Changing Concepts in the Health Facility Planning

0 downloads 0 Views 228KB Size Report
intramural. The extramural system is the ambulance service. The intramural system includes ramps, lifts, conveyor belts, and dumb waiters and trolleys etc.
Growth

Changing Concepts in the Health Facility Planning In evolving hospital concept, the architects and planners have to keep pace with the development in modern medicine, nursing technique and general community expectations. Medical technology is developing very fast so much so that often hospitals become outdated even before they are put to use. There has been very rapid change in last five decades in functioning of hospitals due to medical advances which have direct bearing on patient care. Medicine is an everchanging subject. Discoveries and inventions keep on changing the paradigm of health care delivery. Recent trends in molecular biology, pharmaceuticals and surgical interventions have not only prolonged the life but also improved the quality of life. Information superhighway has turned the world into a ‘Global Village’. These factors have major influence in the planning of new hospitals. The other factors which have direct bearing on hospital planning are: • Costly diagnostic services cannot be provided in all hospitals. Thus, there should be proper choice of place and services to be rendered. • Tertiary care cannot be provided in all places due to high cost and lack of availability of trained man power. • Design should follow function, however, the proper use of esthetic quality and humanized surrounding must be kept in mind so that it looks attractive • A study of activities in health facilities at

different levels is a perequisite of planning as it anweres several important question • For health centres of different sizes and with different functions, what is the proportion of working hours devoted to various broad activities or definite tasks: a. Which different types of staff are needed and in what proportion? b. What are the space requirements to discharge these functions? c. What is the inter-relationship between these functions and consequently, what layout will be more convenient? As conditions vary from place to place, it is necessary to undertake such a study for each project. Health Centres Grouping of closely related activities should be put together in one area. All areas should be located in relation to one another to allow direct communication and easy flow of patients, staff and services. The design and the structural system should allow maximum flexibility and expandability.

Developments in medical sciences and equipment technology have offered many new diagnostic and therapeutic modalities namely ultrasonography, computerized axial tomography, nuclear magnetic resonance imaging, non-invasive cardiac diagnosis, coronary angiography, invasive cardiophysiology, hemo-dynamic studies, pulmonary functions, endoscopic techniques and procedures, lasers, etc., which are now reliable, precise, easy to run and apply. Many of these have special physical requirements including controlled environment, energy and other engineering services. Since these are capital intensive, there has been an increasing concern to effect economy in their use. Task before the architects therefore will be 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 recongnise 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 therpeutic facility. 4. In-patient (nursing care) units. 5. Administration department and business. 6. Hospital engineering services. Each of the functional components need to be suitably placed depending on their inter-relationship but with 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 the minimum. a. Emergency Department is an independent unit to function round the clock like a mini hospital.

Entry to this department has to be prominant and self-guided so that a very minimum time is lost in giving immediate treatment to casualty and emergent cases arriving in the hospital. b. 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 very important role in health care delivery. A well organised and well equipped outpatient department can play key role in reducing the load on the inpatient beds and save a lot of time and expenditure. Emphasis is now more on outpatient facilities which are likely to increase substantially thereby reducing the load of inpatients and the cost the hospital projects as a whole. Facilities of this unit are termed as: • Clinics for various medical and surgical discipline. • Supporting facilities like laboratory, injection rooms, etc. • Pharmacy and Blood Bank. c. Diagnostic and therapeutic facilities include: the radio-diagnostic and imaging department, clinical pathology as diagnostic facilities whereas radiotherapy, operation theaters, rehabilitation and physiotherapy as therapeutic areas are to serve in common to outpatient department and inpatient nursing care units. These facilities are to be suitably placed at different levels in consideration of their functional use and degree of necessity to dependent departments. Diagnostic and imaging units generally deals with radiography and flouroscopy, ultrasound, nuclear medicine and CAT Scan, etc. This being a fast developing technique should be designed keeping in view the future scope of expansion. Laboratories are concerned with the analysis of

diseased tissue and 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

Radiography includes treatment of various types of radiations, ranging from superficial therapy to megavoltage therapy. Size of department depends upon the load, scope of work and type of equipment employed. High degree of radiations, protective measures and air conditioning for the efficient functioning of the electronic equipments are the essential design requirements for the department. Operation Theater

Hospital is technically a therapeutic aid in which a team of surgeons, anesthetic, nurses and sometime pathologists and radiologists operate upon or care for the 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 theratre design. Filtration and recirculation of conditioned air and scavanging of expired anesthetic gases have further enhanced safety and comfort of the patients and surgical team. 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, speciality-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. Speciality-wise wards however, should be located closer to their respective outpatient clinics to act as self-contained centres. 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 Rigg’s 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 is not only a place for admitting a patient who cannot be treated outside hospital, but also a place of training for doctors and paramedical staff. In-patients are likely to fall into one of five broad care grouping in the proportions shown. 1. Intensive Medical Care Where continuous medical and nursing observation and mechanical assistance is necessary to maintain life one

percent. 2. Intensive Nursing Care Where patients are unable to leave their beds, and where their is need to continuous nursing, observation and physical assistance. 20-25 percent. 3. Medium Nursing Care Where patients are able to leave their beds for short periods (upto four hours) each day with assistance 20-25 percent. 4. Low Nursing Care Where patients are able to leave their beds for more than four hours per day, requiring minimal assistance 20-30 percent 5. Self Care Patients leading apparently a normal life, who are in hospital for observation 5-10 percent. Using a similar classification, the proportions of patients in a developing country are likely to be considerably higher in the intensive and medium care categories, perhaps upto 75-80 percent of total patients being within these two areas. 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 health post, health centre or hospital. The functions of outpatient services of a hospital are to provide diagnostic, curative, preventive, and rehabilitative service on ambulatory basis to the the community. The extent of these functions established by the individual hospital will vary, according to aim of hospital, expectation of community and political will. The scope and form is undergoing dramatic change. If it functions well, it can reduce pressure on inpatient care, which can be achieved by increasing diagnostic and treatment service. 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. A hospital brings together the wide spectrum of knowledge, professional skill, and physical facilities so that the present and future generation will advance in health and well-being. If it can be designed in proper fashion it can combine science and wisdom to create holistic approach to health care. The architect has the task of designing a highly complex structure for a very complex organization, but his design has to have sufficient clarity of form to be understood by all who use it. In addition, he has to design individual territories—the departments for each of the groups whose successful interaction is the basis of the work of the hospital. Each separate department needs its own identity and within it, its own map, its own private and public space as well as own frontdoor. The design must allow the identity of many families which form its work force to be identifiable, physically, from inside the complex.

Hospital design must have flexibility, to adopt monsoon time. 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. While selecting the site, one must keep in mind, any further expansion in future size of land required is as follows: Single storey 50 beds 10 acres Single Storey 100 beds 15-20 acres Double storey 200 beds 20-25 acres 3- 5 stories 500 beds 55-70 acres 4- 6 700 beds 80-90 acres stories 6-9 1000 beds 90-100 acres stories. Basement is possible if the sub-soil water is below 25 feet in mid

Preparation of architect brief After obtaining

requirement of clinical and nursing departments supportive service, administrative and business and utility services, a general outline of requirement be 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 suitable project management organization which can develop the project brief by considering and analyzing all important factors. Design Plan (Fig. 6.1)

While designing differnet 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 One kv per bed per day.

Fig. 6.1 : General process of planning a health facility

Sanitary Requirements Toilet for an individual room (single or two bed) 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 beded ward unit, requirement of fitments is given below: Items Water closets Ablution taps

Quantity 1 for every 8 beds (male) 1 for every 6 beds (female) 1 for each water closets plus

1 water tap with drainage arrangement in the vicinity of water closets Urinals 1 for every 12 beds Bath 1 bath with shower for every 12 beds Bed pan washing 1 for each ward in dirty utility and sinks sluice room. Sinks and dishwasher 1 for each ward in ward pantry.

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 Hospital Space Module is taken as 3.5 sqm. This space is enough to accommodate a toilet comprising a WC, Wash basin and a shower. 7 Sqm. is enough for the routine hospital bed, and 14 sqm. will be required for each bed in the Intensive care unit. a. 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. b. Plinth area With all constraints the recommended area per bed is 75 sqm. whereas in developed countries it is 150 sqm. c. Floor height The height of all the room in the hospital should not be less than 3 m and not more than 3.65m. d. 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. e. Dedoing It should be generally upto a height of 1.2 m. In bathroom upto 2 m. and in operating and delivery room dedoing should be the complete floor height. f. Door The minimum width of doors should not be less than 1.6 m. and height 2.1 m. g. 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. h. Exhaust fans should be provided as per following scales. • Operation theatres and delivery suites—20 air changes per hour • Radiography room, Radiothapy room—08 air changes per hour. i Traction—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. j Lifts (automatic control) with speed of 0.36 m.

and 0.75 per second for hospitals of two or more stories are to be provided at the following scale: Two storeyed building lift

Stretcher-cum passenger

Upto 199 beds

One

Service Nil

200 to 399 beds

Two

One

400 to 499 beds

Three

One

500 to 599 beds

Four

One

600 to 699 beds

Five

One

700 to 799 beds 800 to 1000 beds

Six Seven

Two Two

k. Fire protection In a high-rise building the following systems should be provided: • Fire safety system • Fire detection system • Fire alarm system • Fire fighting system Design Competition

If the hospital is big, tender can be introduced to invite the architects for design competition and rate. A group of users and experts can choose best design and rates, etc. Construction by Contractor

A project like hospital has to be contracted only at reasonable price with reputed contractor. A tender has to be issued by engineering department with full and complete specification stating type of work, excepted cost, period of completion,etc. The planning team should take a decision regarding allotment of work. Management must exercise proper control on construction. 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. Figure 6.2 outlines a generic schedule of the facility development process with an appropriate timeframe for each activity. The sequence and duration of each of these activities vary somewhat depending on project scope and implementation strategy. 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.

Quality Leadership For a project team to succeed in its task, it needs technical knowledge, expertise in the subject, knowhow to work as a team, plan, conduct good meetings, manage logistics and details, gather useful data, analyse the data, communicate the results and implement changes. With quality leadership, use of scientific approach becomes standard procedure. The focus is on improving products and services by improving how work gets done (the methods) instead of simply what is done (the results). Quality leadership emphasizes results by working on methods. Principles of quality leadership include: customer focus, obsession with quality, recognising the structure in work, freedom through control, looking for faults in systems, teamwork, and continued eduction and training. Project teams are a crucial tool for quality improvement. The success or failure of projects will have great impact on the health facility. Project team members learn how to work as a team and how to improve processes using scientific tools and techniques. The basic statistical tools used most frequently in a scientific approach to quality improvement include: Flowcharts, Pareto chart, Cause-and-effect diagram, Operational definitions (what something is and how it is measured), Stratifications (to pinpoint a problem by exposing where it does and does not occur. It lets teams avoid wasteful effort, directing their energies to the most potentially fruitful areas), time plots (used to examine data for trends or patterns that occur. Overtime; the data points plotted in time order), Control chart (used to monitor a process to see whether it is in statistical contrtol. It also indicates the range of variations built into the system), Check sheets (used to record data), Scatter Diagrams (display the relationship between two process characteristics), etc.

Fig. 6.2: Stages in Facility Development

• Clarity in team goals The success of a project depends largely on get• An improvement plan ting everything set up correctly: choosing an appro• Clearly defined roles priate process, selecting appropriate team members, • Clear communication and doing the ground work, so a team will know • Beneficial team behaviours what the project is all about. • Well-defined decision procedures The following activities must be incorporated • Balanced participation into every step of project: • Established ground rules • Maintain communication • Awareness of the group process • Fix obvious problems • Use of the scientific approach. • Look upstream When quality is increased by improving pro• Document progress and problems cesses, productivity improves. Better productivity • Minitor changes. Teams must spend time in the early stages of lowers unit costs, which in turn lowers prices. their project planning how the project will unfold. FURTHER READING Planning is the heart of using a scientific approach to 1. Amin Tabish Future Trends in Healthcare. Jr. of quality improvement. Ten ingredients for a sucIntl Med Sci Acad. 2005 cessful team include:

2.

3. 4.

5.

6. 7. 8.

9.

Amin Tabish. Knowledge Based Health Care: Need for Global Health Policy. JK Practitioner 2006;13 (3):119 Amin Tabish. Human Health in Changing World. PMJ 2006 Amin Tabish. Building a Healthy World for Tomorrow. Editorial. IHSJ. Vol 1 No. 1; January 2007 Amin Tabish. Standards for Better Health. International Journal of Health Sciences, Qassim University, Vol. 3, No.1, (January 2009/Muharram 1430H) Amin Tabish. Health Policy Challenges. Jr of Nursing Research & Practice. 2009;5(1,2):54-60 Amin Tabish. Healthcare Industry Needs A Change Model. JIMSA, 2012;25(3):137-138 Putsep E: The Modern Hospital: international planning practice, Lloyd-Luke, 1979, London, 1979 Tabish SA & Nabil Syed. Future of Healthcare

Delivery: Strategies that will Reshape the Healthcare Industry Landscape. International Journal of Science and Research (IJSR). Volume 4 Issue 2, February 2015:727-758