. Principle of Hospital Planning Protection : Protection from unhealthy environment in order to help speedy recovery. Separation : Separation of dissimilar activities. Control : The nurses station should be positioned strategically to enable proper visual monitoring of patients and control all clinical activities. Circulation : All the departments of a hospital must be properly integrated for human traffic, by sufficient corridors, stairways, elevators, escalators, and lobbies. Circulation spaces may constitute up to 25% of hospital area . Light and air : Natural light and air should be allowed in the vicinity.

17. Objectives of Planning Team -Examine existing facilities and its adequacy -Assess the needs of the area -Need for new facilities/expansion, so as to provide adequate quantitative and qualitative healthcare services to people.

18. Steps of Hospital Planning

19. Feasibility Study

20. Data Collection

21. Feasibility Study Demographic pattern : Type of residents- High, Middle, Low Class. Affordability status. Extent of people to be covered Peoples beliefs, attitude, practices and culture. Availability of Rest House, hotels etc. Need Assessment : Type of healthcare need. Population pattern- Age, gender, education, vulnerability. Economic status, source of income Utilization pattern of existing healthcare facility Level of leadership and motivation among people. Accommodation and training facilities for hospital staffs.

22. Need Assessment How many beds in a new hospital will be needed for a particular area, will be calculated as per following formula: WHO standards, a minimum of 3 beds per 1000 population is required

23. Site Selection : The site for the hospital should be carefully selected by the Hospital Planning Team keeping in mind the various factors like accessibility, geographical location, size of the plot, good approach road etc. Expert healthcare consulting firms can help in identifying the right location for the hospital. Land requirement (Approx):

24. -Soil condition suitable for construction, not land-fill area. -Subsoil water and mineral level. -Availability of public utilities. -Proper elevation for drainage & general sanitary measures. -Freedom from smoke, noise, vapour , and other annoyances. -Potential for future expansion.

25. Environmental Study : Area must have clear sun shine, avoid big buildings, trees near-by. Climate should be moderate. No near-by noise emitting industries. Flow of fresh air. Away from roads with heavy traffic. Availability of sun light. (East-West Facing indoor) Availability of Electricity : Electric sub-station in close vicinity. Availability of 3 phase-electric supply with adequate load (1 kw /bed/day) Dedicated electric supply line. Stand-by generator.

26. Water Supply & Sanitation : Availability of deep table subsoil water. Adequate water supply (300-400 liter/bed/day ). Good maintained sewerage system. Easy access to sewerage treatment plant. Availability of safe Bio-Medical Waste Disposal facility. Transportation & Communication : Close access to Rail Station or Bus Stand. 24-hours public transport and private taxis available.

27. Project Planning and Implementation

28. Project Planning and Implementation

29. Master Plan Project Planning and Implementation

30. Project Planning and Implementation

31. Resource Allocation

32. The cost to set up a hospital depends on : 1. The intended capacity of the health care facility. 2. The level of health care the facility intends to offers. In Bangladesh , establishing a tertiary care Hospital-Bed, needs almost 1 crore (10 million) taka to facilitate its every bed with advanced health care, including expenditure on civil (building), medical equipment, human resources, utility capacity, safety standard and administration. In USA, per hospital bed construction cost ranges from $500,000 to $1,500,000 . The land and construction cumulatively require 50-60% of the total capital cost . In addition, another 10% of the total estimated cost is to be set aside for contingency and cost-build up due to processing lags in the hospital setup.

33. Project Planning and Implementation

34. Project Planning and Implementation

35. Construction Plan

36. Sufficient space are planned for future expansion of a hospital Construction Plan

37. Space Requirement for Some Basic Department Construction Plan Area Sq ft/Bed Nursing Unit 250-280 Nursery 12-18 Delivery Suite 15-20 Operation Theatre 30-50 Physical medicine 12-18 Radiology 25-35 Laboratory 25-35 Pharmacy 4-6 Central Sterile Supply Dept 8-25 Dietary 25-35 Medical record 8-15

38. Construction Plan Area Sq ft/Bed House keeping 4-5 Laundry 12-18 Mechanical Installation 50-75 Workshop 4-6 Stores 25-35 Public Area 8-10 Administration 40-50 Total 567-751 Circulation 8-25 Total Net Area 682-891

39. Construction Plan

40. An architect brief is a written document of a complete construction plan , prepared by a person or a team in consultation with the client, that includes all of the things on the " wishlist “ of the owner . It explains types of services to be provided, interrelationship and interdependency of each department, special requirements and facilities need to be available. It includes: Architect Brief - Site Information - Functional Content - Workload - Staffing - Equipment Policies and Procedures Accommodation Zoning Financial Aspects Provision of Air-Light-Water

41. Project Planning and Implementation - When design is finalizes, bidding process starts. A tender is issued in two bid system (Technical and Price Proposal) Bids are examined by the planning team. Finally, contract is awarded to prospective contractor/agency. Tendering and Award of Contract

42. Manpower Planning and Recruitment While construction is on progress simultaneous manpower plan and subsequent recruitment is undertaken. Clinical Personnel Administrative Personnel -Nursing Staffs Paramedics Medical Technicians Electro-Medical Technicians Clerical Staffs IT Personnel Kitchen personnel Sanitary Personnel Other staffs

43. Material Planning

44. Equipment Planning & Purchase -There are Built-in, depreciable and non-depreciable equipments in a hospital. -A room by room equipment list is prepared and reviewed by the admin and clinical staffs. -It is necessary to consult with the architect who is designing the building early, so that the facilities planned will be of sufficient size to accommodate the equipment and render necessary service. -During purchase of costly equipments , warranty period and post-warranty services should be ensured. - Latest version of equipments, as far as possible should be purchased. -Provision of workshop for minor repair should be considered. -Before acceptance of equipment, trial-run should be done.

45. Built-In Equipments This includes counters, and cabinets in laboratory, pharmacy; elevators, incinerator , washing-facility, fixed sterilizer etc. These are included in the construction contract and planning of these equipments is the architect’s responsibility. Depreciable Equipments This include any equipment that has life for five years or more , and not purchased through construction contract. Diagnostic and therapeutic equipments ( MRI, CT Scan , Ultrasonogram Machine, RT-PCR Machine etc) Non Depreciable Equipments Small items with low unit cost , and life span less than five years , and not purchased through construction contract. eg , surgical instruments , linen, kitchen utensils etc

46. A patient-centered environment considers the needs of patients both architecturally and through material selection. It fulfills: Infection control standards Aesthetic value Healing environment Physical environment Interior and Furnishing

47. Commissioning Building commissioning: It is process by which a new equipment, facility, or plant is tested to verify , if it functions according to its design objectives or specifications and as intended by the building owner , done by test-running. Commissioning of an establishment is done, when : - Construction is completed - Equipment and machineries are installed -Recruitment of staffs are done -Advertisement in mass media is given for its operation - Date of inauguration is finalized .

48. Shakedown Period After the commissioning of hospital , some time is taken for full operation to public , due to functional integration of different units , services, staffs, patients and the community. This period is called ‘shake-down’ period. It involves : -Machines are tested. -Staffs are recruited and trained -Standard operating procedures are made -Maintenance service is put in place -Materials, line, and stationary are procured. Then begins the routine and regular functioning of the hospital.

49. The average hospital needs roughly 2,500 sq.ft . per bed in USA . The average cost of hospital construction per bed, ranges from $500,000 to $1,500,000 , and $200 to $625 per sq.ft , which usually depends on the type of hospital, and encompasses cost of affiliated administration, utility, medical units and safety measures. In Bangladesh, establishing a tertiary care Hospital needs almost 1 crore taka per bed , inclusive of men, material, equipment, and capital cost . Thus, hospital is a very costly project. We should plan a hospital with due vigilance and pre-planning efforts, so that we can avoid any costly repair or amendment after the building is erected.

50. Conclusion Medical facilities and hospitals need to stay on the cutting edge of technology to do their jobs properly. Advancements are being made all the time, which means that the hospital needs to be flexible enough to update and change when needed. This may be why, many older hospitals are renovated, with new sections added on, rather than simply building a completely new hospital. Leaving some room for growth in our hospital layout and build-site ensures that we can continue making upgrades as needed for the life of the building. We need to be aware that hospital planning should not be such that either any future development becomes impossible , or it needs to make a hospital completely new.