124970838 hospital-planning-and-project-management-1

Study Material
On
PGDHHM Correspondence Course
HOSPITAL PLANNING AND
PROJECT MANAGEMENT
COMPILED BY
Dr. Vivek Desai
POST GRADUATE DIPLOMA IN
HOSPITAL AND HEALTCARE MANAGEMENT (PGDHHM)
M.B.B.S, DHA, DBM, M.Phil

Symbiosis Centre of Health Care (SCHC)
AUTHOR
Printed and Published on behalf of the Symbiosis Centre of Health Care by
Dr. Rajiv Yeravdekar, Hon. Director, SCHC.
Printed at Gayatri Graphics, Pune - 411 037.
2 SCHC HOSPITAL PLANNING AND PROJECT MANAGEMENT
DrVivekDesai
VisitingFacultySIMS
All rights reserved. No part of this work may be reproduced in any form, by
mimeograph or any other means, without permission in writing from the
SymbiosisCentre ofHealth Care.

PREFACE
The future of healthcare industry in India will see a continued strong demand for
construction of health care facilities, including completely new or replacement
facilities and projects involving major additions and modernization. The annual value
of healthcare construction projects will see a upward trend in the immediate years
ahead owing to various factors like opening up of the insurance sector, privatization
initiatives etc. Therefore planning and design will continue to merit prime emphasis
among several responsibilities of hospital officials. Because of the changing character
of facilities and continuing increase in their complexity, planning and design will
assume greater importance than ever before. Thus planners, architects, builders,
hospital executives, board members, medical staff representatives, and others who
possess responsibility for undertaking hospital construction projects should have
basic understanding of planning process and of appropriate concepts of hospital and
relatedhealthcare facility designobjectives.
There are very few areas where human factors and human requirements play such a
critical role as they do in hospital design. The need for collaboration between those
who care for the sick and those who plan healthcare facilities is of the most critical
importance. A close look at almost any hospital department today demonstrates how
far short we fall in meeting the human factor goals of well being and general efficiency
in hospital facility planning. It was Florence Nightingale who so succinctly pointed out
“the very first requirement of a hospital is that it should do no harm to the sick.” She
was referring not only to the clinical care of the sick, but also to the general
psychological well being of the patient. There have been numerous instances in
modern day hospital care whereby hospital acquired infections owing to faulty air-
conditioning, inadequate water supply/drainage etc. have resulted in patient
morbidityandevenmortality.
One should define planning as the specification of the means necessary for
accomplishment of goals and objectives before action toward those goals has begun.
Planning involves a particular kind of decision making in which one has to specify
alternatives and choose among them. Once the goals are set, alternative plans can be
examined in the context of the opportunities and constraints facing the promoters. In
undertaking any complex project, it is advisable to examine the experience of others in
similar situations and hence such information should be elicited and properly
interpreted. The basic design of a hospital usually is carried out by one or two
individuals, who reflect the labor of the entire planning team in a series of drawings.
The quality of the facility planning effort is ultimately dependent upon designers,
who, it is to be hoped, are capable of interpreting complex relationships, internal traffic
flows, technological requirements, and operational procedures to the extent that a
facility of beauty, reasonable cost, and optimal utility will result. No other activity is in
HOSPITAL PLANNING AND PROJECT MANAGEMENT SCHC 3

the planningcontinuumismoreimportantthan that occurringin the designphase.
Like any other industrial venture, proper planning of hospitals is vital for success of
the venture. It is beyond doubt that if hospitals are properly planned and
professionally, there can be substantial surplus/profit that could be made. The first
step is proper project conceptualization with the right mix of beds and facilities to
generate sufficient income and to attract maximum clientele. For this a
comprehensive market research may be required to assess the need, demand, and
supply for health care servicesapart fromevaluating competition.A detailedfinancial
feasibility report would then show the promoters the viability of the project subject to
various scenarios like effect on profitability with change in the debt/equity ratios,
project cost escalation, etc. Such studies if conducted, will go a long way in avoiding
financialmishaps,whichhave taken heavy toll inmany aproject.
Once the decision is taken to build a hospital, the next step is its architectural design. A
detailed architect's brief has to be first prepared to enable the architect in drawing up
his plans. The landscape, facility mix, bed mix, availability of utilities in the vicinity
will have to be considered. Considerable inputs from the other agencies like air-
conditioning, electrical, plumbing, etc. will be required to finalize the working plan
for the building. Inputs from the equipment vendors especially in specialty areas like
cardiac catheterization laboratories, CT-scanners, MRI's, linear accelerators,
operation theatres etc will be essential. One thing very common in India is the lack of
emphasis given to support services like kitchen, laundry, CSSD, back up electricity
and so forth. Not only are these services vital, but these also have high capital cost and
recurrentexpense andhenceshouldbe properlyplanned.
This module is divided into three parts in order to stress the concept of an integrated
and coordinatedhospitalplanning.
(1) The first section is devoted to conceptualizing a hospital project in terms of the
facilities to be planned in the center. This will deal with understanding the
regional demographics and requirements of health care delivery systems in the
defined geographic service area. It entails undertaking secondary data collection
and conducting market research surveys. This will enable the student to
understandthenuancesoftechnicalandfinancial feasibility ofa hospitalproject.
(2) The second section deals with the planning and design aspects of hospital
buildings and will also trace historical and future development in the field of
hospital infrastructure. There will be descriptive narration to assist the student in
understandingthe importantplanning criteriafor hospitaldepartments.
HOSPITAL PLANNING AND PROJECT MANAGEMENT
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CONTENTS
No. Chapter Page No.
1. Planning ProcessandMarket Research ...............................................7
2. Feasibility Study...................................................................................11
3. Hospital Planning HistoricalGrowth ..............................................15
4. EssentialsofHospital Design .............................................................22
5. StepsInvolvedin HospitalDesign ....................................................35
6. TheDesignProcess...............................................................................54
7. Planning ofInpatient Wards ...............................................................62
8. Planning ofClinicalDepartments ......................................................68
9. Planning SupportServicesin aHospital..........................................126
10. DisasterManagement .......................................................................144
11. TheHospitalProjectTeam ...............................................................165

About the Author :
Dr Vivek Desai
6 SCHC

CHAPTER 1
Healthcare inIndia
Stakeholders
PLANNING PROCESS AND MARKET
RESEARCH
Healthcare in India is in a developing stage and it needs a radical policy shift at
government level to propel in the future to face the challenges of the future. Under the
umbrella of health care providers are outpatient set-ups, nursing homes, hospitals,
medical colleges, health spas, diagnostic centers, ayurvedic and naturopathy centers,
hospices, old age homes etc. Most of theses institutions will have varied needs, which
will differ vastly in terms of their planning needs. Health care provision in India is
different in rural and semi urban settings where it is more unorganized to modern day
super specialty centers where it more institutionalized. The sector suffers form long
years of neglect by the government in terms of priority funding despite being a basic
need of the community. The mechanisms for funding are fast changing to the private
sector involvement thereby pushing up the cost of both setting up hospitals as well as
availing health care in these hospitals. The lowering of interest rates over the years
have no doubt helped the cause of the private sector wherein more entrepreneurs are
coming forward to set up hospitals as it has become affordable to take loans and repay
them. The burgeoning growth of the insurance sector is equally helping the
communityto facethe problempf spiralinghealth carecosts.
There are innumerable stakeholders in the health care delivery domain including the
government, philanthropic trusts, educational institutions, corporate sector, insurance
companies, bio-medical vendors, architects, construction companies, patients,
relatives, the pharmaceutical industry, professionals like doctors and other para-
medical staff, and the funding agencies. Given the wide spectrum of stakeholders, the
industry growth willbenefit many in thepopulation.
Thehospitalownershippattern canbe basically three types:

i) Governmentowned-central /state / district/ autonomouslike army, railways etc
ii) NotFor Profit Managedby Trusts/ Societies
iii) For Profit Corporate Sector
The opening up of the economy has definitely helped the cause by brining in the
accountability on various stakeholders. Even the government funding is now aided by
multi-lateral agencies like the World Bank, UNICEF, European Commission, WHO etc
wherein sustainability of the initial capital expenditure is the main concern. This is no
doubt helping us to improve the delivery mechanisms. The private sector too is
developing, aided by growth in health insurance and the industry per se is moving
towards a market economy concept throwing up cafeteria choice for the consumer.
Adding fuel to growth is the concept of medical tourism wherein Indian hospitals are
gearing up for the challenge of treating foreign patients. This needs a definite focus on
hospital planning as we have to meet the global standards, which by far exceed the
onesfolloweduntil therecent past.
ProjectConceptualization
Thefirst step inhospitalplanning isto freezethe projectconceptin termsof :
Identificationofthe market needs
Finalizationof thefacility mix
Deriving theappropriatesize oftheproject
Determining the possibilityofgetting skilledmanpower
All the above factors have a bearing on the project cost and its viability in future. This
process understands the need of the community that will be served by the hospital in
the given geographic location. For doing this, one needs to undertake a detailed
Market Survey by collecting secondary data from various sources like the internet,
libraries, media publications, news paper archives, ministry of health and district
health departments records etc. Unfortunately India does not have a reliable
mechanism for capturing health related data especially in the private sector. Hence,
one needs to undertake primary data search by conducting interviews with house
?
?
?
?
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holds, practicing doctors and visiting existing institutions. There can be three types of
surveysrequired:
a) House Hold Survey : This is essentially done to understand the health care seeking
behavior pattern of the community as a whole. Sampling techniques are used to
map the statistically significant number of households. The basic information
which shouldbe collectedandanalyzed is asfollows:
- Demographicdetailsofthe family
- Education&Incomedetails
- Diseaseprofilein lastthree years
- Choiceofhealth care providerfor minor&majorailmentswith reasons
- Methodofpayment foravailing healthcare
- Their feelondeficiencyin health caremarket
- Critical successfactorfor theproposedproject
b) Doctor's Survey : Medical professionals are normally the best judge of the
deficiency in the health care market and need to be interviewed carefully to
identify the project concept that would succeed in the geographic service area. The
sampleof doctors to be interviewed should include professionals from all
possible faculties in medicine and surgery including those from diagnostic
divisions like laboratories, imaging, physiotherapy etc. The basic
informationto be collectedand analyzed fromthemwouldbe :
- Personaldetailsonspecialty, qualification,experienceetc
- Areaofpracticeandhospitalattachments
- Patients seen andtheir drainage area
- Referrals to otherhospitals/diagnosticcenterswith reasonsforreferring
- Views ondeficiencyinhealth care market andsolutionsfor same
- Patient'scapability to pay
- Critical successfactorsfora hospitalprojectin theservicearea
c) Institutional Survey : Getting a basic feedback on the competitors in the primary
service area of say 5-10 km radius would be important to assess the strengths and
weakness of major players. One would also need to know the productivity, tariffs,
salary structure etc which would help us in preparation of the feasibility report.
The importantinformationto be collectedwouldbe asunder:
- Ownershipwith historicalgrowth pattern

- ServiceMix(diagnostic,therapeutic, medical,surgical, supportservices)
- Bedmix
- Productivity ofmajorservices
- Tariffsofmajorservices
- Bedto manpowerratio
- Technologylevel
- Annualrevenue/expense inlast 2-3yearsto understandgrowth pattern
Data Analysis:
The data collected through secondary and primary sources is then analyzed to identify
a proper facility mix for the proposed project. It will also determine the scale pf the
project in terms of its bed size. In case it identifies some atypical need like cancer
treatment, it would perhaps need more research to understand the profitability of such
capital intensive specialty. The end result should give definitive information on the
following:
i) Specialtiesto be practicedin theproposedproject
ii) NumberofOPD rooms
iii) Bedmix withbreak up
iv) Noofoperationtheatres
v) Diagnosticservices
vi) Bloodbank
vii) Supportservices
In case the project is to be developed in phases the facilities to be phased should be
clearly identified as the engineering services and areas for the phased development
willhaveto be carefullyplanned.
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CHAPTER 2
FEASIBILITY STUDY
After finalizing the Project Concept in terms of its facilities and size, the next important
step is to analyze its financial viability. This will also help the promoter in planning the
means of financing the project based on its profitability and capability of servicing the
debt proportion.
The first step of the feasibility process is to identify the cost of the project in a realistic
manner. Many projects have failed midway through construction process wherein it
was identified that the cost overrun would be in more than 50% of the estimated
budget. Hospital buildings are very complex in terms of its engineering needs and
hence specialized agencies are required to plan these and identify the cost. The cost of
the projectshouldbe broken downunderthe followingheads:
I) Civil Works including RCC, masonry, doors, windows, interior, and
façade treatment
ii) ElectricalWorks
iii) Plumbing and fire fighting
iv) AirConditioning
v) Landscapeand sitedevelopment
vi) Elevators
vii) Medicalequipmentbroken downunderdepartmentalheads
viii) Non medicalequipmentlike kitchen, laundry,computerhardware &softwareetc
ix) Hospitalfurniture andfixtures
x) Professionalfees
xi) Pre Operative Expenses
xii) MunicipalTaxes&deposits
xiii) Interest duringconstruction
xiv) Contingency
The estimates for all the above should be compiled meticulously after detailed

discussions with experts and undertaking adequate research. Financial institutions
also required sufficient back up data to accept the costs before accepting the project for
funding.
After compiling the project cost, the next important step is to ascertain the income from
the project from various heads. Whilst doing this, one would rely heavily on the
institutional market research to understand the industry benchmarks for making
assumptions. Income assumptions will need to be made for the following income
heads:
i) Room rents for all categories of beds like general ward, twin/single rooms,
ICU,NICUetc.
ii) Departmental income for diagnostic services (lab, radiology, EEG, EMG,
non-invasivecardiology,audiology,cath lab,refraction etc)
iii) IncomefromOPD &IPDconsultations
iv) Incomefromsurgicaloperations(majorandday caresurgeries)
v) Health checkschemes
vi) Pharmacy
vii) Emergency
viii) Dialysis
ix) Deliveries
x) BloodBank
xi) Emergency
xii) Any specialty service like LINAEC, IVF, Angioplasty, Minimal Invasive surgery,
organ transplant etc.will needto be separately assessed
For calculating the income some important assumptions will need to be made with
regards to the number of OPD/IPD days in a year, bed days available depending on
the bed capacity, average length of stay (ALOS), number of admissions, number of
operation theatres, number of OPD rooms etc. These assumptions form the important
basis for assuming a realistic productivity for various departments which when
multiplied with an average tariff rate will give the income on an annual basis. An
examplefor assumptionisgiven below:
Income Assumptions:
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Numberof beds - 100
NumberOPD days - 300
Numberof IPDdays - 365
BedDays available - 100 x 365 = 36,500
ALOS - 5 daystherefore noofadmissions
= 36500/5 = 7300/annum
Numberof theatres - 4 ,Noofsurgeries/ OT / day
= 4,therefore surgeries/annum= 4 x4 x 300
Numberof OPD - 10, noofpatients /OPD / hr = 4,
NoofOPD/annum= 10x 4 x 10hrs= 400
Numberof X-ray - 1 per admissionfor IPDand10% ofallOPD cases
One has to assume such productivity for all departments by using sound logic and
keep cross checking it with some industry benchmark. All income is calculated on
100% capacity utilization and then adjusted for year wise utilization as % in year 1, year
2,year 3,till year10. Itis importantto includeallheadsofincomeasmaybe possible.
The next important step is to compute all the important expenditure heads for the
projectoperations.Theseheadswouldincludethefollowing:
I) Salaries and wages these should be computed on a cost to company basis and
shouldtake into astaffing pattern inclusiveofthose forleaves,contractlabors etc.
ii) Departmental expenses in terms of consumables. This could be arrived as
percentage expenseto the departmentalincomeby taking industry benchmarks
iii) Professional fee payable to doctors for rendering clinical services. This would
differ from assuming a flat salary to incentive based remuneration. Again
industry benchmarks will have to be followed for same. Some hospitals have a
mixof boththe options
iv) Energy costsintermsofelectricity, water,medicalgases, generator
v) Foodexpensesforpatients andstaff
vi) Laundry&linen expensesforpatientsand staff
ExpenseAssumptions:

vii) Housekeeping expensescan becalculatedona per sqft basisforthe building
viii) Stationery expenses
ix) Telecommunication
x) Conveyanceandcarmaintenance
xi) Marketing expenses
xii) Repairsandmaintenance
xiii) Insurance,Legal and Auditcharges
xiv) Miscellaneousexpenses
xv) Depreciation
xvi) Interestcostforloanstaken
xvii)Taxesfor corporatehospital
After computing the income and expense statements as mentioned above, one arrives
at the various financials such as Profit & Loss statement, Balance Sheet, Cash Flow,
break even analysis. After computing these statements once can undertake sensitivity
analysis by subjecting the project assumptions certain changes and evaluating the
impactonprofitability like:
- Change indebt to equity ratio
- Change ininterest ratesonthe loantaken
- Change incapacity utilization overthefive year period
- Effectofcostescalation
Such meticulous financial analysis will give the promoter confidence to decide on
whether to undertake the project or not. This also helps them to arrive at a proper debt
to equity ratio for theproject.
FinancialStatements:
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CHAPTER 3
HOSPITAL PLANNING - HISTORICAL
GROWTH
The hospital as an institution offering care to those who need it is of great antiquity.
The modern word is derived from the Latin hospes (“host”), which is also the root for
the words 'hotel', 'hospice', and 'hospitality'. The earliest examples approximating the
institutions we call hospitals, however, were the Egyptian temples of 4000 years ago.
Theassociationof religionandmedicinewasa naturalone inmany ancient cultures.
Originating in the time of the matriarchal goddess religions, when the cyclical process
of nature and women's ability to give birth were revered, the relationship between the
midwife and the woman giving birth was the first healer-patient relationship. In
primitive societies those seen as holding mystical powers came to acquire more formal
ones.Thushealing and believing brought forth the faith healer.
Early knowledge was gained both from intuition, as well as from watching animals
and then passing on the accumulated knowledge down through the generations.
Apart from primitive tools there was no technology and medicine was based upon
touch,comfortand belief.
The early Egyptians identified over 250 diseases and combined medicine with magic
and religion. As they developed the science of medicine, treatment and drugs, there
was parallel development in improvements to public hygiene and sanitation. The
Babylonians further developed medicine and records show that fees were charged for
a healer's service. Yet it was the Greeks who gave us Hippocrates and the famous oath.
Greek buildings used for medical care were still similar to temples. The Greeks
however viewed healthcare in a natural and totally holistic framework. The Greeks
assumed, as only natural, that healthcare treatment should include music, poetry, arts
andgoodcuisine.Templesdedicatedto Asclepiuswere notedfor their cures.
The idea of an institution created specifically to care for the sick appeared in Hindustan
in the third century B.C., and in first century Rome. In Hindustan, the king Ashoka is
credited with establishing some 18 centers for treating the ill. There were physicians
and a nursing staff, and the expense was borne by the royal treasury. Hospital style

institutions appeared in China in the first millennium A.D., as part of a state supported
care system, while in Rome there were special institutions for slaves, gladiators, and
soldiers.
From about 500 BC to 475 AD the Romans assimilated medical cultures from the
territories that they inhabited. Generally, the Romans, as the Greeks, provided
healthcare in the community. The Roman hospital was built upon a military regime
within a rigid institutional setting. Thus the early example of what has become known
as the medical model was indeed based upon the military model, that is, the provision
ofcarewithin anorderedandmilitary setting.
The early Christian era, between 1 and 500 AD brought the return of women in the role
of healers through the Church and convents. It was the Christian commitment to care
for the sick, to comfort the lonely, and to feed the hungry which motivated the
prodigious growth of hospices, orphanages, old age retreats and hospitals proper
throughout the medieval world. The first Christian Hospital was completed between
368 and 372 AD. During the chaos that followed the collapse of the Roman Empire
between 500 and 1000 AD, monasteries retained the teachings of the early Greek texts.
Monks used their knowledge of medicine and herbs to care for the sick and the term
hospital was synonymous with offering hospitality, i.e., refuge from the ravages of the
outside world. Clarity of form was lost during the medieval Christian period, and
hospitalsonceagain becameindistinguishable frommedievalarchitectural forms.
In the medieval west, as in the east, the church bore primary responsibility for
developing institutions of care. Among the hospitals built by it was the Hotel Dieu,
founded by the Bishop of Paris in the seventh century, which today is the oldest
working hospital in existence. Hospital facilities expanded radically from the eleventh
through the fourteenth centuries. The Crusades were in part responsible. The
crusading orders built hospitals in Germany and throughout the Mediterranean
world. Royal and noble families also contributed to the growth. England's first hospital
was built at York in 937 by Athelstan, a grandson of King Alfred the Great. In the
twelfth and thirteenth centuries, when Europe was in the grip of a vast leprosy
epidemic, hundreds of leper asylums or leprosaria were built. It has been estimated
that in 1225 there were 19,000 leprosaria in Europe. As leprosy declined, some of these
leprosaria became hospitals. Thus the Hospital des Petits Maisons outside Paris which
began as a leprosaria was alter used for indigent syphilitics and mentally disordered
pilgrims. When the bubonic plague struck Europe in the fourteenth century, the
leprosariawere thefirst plague hospitals.
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During the seventh century, the rise of Islam led to the Muslim conquest of many
countries. Islam inherited a rich medical tradition, and by the ninth century it had
established a sophisticated medical system. Hospital complexes were constructed at
Baghdad in the ninth and tenth centuries which employed up to 25 staff physicians,
which maintained separate wards for different conditions, and which gave medical
instruction. Thirty-four such hospitals have been identified in Muslim cities from
Mughal India to Spain. Islam, like Christianity, emphasized the community's
responsibilityfor thosewhoneededhelp.
Byzantium's political resurgence under the powerful Macedonian dynasty in the ninth
and tenth centuries brought further hospital construction. The famous Pantocrator,
which was begun by John II Comnenus in 1136 was built as part of a complex of
buildings which included a sumptuous church, tombs for the ruling dynasty, and a
monastery. This hospital was the greatest achievement of the long Byzantium
tradition. The hospital comprised 50 rooms which were divided into 5 departments.
There were 5 rooms for surgical cases, 8 for acute illnesses, 10 each for men and women
with various complaints, and 12 for gynecological cases. The remaining 5 were
available for miscellaneous use, including emergencies. Each department had a staff of
two physicians, five surgeons and two nurses or attendants. There were also an out-
patient department forambulatory cases,apharmacy,baths, amilland abakery.
Later, in classical antiquity, the rational processes of thought were reflected in the plan
form, which gradually evolved a character of its own. Order and clarity became
evident and clear patterns of circulation were delineated and attention was paid to
functional groupings. More scientific methods of healing appeared throughout the
Renaissance period, 1400 - 1700 Ad. This was also the time of Michelangelo and
LeonardodaVinci whosaw the integration of art, inventionand medicine.
In England the traditional role of the Catholic Church in healing and medicine
declined as Henry VIII broke away from Rome. The closure of monasteries by him and
the resulting loss of there medical expertise was a spur to the development of the
medical profession, which then developed outside it's religious origins. He
encouraged and gave authority to physicians, granting the College of Physicians a
charter in 1518. The years 1550 to 1850 were the dark period of nursing. Women were
assigned nursing duty in lieu of a jail sentence. Many hospitals fell into decay, and
unsanitary conditions, epidemics and diseases were common. The hospital was seen
as a place to warehouse the sick and dying and not necessarily a place for care and
treatment.

By the end of the sixteenth century, monarchs and municipalities had become the
prime movers in hospital development. In France, as in most continental European
states, the central government took responsibility. In 1656 the Cardinal Mazarin
created the Hospital General in Paris. These hospitals showed the evolution of the
medieval concept of care into the secularized one of the sixteenth and seventeenth
centuries. Though much larger and administratively complex than their medieval
predecessors, these institutions were similar in that social functions were
fundamental, while treatment was of minor importance. A further change, however,
was coming. Vesalian anatomy, William Harvey's circulation theory, and a growing
interest in clinical medicine were giving hospitals a new significance. It was there that
the actual sick could be observed, that medical applications of scientific discoveries
could be made most conveniently, and that students could be taught. Bedside
observation and teaching began in 1626 at Leyden and Utrecht, won support from
leading English scientists including Sir Francis Bacon, and through the work of
Hermann Boerhaave, the Leyden clinician and one of Europe's greatest teachers,
gained a European following. Even so, the transformation of the hospital into a
medicalinstitution wasnot completefor another century andahalf.
Between 1700 and 1850 the foundations of the modern hospital system were
established. The number of hospitals increased, the quality of medical practice
improved, specialization advanced, and the emphasis shifted from care towards
treatment and cure. The process was most rapid in England, whose 18th century
development was phenomenal, but by the middle of the 19th century most European
societies as well as the United States had established a basic hospital system. In the
American colonies the first hospital was founded in Pennsylvania in 1751, with
Benjamin Franklin as a Trustee. Throughout the entire period of development, two
contrasting systems for planning and financing hospitals appeared. In England and
America, private funds and independent boards were the norm. On the Continent,
central governments and public funds led the way. The American hospitals served a
social need, but their staffing with trained physicians as both house physicians and
consultantsshowedanorientationfromthe beginning towardstreatment andcure.
The brilliance of French medical scientists both before and after the revolution was
unconnected with the state of hospitals or other institutions. At this time, hospital
reformers, activated by a humanitarian concern over the real suffering of those
unfortunate enough to be hospitalized and convinced that an enlightened age had the
means to relieve it, began to agitate for changes. John Howard, an English prison
reformer who became interested in hospitals, was probably the person who did the
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most to popularize reform ideas on the Continent. He was particularly emphatic about
the need for cleanliness and fresh air to combat the deadly miasmic vapors which were
thought to be responsibleforillness,infection,andhigh mortalities.
Probably the most important 18th century Continental hospital was Vienna's
Allgemeine Krankenhaus (general hospital) built by the order of the emperor Joseph II
in 1784. This hospital epitomized the Enlightenment absolutist's approach to medical
care and public health through administrative centralization and rationalization of
function. It also showed the growing conviction that hospitals were primarily
institutions for treating sick people, while its provision to accommodate both the poor
and paying patients struck a modern note. Vienna's influence was also significant
throughout other parts of Europe, appearing in a series of 100- to 200-bed hospitals
built between 1784and 1850.
The combination of further scientific study and epidemics such as cholera in the
United States from 1830 to 1850 created a demand for more hospitals. As hospitals
grew larger, so the incidence of cross-infection became greater. A big turning point for
health-care was the Crimean War. In Crimea, Florence Nightingale gained fame for her
nursing skills. At the end of the war Nightingale became committed to designing
hospitals. She devised a series of concepts that had to do with light, air and cleanliness.
She understood the need to plan care buildings to avoid cross-infection. The
dramatically low mortalities in her temporary barracks at Scutari made her a nearly
irresistible influence on questions of hospital organization and architecture. She
introduced a regime of greater cleanliness and order and the now famous Nightingale
ward, born out of the need for a stricter regime of care and discipline, left an indelible
mark onthe subsequentplanning ofhealthcare buildings.
Both in the Crimean War and in the American Civil War, a need was recognized to
improve medical care through cleanliness, discipline and scientific rationality. Both
sides built large temporary military hospitals which were considered models of
organization and further proof for the 'fresh air' thesis. Treatment on the battlefield
became the generator for new models of care planning. Surgery until then was always
seen as a last resort. The outcome was invariably poor due to cross-infection and pain
must have been horrendous without proper anesthetic. Yet towards the end of the 19th
century, with Louis Pasteur's and Joseph Lister's understanding of living organisms
and methods of antiseptic, the surgeon came to the fore. As it became understood that
surgery was best undertaken in antiseptic conditions, the importance of the hospital as
the focus of healthcare treatment became further established. X-ray technology, which
developed first as a diagnostic tool, became a form of therapy requiring special
instrumentation and facilities; while advances in biochemistry opened a wide variety

of treatments and diagnostic tests which only a fully equipped laboratory could
perform. In much the same way that manufacturing technology shaped the factories
and shops necessary to its efficient use, medical technology influenced the
developmentof themodernhospital.Thekey datesmay saidto be :y 184The discovery
ofanesthetics,whichspreadthroughout theWesternworldwithin a fewyears.
1866-9-Lister's use of carbolic sprays for antiseptic surgery, which by
combatinginfectionenormouslyreducedthe numberofpost-operativefatalities.
1886 - Von Bergman's introduction of aseptic techniques, the sterilizing of
instrumentsandthe useofautoclaves.
1895 - Roentgen used X-rays as an aid to diagnosis. Instead of relying on their
five senses, doctors now had the possibility of confirmation in black and
white. Laboratories similarly added a new dimension to medicine and
enormouslyextendedtheuseofpharmaceuticals.
Not until the late 18th and early 19th centuries was hospital planning treated on a
functional and scientific basis. Then the 'pavilion' type plan evolved, segregating
patients into small groups and ensuring natural light and ventilation. Two other
factors led to this kind of planning. Fear of contagion led to segmentation into
increasingly isolated pavilions, and differentiation of the medical profession led to the
organization of many pavilions into specialty departments. The period from the turn of
the century to the present day has seen the architectural forms of hospitals change from
lowhorizontalpavilionsto a verticalmono-block.
With the discoveries of X-rays and radium, the diagnostic approach to healthcare
became bound to a building rather than being brought to the people. Technological
advances accelerated throughout the 20th century. Each bore the need for new
equipment, with technology further centralizing and emphasizing the place of the
hospitalasthe mainfocusof medicalskills.
After World War II, major factors influencing the evolution of hospitals in the US were
primarily internal in nature. Major design influences related to changes occurring
within a particular hospitals medical staff or those produced by new treatment
modalities and equipment. External forces played a relatively minor role in
influencing design, and the evolution of one hospitals facility was little influenced by
any otherinstitution, except during periodsofcompetitiveaction.
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During the 1960's, architectural firms in the US specializing in hospital design directed
their efforts to developing new programming techniques, applying systems theory to
planning, and updating departmental planning through functional analysis. The space
age that flowered in the 1960s was another turning point for hospital design. Electronic
devices developed for NASA included CRTs (cathode ray tubes) for monitors and
imaging devices. With the 1970's came several changes in the health care system which
shifted emphasis in hospital design. The most important factors influencing the
physical organization of the hospital were no longer internal changes but external
constraints.Importantforcesofchangewere :
Federalgovernment'sparticipation in thehealth field.
Changing patterns ofillnessandnew modalitiesoftreatment.
Anew emphasisonthe treatment ofchronicdiseases
Extensionofhealth carebenefits to employeesthrough OSHA.
The principal areas in which these changes made their impact on the physical plan
ofthehospitalwere :
Size,type anddistributionofinpatient careunits.
Growthofoutpatient servicesandincreasedemphasison ambulatorycare.
Roleand designofemergency departments.
Inter-relationshipsofthe variousdepartmentswithin ahospital.
Overall relation ofthe hospitalto the communityit serves.
Regionalizationof thehealth care system.
Scientific medicine administered through hospitals has proved to be very costly.
Publicly funded insurance and compensation plans and state-funded free medical care
have helped to ease this problem in Europe. In the United States private health
insurance has been the favored method. In the course of the 1970's, it became clear that
private insurance protection against high hospital costs was inadequate, and the
creation of a further national health insurance program has become a political issue. It
is also widely believed, however, that insurance programs have underwritten the
rising costsof hospital medicine while promoting unnecessary use of hospital facilities.
At the same time, rising costs have produced cutbacks in hospital services as well as
hospital closures, raising again the problem of accessibility to care for the poorest
groupsin society.
Today, the weight of economics, social values, and futurist ideas necessitates a
reassessment of this series of “gifts” of history. Some of these gifts have become
liabilities. The reasons for original design are important; if they are understood, it will
be easier to decide whether the reasons apply today. If not, new designs should be
created.

ESSENTIALS OF HOSPITAL PLANNING
CHAPTER 4
Choosing aSite
(1) The first consideration in choosing the site of a hospital is convenience for the
patients. In view of the increasing importance of the outpatient service given by the
hospital, convenience of access to patients is absolutely essential, and should take
priority overotherfactorsinthe selectionofthe site.
(2) The next most important consideration is that the site should be large enough to
enable the hospital to expand and develop in the future. Central positions, in urban
areas, are in great demand; it is often difficult, to find a site big enough for a hospital in
a central area. Sometimes there is a fairly well developed main residential area, and
the hospital can be sited in a central position in relation to this. Sometimes it is known
that the town is going to expand in a particular direction; and it may be possible to find
a large site fairly near the periphery of the present town that will, in due course,
becomecentral tothe majorresidentialarea.
(3) Close collaboration with town-planning authorities is necessary in choosing the
hospital site. In determining the area for the hospital, preliminary calculations are
necessary. These will show the approximate total volume of the building, and the site
area must be related to this. The degree of crowding on a site can be considered in
terms of “plot ratio”. This is the ratio of the total area of the building on all floors to the
area of the site. A “plot ratio” of one represents a building whose total floor area is
equal to the area of these site that is to say, if the hospital is to be a two-storey structure,
half of the site will be covered with buildings and the other half will be available for
openspace,accessroads,carparking, andsoforth. For purposeof reference, it may
be assumed that a plot ratio of two to one is the greatest that should be considered for
hospital development, and that this ratio is acceptable only in the centers of cities,
where a high density of building is the rule. Generally speaking, it will be found that
hospitalsdevelopedat aplot ratio oftwoto one will give a crowded site, high
buildings close to one another, very little open space, and a certain amount of
overshadowing and overlooking between the buildings. In suburban and rural areas,
a site should be sought and given plot ratios of 0.5 to one or less. The degree to which a
sitemay be built up will depend,to someextent, on whether the hospital is in an
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urban or rural area, on the climate, and on the general character of buildings in the
neighborhood.
(4) In most cases a site should be accepted only if it provides room for substantial
future growth.
(5) In principle, the site should be at least double the area required for the hospital as
it is originally planned.
(6) As soon as one or more possible sites satisfying the requirements as set out above
have been found, they should be surveyed by the architect, assisted by an
engineer.
(7) The site will need to have available, from public services, supplies of water,
electricity,and, perhaps,gas.
(8) It should also have main sewerage that is capable of carrying the hospital effluent.
If main sewerage is not available, the suitability of the soil for the installation of an
effectivesewageplant willhave tobe investigated.
(9) It should also be established that the site is free from air pollution from adjoining
industriesorothersourcesand freefrominsect vectorsofdisease.
(10) Theproximity ofsourcesofnoiseshouldbe avoided.
(11) In hot climates, it is important that the site be exposed to breezes, and in harsh
climates,it shouldbe reasonablysheltered.
(12) The bearing qualities of the soil will also require investigation; the risk of earth
movements, geological faults, or underground mine workings has to be
considered.
The first task of the architect is to prepare a master plan for the site as a whole. This
plan should take into account foreseeable future developments of the hospital as well
as the buildings erected in the first project. An architect who has specialized in hospital
construction will be able to prepare a hospital plan once the results of the early studies,
previously discussed, are available. At this stage there will be no schedules of
accommodation or detailed plans of the individual buildings, but an architect with
sufficient experience will be able to calculate the approximate volume of each building
fromthe general data that are available.
TheMasterPlan

The master plan is the equivalent of an exercise in town planning. It is mainly
concerned with establishing the circulation routes on the site and the relative
disposition of the various departments and buildings that make up the hospital. The
circulation routes on the site are of prime importance, and the success of the hospital
plan depends very largely on getting them right. A hospital has two independent sets
ofcirculationroutes external and internal.
All the major departments need to be linked by internal traffic routes for the use of
patients and staff and for the delivery of supplies from the supply areas to their points
of use. A great deal of the interior traffic in a hospital involves the use of trolleys.
Bedfast patients are moved on beds or trolleys; food and supplies are generally also
moved on trolleys. Trolleys cannot be pushed up stairs, and all vertical circulation
points within the hospital therefore have to be provided with lifts. Much of hospital
planning stems from the problems of internal circulation and, in particular, the need to
localize vertical circulation, so far as possible, at certain key points. It is very much
more economical and efficient to concentrate lifts than to distribute them among
different parts of the building. Four lifts banked together will give the same service as
eight individualliftsdistributed at separate points.
The external traffic within the site is considerable. Ambulances and delivery vehicles
need access to the buildings at various points. Staff and visitors to patients need car-
parking facilities. There is likely to be a point, or points, where the majority of
deliveries are made for the hospital as a whole, it is also desirable to have road access to
all major sections of the hospital, and certainly to any independent buildings that there
may be. This access will facilitate the bringing of heavy items of equipment close to the
point where they are to be installed. It is also necessary for the use of fire engines in the
event of fire in the hospital, and will facilitate the maintenance of the fabric of the
buildings.
In developing the master plan, areas have to be allotted within the site for each major
department of the hospital. These areas should always be large enough to allow for
each department to expand by additional building while remaining properly
connected to the circulation networks. Only if this is done will it be possible for the
hospitalto grow inan orderlymanner.
Certain broad principles for establishing the departmental zones may be set forth. The
parts of the hospital that are most closely linked to the community should be allotted
positionsclosestto themainentrance to thesite.
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These include the outpatient, casualty services and such offices or other facilities as are
needed to provide a base for domiciliary services. Next in order of distance from the
entrance should be a zone allotted to the medical service departments, such as radio
diagnosis and the laboratories. These departments receive a great deal of work
directly from the outpatient department and need to be close to it. Beyond this is the
area allotted for inpatient care. Apart from the areas of the hospital used by the
patients, there is a substantial area required for the housekeeping and domestic
services stores, laundry, kitchens, and boiler house. These departments are best
grouped together around a service yard, to which most of the delivery vehicles will go.
This service area should be independent of, the main hospital entrance. Staff housing,
which will take up a substantial proportion of the site, can best be placed around the
perimeter,to give the staff easy accessto roadsandpublictransport.
The considerations set out above will need to be related to the nature of the site. In
many climates the orientation of buildings in relation to sunlight or to the prevailing
breeze will determine many aspects of the master plan. Many sites are sloping, and
thismay providebothdifficultiesandopportunitiesin planning
The first requirement in providing for growth and change is room for expansion in the
master plan, but there are other factors that need consideration. The master plan can
develop in the form of (1) A very concentrated building, making use, where necessary,
of multi-storey blocks; (2) Or it can be comparatively loose, occupying more area on
thegroundand employing lowerbuildings.
The former approach will lead to a hospital, which is compact and in which the
distance from point to point within the hospital is minimized. There are many
advantagesin acompacthospital,
(1) Itsavesthe timeofthe staff,
(2) It helps to promote collaboration by making it easy for members of the staff to
meetone another.
(3) But the more the hospital is planned as a single, massive block, the more difficult
willit be to make effectiveprovisionforgrowth andchange
(4) The concentration of all departments close to one another means that only a very
little spaceis available foreachto expand
(5) Further concentration makes it inevitable that the buildings go up to a fair
Planningfor Growth andChange

number of storeys; and to add to a department on the fourth or fifth floor of a block is
always difficult, and sometimes impossible. If such a department needs to be
extended,it means taking over space from some adjoining department above or
below it. This will involve massive redistribution and reorganization of many
departments. It is therefore necessary to weigh very carefully the advantages and
disadvantagesofconcentratedversusdiffusetypes ofstructure.
The principal factor in the decision will be the prediction of the amount of change and
growth likely to occur. It may be that some sacrifice in concentration during the early
years of the hospital's life will be justified in the interests of allowing for future growth
and change. The preparation of a master plan at an early stage will being this
consideration forward and enable the advantages to be weighed and a rational
decisionto be reached.
It is essential to consider which parts of the hospital are most likely to require room for
growth and whicharerelatively static.
The increase in cases coming into the hospital results directly from the increase in
motor traffic, and sometimes from mechanization in industry; and there seems no
reason to suppose that further development in these directions will not cause
continuedincreasein casualty rates.
The medical service departments, particularly the radio-diagnostic service and the
laboratories, will generally need to be extended. The demand for these services by the
clinical staff is continually increasing as new methods of diagnosis and treatment
become available. Therefore, these departments should be planned to allow for
substantial growth and should, if possible be at ground level, or in two-storey
buildings.
The accommodation for in-patients may, as the services required on each in-patient
floor can be conveniently and economically designed to run up and down in a vertical
building, e.g., lifts can be planned to deliver food trolleys to the ward pantries of every
floor. The lavatories, bathrooms and sanitary rooms can be replaced one above the
other,making useofvertical ductsforplumbing services.
It may not be necessary to increase the total amount of in-patient accommodation
within a hospital. It will almost certainly be necessary to redistribute the
accommodation among the different clinical departments, whose relative
requirements for beds are likely to change within the life of the building. This can best
be provided for by having on each floor a single, general- purpose arrangement,
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capable of taking any category or patient; then, shifting a user from, say, medicine to
surgery on a particular floor will not involve any structural change. Certain in-patient
accommodation - for children, maternity, infectious diseases, and psychiatry will
require special planning, As a result, the in-patient accommodation for these services
may best be plannedasseparate wings apart fromthe mainblock.
This is important criteria in country like India wherein there is diverse climate as we
move from North to South and East to West. In certain climates, building have to be
heated in winter or cooled in summer; and, in some areas, buildings may need both
heating and cooling, at different times of the year. Wherever this is the case,
concentrating the buildings as much as possible can reduce running costs. The more
spread out the hospital, the larger is the surface available for heat loss or heat gain and
the more expensive is the maintenance by artificial means of the desired internal
conditions.
The expense of cooling by air- conditioning is very great, far exceeding that of heating
in most climates. Therefore, wherever air- conditioning is deemed to be necessary, the
building should be designed in as compact a manner as possible. The cooling costs will
be directly proportional to the volume of the building, so the volume should be kept
down by the use of low ceiling and by restricting the size of rooms to the absolute
minimum. It is of vital importance that the decision should be taken at an early stage as
to whether cooling by air- conditioning is required, as the whole design of the building
will be affected by this decision. When in a hot climate it is concluded that air-
conditioning is unnecessary or impracticable, the design of the building must be
carefully considered in order to get the maximum natural cooling. In hot climates, air-
conditioning will always be needed for operating theatres and, very often, for recovery
wards,labor rooms,X- rayrooms,andotherspecialareas.
There has been considerable research on the design of buildings for various tropical
conditions, and the results are available in the form of recommendations. It is worth
noting that the design of a building for comfort in a hot, humid climate is totally
different from that in a hot, dry climate. Broadly speaking, in the former air movement
past the body is the main objective. The buildings should be light and open and
planned so that even the slightest breeze can pass right through the buildings at low
level to cool the occupants. It is impossible to plan highly concentrated hospitals for
use in hot, humid climates without recourse to air- conditioning. In hot, dry climates,
the nights are cool, and the object of the building design is to protect the occupants
ConsiderationsBasedon Climate

from the fierce heat during the day. Buildings in these climates are therefore massive,
with heavy walls and small windows. The heavy walls absorb the daytime heat and
dissipate it at night. The small windows keep the amount of radiation entering the
buildingto a minimum.
In developing the master plan, attention must be given to the relation of building to
each other with regard to sunlight and shade. In cool climates, where sunlight is
desirable, buildings should not be planned so as to cut off one another's light. In hot
climates, the buildings can be planned to shade each other to some extent. The shadows
cast by the sun can be studied by means of models on a device known as the heliodon,
which simulates the movement of the sun. Architects concerned with the building of
hospitals in tropical climates should take care to familiarize themselves with the great
massofvaluable informationnowavailable on designfor comfort.
In temperate climates, where the winters are not very long or very severe, it will not be
necessary to give great weight to the problem of heating in relation to the general plan
of the hospital, which can be designed primarily with other considerations in mind. But
in climates of extreme cold and long winters, where the cost of heating is heavy, some
thought should be given to making sure that the general plan results in a reasonably
compactbuilding.
The methods used for heating and ventilation of the hospital are important, as bad
design can increase the risks of cross-infection.Massive ventilation is very
advantageous in reducing this risk. In warm climates, massive natural ventilation is
easily obtained and is desirable, for comfort. It will therefore be wise to rely, in hot
climates, on natural ventilation as much as possible and to have recourse to air-
conditioningonly underextreme conditions.
In cold climates, the ventilation of hospitals during the winter presents difficulties, as
sufficient ventilation is apt to cause undue cooling by the introduction of cold air from
the outside. Any proposal for artificial ventilation or air-conditioning in hospital
buildings must, therefore, be submitted to expert bacteriological criticism before
adoption.
Certain areas of the hospital must always be provided with artificial ventilation or air-
conditioning. These include the operating theatres and any other areas where open
wounds are exposed to the air. These areas must be ventilated by special means to give
a high degree of air hygiene. The design of a ventilating plant for these purposes is
highly specialized,andmustbe entrusted to anexpert.
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LightandColor
VisualImpact of theHospital
Windows light most hospitals. It is important that patients lying in bed should not be
exposed to too large an area of sky in direct view through the windows. Control of
glare from windows requires great care in design, and various special arrangements
have been proposed for this purpose. It is therefore important for the architect to
consider the design of the windows in the light of criteria that are now known to be
goodforhospitalpurposes.
Criteria for the artificial lighting of hospitals by night have also now been established.
A note of caution is in order with regard to fluorescent lights: these may give rise to
difficulty for doctors and nurses who have to assess a patient's condition partly by
referencetohis skincolor.
Emergency arrangements for providing artificial lighting by a stand-by plant, in the
eventofa failureofelectric powerfromthemainsource,are alwaysessential.
The color used internally on the walls, ceiling, and floors of a hospital is an integral part
of the design of the building and should be determined by the architect. The general
lighting of a room is greatly affected by the color scheme, and it is necessary for the
colorsto be consideredsimultaneouslywith the designof the windowsif the best effect
is to be achieved. Color can make all the difference between a depressing or
disquieting atmosphere and a restful or a pleasantly stimulating one. There now exists
aninternational colornotation, andcolorscanbe specifiedin relation to this.
Hospital buildings are very large. As the hospital is very often set in a residential area
among buildings of a domestic scale and character, the contrast between its size and
thesmall,scatteredhousesaroundit may be very violent.
Consideration of planning for growth and change tends to soften the visual impact of
the hospital. The parts of it that form its front door or shop windows are the buildings
for outpatient care, reception, and emergency care. These will almost certainly be
located nearest to the entrance to the site, and may very well be planned as
comparativelylow buildings,in theinterests offuture growth andflexibility.
The architectural handling of the design will also affect the visual impact of the
hospital. The architect has the opportunity, in planning the hospital, to give visual
expression to the human units of which the hospital is composed, or to suppress these
divisions in the interests of uniformity. For instance, in designing a ward building, he

could allow each nursing unit individual expression on the façade of the building; or by
giving each unit an identical series of windows, he could carry uniform architectural
treatment overthewhole.
More than a third of the cost of hospital building goes into the mechanical engineering
services heating and ventilating, electricity, lifts, and communications. These services
form the circulation and nervous systems without which the hospital cannot function.
Therefore, the contribution of engineers to the design is of capital importance. Their
help will be needed at an early stage, when the approximate demand for water, electric
power, fuel, gas, and sewerage is being estimated. Their advice will be needed on the
choice of site and on the master plan for the hospital. Later, they will have to design
systemsofheating andventilation, liftsandtelephonicandothercommunications.
Engineers will have to concern themselves with the installation of all the mechanical
equipment also with its subsequent maintenance. They should advise the hospital
authority on maintenance problems at a very early stage in the design. They should
advise against the installation of any machinery or equipment for which maintenance
arrangements cannot be guaranteed. Decisions on these matters may affect the master
planof thehospital,andthey shouldbe consideredat anearly stage.
The engineers must also collaborate with and advise the architect on the space that will
be needed in the building to house the mechanical services. This space must be of
sufficient size to allow not just for present services, but also for any future services that
may be required. The mechanical services must be planned so that easy access can be
obtained to all equipment for repairs and maintenance without disruption of the daily
function of the hospital. Provision must be made for stand-by power in the event of a
general powerfailureat themainsource.
All these considerations point to the fact that a modern hospital can be built and
operated only if the town in which it is located is sufficiently well equipped with
electric power, potable water, sewers, and other technical infrastructures. In addition,
competent personnel must be available to maintain the mechanical and electrical
equipment; and spare parts and other essentials for repair must be obtainable. All
these resources must be fully developed and at the disposal of other institutions as well
as the hospital; it would be unrealistic to think that an isolated and self-supporting
hospitalcouldbear the costofsuchtechnicalservicesonly for itself.
HospitalEngineering
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HospitalHygiene
Another important factor is hospital design is the special attention that must be given
to conditions of hygiene. Hospitals exist to treat illness, and often act as reservoirs of
infections. Surveys have found that a substantial proportion of patients acquire
infections during their stay in hospital. The cost of extra patient-days in hospitals as a
result of cross-infection, bears heavily on the patients, sickness insurance and on the
national health budget. It is therefore essential to take reasonable precaution in the
designand organizationofhospitalsto minimizethe riskof infection.
In addition to the risk to patients and staff, hospitals can also prove a danger to the
community if the arrangements for waste disposal are inadequate. The hospital's
sewage may contain dangerous organisms. Outbreaks of typhoid have been traced
back to pollution of the water supply by hospital effluents. The approval of health
authorities should be sought with regard to hospital sewerage and disposal
installations.
Introduction of antibiotic drugs substantially reduced the dangers of infection within
the hospital. As a result, many precautions in the design of the buildings and in the
methods of work by the hospital staff were abandoned or neglected. Strains,
particularly of Staphylococcus, have developed resistance to nearly all antibiotics
known at the present time. These resistant organisms tend to establish themselves in
hospitals, hospitals, whose staff often become carriers. It is therefore, more necessary
than everto pay the strictestattention to allavailable methodsofcontrolofinfections.
The first line of defense must be appropriate training of all staff in correct methods of
work. Staff must be trained in aseptic techniques for use in all surgical procedures and
in “barrier” nursing of infectious patients. It may be extremely useful to secure the
permanent advice of a technician with an engineering background in order to control
and periodically survey all the vulnerable points of the hospital, such as sewers,
drains, faucets, lavatories, sinks, and so forth. The design of the buildings can also do a
great dealto facilitate safeworking by thestaff.
One of the most important matters in planning a hospital is to consider the disposal
routes of all waste and infected material. In every part of the hospital where patients
are treated, there will be infected material to be disposed of. In wards there will be the
patients' bedding and infected utensils, and other waste material of various kinds.
Operating rooms and surgical treatment areas will have infected dressings, dirty
instruments, and soiled linen to dispose of. In principle, it should be possible to take

infected material away from its point of use without contact with any clean supplies
coming into the unit and with minimum handling by hospital personnel. In the
nursing units, soiled linen should preferably be taken immediately from the patient's
room to a disposal room, from which a lift or other special route is available to a
reception point where the linen can be sterilized or otherwise dealt with to make it safe.
Dirty materials should, in general, go into a bin, bag, or other disposal container at its
point of origin and remain in that container until it reaches a point at which it is
sterilizedorincinerated.
It has been demonstrated that chutes are to be avoided at any cost, because they cannot
be cleaned and disinfected.Moreover, because of the possible difference in
atmospheric pressure between the upper floors and the basement, clouds of dust can
circulate through the chutes. Small lifts or vertical conveyors of the “dumb-waiter”
type shouldreplacechutes.
It should noted that under no circumstances should nurses or other persons concerned
with the care of patients be required to sort or count soiled linen. The disposal route
from the wash-up room serving the operating theatre should be direct to the central
sterilizing department, and should not pass through the operating room or any other
roomin the operating suite.
Blankets used on patients' beds are a special problem, as the wool blankets
traditionally used cannot be sterilized or laundered without becoming felted and
rapidly destroyed. Therefore, it is preferable to use blankets of cotton or other material
that can be boiled.
Cleaning methods can help or hinder hygiene. Sweeping and dusting as traditionally
performed are dangerous. They spread dust in the air and raise the bacterial count.
Wet cleaning by approved methods and vacuum cleaning by approved types of
machinewithspecialfiltersmust be themethodsadopted.
Surgical instruments and bowls have, until fairly recently, been sterilized in boiling-
water sterilizers at various points in the hospital; and dressings have traditionally been
sterilized in drums in autoclaves. These methods have not proved adequate however,
and in recent years this type of sterilization has given place to sterilization in a central
department serving the whole hospital. It is recommended that new hospitals should
be planned, from the start, with facilities for central sterilization. Under this system,
all objects that require sterilization are supplied in sealed packages from the central
department to the point of use. After use, non-disposable items are returned to the
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central sterilizing department for re-sterilization. In recent years many newdisposable
articles of equipment (e.g. syringes and needles, surgical bowls, and sputum mugs)
have come on the market. It may be found more economical to use these items than to
incurthecostofcleaning andre-sterilizing theconventionalequipmentafter eachuse.
The planning and operation of the central sterile supply service require exper technical
advice. However, several authoritative reports that give guidance on the subject are
available. It should be noted that the adoption of a central sterile supply service, which
has gained favor on grounds of improved safety may have economic advantages as
well. It affects the planning of the hospital radically, inasmuch as it eliminates the need
to provide sterilization facilities in the nursing units, outpatient and casualty
departments, and many other points within the hospital. In addition, this type of
sterilization avoidsthe damageto paint that sterilization with boiling watercauses.
Many surgeons like to have their own individual sets of instruments. It is more
convenient to arrange for these to be sterilized in a room adjoining the operating room.
All other requirements for operations, including dressings, bowls, syringes, and so
forth, canbe suppliedto the operating roomfromthe centralsterilizing department.
In planning operating rooms and treatment areas generally, it is of vital importance to
separate clean and dirty areas and to ensure that clean material goes directly to its point
of use without coming into contact with any used material or with personnel
concernedwith thehandling ofusedmaterial.
Proper techniques by staff and effective sterilization of instruments, bowls, and
dressings will combat infection arising from contact. Many infections are air borne,
and air hygiene is a vital part of hospital design. Air-borne organisms through the
mouth and nose may infect patients and staff. Open wounds are particularly subject to
infection from air-borne organisms. Hence, air hygiene must be considered as affecting
the atmosphere in the hospital as a whole, and particular regard must be paid to it in
operating roomsand treatment areasin whichopenwoundsare exposedtothe air.
So far as the general areas of the hospital are concerned, it is important to ensure a good
general rate of ventilation, and standards have been established for this purpose. It
should be noted, in addition, that isolation rooms should be provided with special
ventilation arrangements to ensure that contaminated air from them does not reach
other parts of the hospital. The ventilation of operating rooms is a highly technical
matter on which important research has recently been conducted; it is now possible to
specify with considerable exactitude the requirements for the special ventilating

system needed in operating rooms. Such systems need very careful design by
engineers,andshouldbe subjectedto bacteriologicalcontrol.
When hospital sewage is not passed into the public sewage disposal system, it requires
treatment by an effective disposal plant kept under continuous bacteriological control.
All hospital drains, including those from washbasins and baths, must be fully enclosed.
A central incinerator should be provided in which all infected material is destroyed.
Opportunities should be taken whenever possible to use disposable materials, which
canbe destroyed.
The next stage in an actual project would be the preparation of the architect's brief. At
this point it is necessary to go into the needs of every service and department
individually and in great detail, always bearing in mind the general principles
governing theplan asawhole.
It is necessary to consider, first, the function and organization of each section, whether it
is the surgical service or the catering department. It is essential to decide on controlling
principles and to reach decisions on methods of working before attempting to draw up
schedules of rooms. At this stage advice should be sought from people with practical
experience in the running of the various services. It is important, however, to pose
problems in a general form to these advisers and to press them to think afresh to
consider not only how they have organized their work in the past, but also how they
would organize it for better service to patients, or for greater efficiency, if free to think
things out from first principles. Unless care is taken at this point, there is a risk that the
architect'sbrief willreflect, with minorimprovements.
It is of the utmost importance in planning a hospital that a large measure of imaginative
foresight should be brought to bear in an endeavor to identify the probable growing
points and to plan the greatest degree of adaptability in those services that seem most
likely to expand.
TheArchitect's Brief
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STEPS INVOLVED IN
HOSPITAL DESIGN
CHAPTER 5
PlanningtheGrid
'Grid' is defined by Merriam-Webster's Collegiate Dictionary as: “a network of
uniformly spaced horizontal and perpendicular lines (as for locating points on a map);
also:somethingresembling sucha network.”
A planning grid is an architectural design tool which is “something resembling such a
network.”
Healthcare designerscanderivetheir planning gridsin oneofthe twofollowing ways:
1. In urban situations, where the hospital takes the form of a vertical building
comprising of a podium containing diagnostic / therapeutic and interventional
services and a tower housing the inpatient facilities, the planning grid is determined by
the layout of the inpatient tower. The module(s) used to determine the shape and size
of this grid is the module(s) used to house the various kinds of inpatient facilities
(rooms + toilets) conceptualized by the designer. In the example given below you can
see how the planning grid modules (in red) of 3.90 M x 8.50 M is determined by the
accommodation desired for a single bed patient room, a double bed patient room and
their toilets.

Expanding on this with the addition of the access corridor and stringing the rooms out
in a line, as in the plan below, we see how the planning grid starts taking the form of the
“network of uniformly spaced…lines” we started with. Looking more closely at this
plan we can see something important has been added, namely, the positions of the
columns that will support the building. We can thus see how the structural grid, the
network of lines defining the location of columns, has been derived from the planning
grid. The structural grid need not necessarily be the same as the planning grid, but is
alwaysderivedfromit.
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The positions of the structural columns determined by this planning grid, twisted or
otherwise, will continue downwards through the rest of the hospital, through the
lower floors (the podium mentioned above) till their respective foundations, where
they will transfer their load to the ground below. Hence the lower floors (the podium),
which will contain the Operation Theater Suite, the Radiology and Imaging Sciences
Department, the Main Kitchen and the Mechanical Areas in the basement, to name just
a few, will all need to be designed within the constraints of these column positions.
Extrapolating from here, we can see how the façade of the hospital will need to be
designed in harmony with the windows of the inpatient rooms above, which will be
designed with the use of the planning grid. Even if the podium extends beyond the
footprint of the tower above, it is almost certain that the positions of the additional
columns required would be derived from the structural grid used for the tower, which
hasbeenderivedfromtheplanning grid determinedby inpatient facility design.
2. In semi-urban or rural situations, where the land available is very likely to be larger
with respect to the built-up area desired, determining the planning grid is another
ballgame, onewith muchgreater flexibility inthe rules.
In this situation, the planning grid will be determined by what designers call as their
'concept' for the hospital. This 'concept' is also an ordering tool, and will have been
used to determine the form of the hospital in even the previous example of the urban
site, but with less freedom. When there is a lot of land available, it gives the architect
more elbowroom, and his hand is likely to move with more (hopefully graceful)
abandon.Thisfreedomenables manydifferent types ofbuilding layout and form.
The thought process behind design can be described as a process of analysis and
synthesis or divergent and convergent thinking. That is, a 'parting' followed by a
'meeting' of thought within their minds. At the point of separation, the designer throws
up a whole lot of different ways in which he could define an ordering principle that he
would use to design the hospital. Suffice it to say for now that based on his / her chosen
criteria the architect will (converge) select one or a combination of concepts to provide
theorderingprinciple.
The focus of our discussion here, the 'planning grid', in this situation gets relegated to
an almost incidental design tool, subject to great local variation if the structure is single
storied, and might vary substantially even if the hospital is partially high rise and
Invertically organized healthcarefacilities,wedesignfrom the topdown.

partially low rise, as the two forms of building could have planning grids independent
of each other. Façade design might also vary greatly, there being less discipline to be
followed.
Another important design issue in the planning of a hospital is the layout of the major
circulationpaths.
Hospitals, like the small cities they are likened to, contain main circulation routes often
described as hospital streets. The way in which the different parts of the hospital are
assembled, as a coherent whole but with the parts differentiated, make for analogies
with urban design; the way in which traffic moves, and the routes that are taken by
mechanicaland electricalservicesare fundamentalgenerators oftheplan.
In a vertically stacked hospital, which could also be called a functionally stratified
hospital, almost always the inpatient areas are placed on the upper floors, to allow for a
more pleasant, naturally lit environment. As we read in an earlier lecture (entitled
“The Planning Grid”), the planning grid is determined by the layout of these inpatient
floors. Another important planning feature, the vertical circulation core, is also to some
extent located within the building by the layout of the inpatient floors. We somewhat
simplistically claimed in that earlier lecture that in vertically organized hospitals we
design “from the top down.” What we actually do is during the layout of the inpatient
floors, we provisionally decide on a position for the vertical circulation core and other
staircases that may be required, many times by the local building codes. This location,
however, is to be checked for it's design impact on the lower floors containing the
diagnostic / therapeutic / interventional departments. This 'checking' process is
described by the diagram of the design process presented in the self-same earlier
lecture.
The pattern of circulation conceptualized for the hospital under design will be
considerablyimpactedby the location(s)ofthevertical circulationcore(s).
The vertical circulation core is the center, the focus of all the major circulation paths of
the hospital. An attempt can be made through design to minimize vertical
Different parts of the hospital may have different planning grids derived from the
functionalplanningrequirementsof thehospitaldepartmentsthey house.
Circulation :
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transportation by siting (for example) all surgical beds, operating theatres and the
intensive care unit on the same floor. This design approach may be used as a
justification to reduce the number of elevators, or the width of the staircases, but in no
way doesthismean that thecorecanbe locatedmorecasuallyby the designer.
Avoidance of dependence on lifts is particularly important in places where
maintenance and availability of spare parts is unreliable; long waits for lifts are a major
cause of inefficiency and frustration to hospital users more of a problem the taller the
buildingis.
It is important that patients, visitors and staff be able to orient themselves while
moving through the hospital by providing windows in corridors to enable them to
look out and to allow natural light in, important in alleviating the tedium of long
corridors.Ifthe site enablesthem, courtyardsare alsoan excellentmeansto thisend.
As such there is no easily available prescription for the way the circulation pattern for a
healthcare facility should be. The qualities it should possess, however, I will try to
enumerate:
1. It should have conceptual clarity. By this I mean it should be designed with
purpose, and should not be leftover space or squeezed into the gaps between
other areas. Geometry can be a recourse, but it should work with
other planning imperatives, and junctions should be uniquely treated to avoid
confusionoverwhichcornerofthe hexagon (forexample)you havereached.
2. It should not be boring. Try to make walking from one place to another interesting,
modulate those corridors, color them differently, hang artwork along the way.
Niches,outsideviews,courtyards,allthesewillhelp.
3. It should enable way finding. In combination with well-designed signage and
maybe super-graphics, people should be able to find their way to their destination
with ease.Color-codingfor floorsordepartmentsis sometimesused.
4. They should be wide enough to handle anticipated traffic. Stretcher traffic needs
8'- 0” width of corridor for easy movement (turning). 7'-0” will work, but use 8'-0”
if you can. Corridors between Operation Theaters make sense even with 10'-0”
width. There may be a lot of stuff parked along the sides, despite instructions to
OT staff to thecontrary.

5. They should be indirectly lit. Patients on stretchers get to look at the ceilings. The
sign put up by the traffic police at the end of Marine Drive in Mumbai says, “Drive
carefully. Hospital ceilings are boring.” While not advocating rash driving, we
wouldadvocatemaking the ceilingsinteresting.
Some of the hospitals currently existing in India have been provided with ramps in
addition to the usual elevators and stairs. Power cuts are realities that have to be
considered. But consider putting some (two) of the elevators on a generator, if this
helps in avoiding the ramp, which is wasteful of space and difficult to use, as the
gradient is often excessive. (With an acceptable gradient, the length becomes excessive,
considering that the lower floors of hospitals are considerably higher than those of the
usual non-hospitalbuilding.)
When planning for the area occupied by this circulation space (corridors) in the
architectural space plan, it can be provided for as a percentage of the department area
(usable, built-up area). This percentage will vary depending on the department and
may also vary if the architect has any special feature in mind for that department which
is not explicitly provided for in the room-by-room area statement (such as semi-
covered, landscaped waiting). The percentage can vary from 35% for an Operation
Theater Suite(with8'-0”corridors)to 20 25%forthe AdministrationDepartment.
On the Inpatient floors or even in the Outpatient Department, these corridors can be
modulated by recessing pairs of doors that occur at regular intervals, and using an
accent color in the niche so created. This helps relieve the boredom of walking through
long, uninteresting corridors.
Very frequently the major circulation paths through the hospital are laid out even
before the tentative space allocation for the hospital departments is done. Thus, the
importance of conceptualizing these paths in a way that they contribute to the concept
and functional layout of the hospital is not to be underestimated, the exercise should
not be donecasually.
Frequently the manner in which the healthcare architect conceptualizes the working
(and therefore layout) of certain hospital departments, notably the Operation Theater
Suite and the Radiology & Imaging Sciences Department (as described in a later lecture
titled “The Architecture of Imaging”) will determine the circulation pattern through
that department, and hence affect the layout of circulation paths in contiguous areas of
the hospital.
Defining major circulation paths through the proposed and future buildings is a
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design decision that will considerably impact the form, layout and thus the eventual
functioningofthe healthcare facility being designed.
Identifying and understanding the conditions which constitute barriers to those with a
disability (this category includes, besides the wheelchair bound, those who for any
reason have difficulty in walking, and also those with a sensory that is, visual or
hearing impairment) is a fundamental requirement for the effective provision of
accommodationand facilitiesto be usedby disabledpeople.
If the needs of people who have temporary or permanent disabilities are taken into
consideration, the resulting design can make the design easier and safer to use for
those with children, those using wheeled equipment and those carrying other items.
The principle of applying critical criteria should be used for example, where space is a
consideration, wheelchairs or other larger wheeled items need to be considered; for
vertical fixtures or fittings, the shorter person and wheelchair user must be considered;
and for wayfinding those with visual and hearing impairments must be considered.
The resulting design will help not only people who are ill or disabled but also those
who are suffering from shock or stress, as many users of health buildings are. Building
design that gives consideration to all users will also be easier and safer during an
emergencyevacuation.
The best design philosophy is to consider the journey through the healthcare facility
from start to finish, analyzing all the related components of the task (negotiating
entrances, corridors, lifts, reception areas, toilets, etc) to ensure that the features,
equipment and fittings encountered in completing the journey are suitably designed
so that the overall task can be completed easily and conveniently, bearing in mind the
different requirements of staff, patients and visitors with varying degrees of functional
mobility. In this way building users will be more independent (less reliant upon staff)
andconsequently lessstressed,anxiousandfrustrated.
People with disabilities can be defined as those who, as a consequence of an
impairment, may be restricted or inconvenienced in their access to, and use of,
buildings because of the physical barriers such as doors that are too narrow, flights of
steps, or unsuitable facilities (for example inadequate lighting, or lack of handrails on
staircases or grab-rails in toilets.) Some people will be temporarily disabled as a result
oftheir need forhospitaltreatment.
SpecialConsiderationsfor Designingfor the Disabled

Thefollowingcategoriesofbuilding userare generally recognized:
1. : persons who are fully physically capable of carrying out all
activities necessaryto their roleorfunction.
2. : persons who walk with difficulty or are otherwise insecure, as a
result of a temporary or permanent impairment of the lower limbs. They may walk
with or without a walking stick (sticks, crutches, walking-frames, etc) and/or
require the assistance of another ambulant person. Some people in this category
will, in addition, have reduced strength and dexterity in the upper body and/or a
sensory impairment. Semi-ambulant people find it difficult to cover long distances
(even 50 M may be too far). Specific design requirements include: short distances;
provision of handrails and suitable spaces for taking a rest; and even non-slippery
surfaceswithout any changesin level;
3. Non-ambulant : persons who temporarily or permanently require to use a
wheelchair for mobility. They may propel themselves, or be pushed and
maneuvered by an assistant who may or may not be needed to assist with other
tasks. Some people will be using a wheelchair for the first time due to being in
hospital and will be unfamiliar with maneuvering it. Some people who use
wheelchairs will, in addition, have reduced strength and dexterity in the upper
body and/or may also have sensory impairment. Some will be able to stand on
their feet whilst transferring to and from a wheelchair or to and from other facilities
(such as a toilet, chair, or bed); others will require assistance to do so (in some cases
the useofahoist). Specificdesign requirements include the provision of sufficient
space for passing and turning; even surfaces without changes in level; and
ensuring that any counters, signs, handles, etc are within the user's range of vision
and grasp.
4. Manually-impaired : persons who have a temporary or permanent lack of strength
and/or dexterity in the shoulders, arms and/or hands. They may also be semi-
ambulant and/or have a sensory impairment. Specific design requirements
includedoorswhicharenot tooheavy, suitably designedhandrailsand control,etc.
5. Visually-impaired : persons who are totally blind or partially sighted. Blind people
find their way by noticing changes in the textures of floor or wall surfaces and
ambient sounds and smells; some also need the help of a cane for orientation and
detecting obstacles. Partially-sighted people need plenty of light and the colors of
Fully-ambulant
Semi-ambulant
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any fixtures or fittings they are trying to locate (or are on their guard against) must
stand out plainly in contrast to the background. It must be remembered that vision
deteriorates considerably with age. 40-year-olds need twice as much light and 60-
year-olds three times as much light to see the same object as clearly as a 20-year old.
The more strongly an object contrasts with its surroundings, the easier it is to see.
However, colors do not have to be garish; subtle changes in color can be
aesthetically pleasing, and can fit in with the general décor as well as providing
contrast.Different colors in the same tone can appear very similar to people who
are color-blind for example, a strong red and green together can look much the
same and so, contrasting tones, or a combination of tone and color, are very helpful
for people with poor sight. Any type of cluttered design should be avoided, for this
makes it more difficult for a visually-impaired person to “read” the shape of a
space,and consequently impedes their ability to navigate. Good design therefore
shouldnot only contribute towards the legibility of a building, but also facilitate
easy navigation through it. Specific design requirements include: a simple, well-
planned layout even surfaces with tactile indications of direction; no obstructions
in walking areas; well-lit areas; signs placed at a convenient height, with space to
stand in frontto readthem.
6. Hearing-impaired: persons who are deaf and hard of hearing have the additional
problem that their disability cannot be seen and is therefore not noticed by other
people. For effective lip-reading, building areas must be well lit in order that the
face of the person speaking is illuminated. Specific design requirements include: a
simple, well-planned layout with well-lit areas; surfaces which dampen ambient
noise, signs placed at a convenient height, with space to stand in front; provision of
inductionloopsat receptionareasandin auditoria.
A check-list giving a suggested sequence of activities to be followed in the planning
anddesign ofaccessandfacilitiesfordisabledpeopleis given below:
1. Are there parking spaces adjacent to the buildings to minimize the distances to be
traveled?
HealthcarePremises:
Checklistof AccessandFacilitiesfor DisabledPeople
Parking :

2. Is the parking spaces wide enough to allow a car door to open fully to allow
unobstructedtransfer intoawheelchair, either unassistedorassisted?
3. Is the location of the disabled parking spaces such that the approach route to the
building / facility is not obstructed by other parked cars and away from moving
traffic?
4. Arekerbsand otherchangesof levelramped?
5. Isthe parking spaceand accessrouteundercover?
6. Are there adequate signs to identify the reserved parking spaces and the best
routesinto thepremises?
7. Isthe approachroutesmooth,slip resistant(whether wet ordry), freefrom
incidentalobstructionsorhazards?
8. Are handrails provided on all slopes and resting places provided at intervals
wherea ramporapproachislong?
9. Areallpublicentrancesto the building/ facility accessible?
10. Areaccessdoorswideenough tofacilitate wheelchairmovement?
11. Arethresholdseliminatedorkept to aminimum?
12. Dodoorcharacteristicsanddimensionsofrelated spacesallowit to beopened
(andclosed)easily by independentwheelchair users,movingin either direction?
13. Whatdoorscanbe eliminated?
14. Are lobby sized adequate and safe for both independent and assisted wheelchair
use?
15. Are corridor and approach routes satisfactory? Do they allow passing and
turning andtake adequate accountofcorridortraffic conditions?
Approachto Building:
Internal Circulation :
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16. Haveallobstructionsand projectionsfromwalls(or ceiling)orsimilarhazardsat
floorlevel suchaschangesoflevel been avoided?Ifunavoidableare they clearly
discernible?
17. Areinternal doorwidthsadequate to allowturning through 90 fromthe corridor
orlobby? Shouldeither ofboth be increased?
18. Have safety handrails been provided on corridors, ramps, and steps or at other
pointswhere they arerequired by personswithimpairedmobility? Havethey
been producedwherethey usedaslocationaidsby visuallyimpaired people?
19. Are any large areas of glass close to circulation areas marked or framed so as to be
clearlydiscernibleto partially sighted people?
20. Are seats available at intervals to permit an ambulant disabled and elderly
personto take a shortrest whenfacedwith long corridorsto negotiate?
21. Are staircases safe and optimally comfortable for elderly and disabled people?
Arehandrailand landingcharacteristicssatisfactory?
22. Areliftsavailable, conveniently placed,accessibleandclearly signed?
23. Are lift controls accessible to the independent wheelchair user? Are the visual
and audible signals, alarms and floor designations satisfactory? Are digits
embossedandsatisfactoryfor blindorpartially sighted persons?Istherea
24. Are there correctly designed unisex toilets, that are where a husband and wife
may enterthe cubicletogether, available in the publicareasofthe premises?
25. Are there suitable cubicles for wheelchair users in other male and female toilets
in thebuilding?
26. Do cubicles for wheelchair users provide adequate maneuvering space within,
areturning spaceprovidedoutside?Isthelevel ofprivacyaffordedsatisfactory?
27. Are there cubicles available with appropriate grab rails for the use of ambulant
disabledpeople?
0
VerticalCirculation :
Toilets :

28. Are the WC and washbasin arrangements accessible to independent wheelchair
users? Are the grab rails, mirrors, towels, door closing bars and other aids placed
satisfactorily?
29. Can ambulance discharge patients under cover within close proximity to the
entrance? Are waiting areas protected from draughts as patients move in and out
through the entrance doors? Can patients using wheelchairs (their own or
hospital chairs) whilst waiting for treatment, sit with other patients without
obstructing the corridorsorcirculationarea?
30. Canpatients in wheelchairsusethe receptiondesk convenientlyandprivately?
31. Areallconsultingand treatment areasfully accessible?
32. Are there changing cubicles suitable of wheelchair users, with room for
assistanceto be given ifrequired?
33. Arerefreshmentareasaccessibleto disabledpeople?
34. Areclear,well lit, signspostedto ensureeasy circulationwithin thebuilding?
35. Are telephones and other public mechanisms accessible to wheelchairs users?
Are knobs, dials, switches, handles and other controls operable and within
convenientreach?
36. Do sanitary facilities offer maximum independence and privacy to disabled
patients, both those who will be using wheelchairs and those who have walking
difficulties?
37. Is the day room accessible, with a variety of seating heights to help ambulant
disabledpeople?Areall noticeseasy to seeandunderstand?
38. Are window controls, radio and television and call bells easily reached by
disabledpatients?
OutpatientAndTreatment Areas :
Ward Facilities:
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39. Can disabled visitors conduct private conversations with their friends in bed or
in the ward?
40. Could disabled employees work in the building with particular reference to
offices,laboratories,canteen,rest roomsand toilet facilities?
41. Areemergency evacuationroutesand emergencyexits satisfactory?
42. Arefire alarmsreadilyaccessibleto thesemi-ambulantandwheelchair disabled?
Areemergency callfacilitiesinstalledto summonassistanceto removelocations?
43. Areaudiovisualalarmsignalsprovided?
Hospitals should take the lead in providing disabled-friendly access to themselves as
well as wayfinding. Use the above checklist to make any facility you are planning easy
toenter and useby thedisabled.
Another important design issue in hospital planning is the need to design for
flexibility.
'Flexible' is defined by Merriam-Webster's Collegiate Dictionary as: “Characterized by
aready capacityto adapt tonew, different orchangingrequirements.”
Flexibility, as an architectural principle applied to the design of a hospital, would be
the inbuilt capacity of that hospital to adapt itself to “new, different or changing
requirements.”
John Weeks, the first architect in Britain to fully grasp the need for this flexibility in the
design of hospitals, made the then revolutionary point that ' user studies of function
are by themselves not a sound basis for hospital design. Functions change so rapidly
that designers should no longer aim for an optimum fit between building and function.
The real requirement is to design a building that will inhibit change of function least,
andnot onethat will fit specificfunctionbest.'
At Northwick park hospital, London, he designed a 'hospital street' along which were
placed blocks of buildings that could expand at right angles. Both the blocks and the
Otherfeatures :
Designingfor Flexibility

street were openended.Theplansofthe hospitalbelowillustrate this.
Shown above are three plans showing the development method at Northwick park
hospital and clinical research center. A linear hospital street forms the backbone to
which ribs can be attached with relative freedom. It is the earliest example of deliberate
indeterminacy in post-war hospital planning. The hospital and research departments
can be constructed and later altered or expanded, independently of one another.
Construction was carried out in phases over a period of nine years and during this time
extensions and alterations to the original brief were made without disturbing the basic
design.
This design concept proved very influential. However, the hospital sprawled over
dealofland.Thenwhat doneonurban siteswhere landwas ata premium?
An answer to this was the concept of 'universal space': that is, a series of structurally
uninterrupted floors, to which any services such as electricity, gas, water, could be
brought fromabove,andfromwhichallwastescouldbe taken frombelow.
The Greenwich Hospital, UK was the first hospital to have 'interstitial' spaces or
services sub-floors between each hospital floor. This solution is most strongly justified
in hospitals where the climate makes air-conditioning or mechanical ventilation
necessary throughout. The dedicated space for air-conditioning ducts, pipes and
great
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wiring means a greater overall building volume, but the ability to service them without
entering the hospital areas they are sandwiched between is an advantage; full benefits
are only reaped if three-dimensional zoning is maintained, by “reserved rights of
ways” for the various services. Shown below is a section showing 'interstitial' spaces or
servicessub-floors.
This approach makes an important point. Making a building that is adaptable to
changing requirements is largely an issue of providing the necessary building services
required by the changing requirements at the desired point in the existing building. In
India, with our RCC column and beam method of construction, this need impacts the
structural system design for the building in that punctures in the slabs may be
necessary during this change of function and thus the structural system chosen
initially hasto cater to that requirement.
In order to provide for planned expansion it is necessary to develop a master plan that
provides for both short - and long - term expansion and change within the hospital and
throughout the campus. The master plan should establish major paths of circulation
projected through foreseeable phases of new and renovated buildings. The design
concept should contain within it an overall ordering principle for the entire campus,
integrating into thedesign abuilding systemsframework (See:Illustrationbelow).

Source: HospitalsandHealthcare Facilitiesby Redstone
With hospital accreditation by health insurance companies in India being just around
the corner, old hospitals that are too tightly tailored to the needs of initial users will
become obsolete due to the changing standards demanded by these companies, who
are likely to emergeasthe new driversofthehealthcare industry.
Changing market demands, new technology replacing the old at an ever-increasing
rate of change, advances in the science of medicine and changing patterns of disease all
50 SCHC

underline the need to design healthcare buildings for flexibility. The functional,
technical and hence financial success of hospitals thus depends on the ease with which
they can grow and change, and this dependence increases with time. The aesthetic
implications in designing buildings that will expand and change over time also
become an issue. An urban design approach is necessary; an initial building whose
form is symmetrical will tend to look skewed when expansion takes place. The higher
the buildings are, the greater the aesthetic, technical and functional difficulties in
making aworkable addition.
The fact that many hospitals are built in a number of phases further complicates the
problem. There may be a series of replacements of older buildings on an existing site or
limits to the amount of investment possible at any one time. A comprehensive and
firmly established Development Control Plan is essential for a hospital built in phases
to specify thestrategic directionoffollowingphases,but not their detaileddesign.
The issue is complex; it involves a multiplicity of design factors that may be making
contradictory demands on the designer. We suggest you consider the various options
keeping in mind the needs of future generations to whom you will bequeath your
design solutionin its built form.
What does this requirement for flexibility augur for the hospitals to be built in the 21
century?
1. Buildings will be designed to facilitate the docking of mobile and plug-in
modules. It is likely that specialized major diagnostic and diagnostic-surgical
equipment will be manufactured in self-contained pre-constructed modules
intended for docking at strategic points “ports” in the building. Such mountable
and demountable components could be readily downloaded to other facilities
forexample, anex-urban satellite ofthe mainhospital.
2. HVAC systems will be modularized and zoned, with vertical circulation,
mechanical shafts and transport systems moved from the core of the building to
the perimeter in order to create free fields within the core floor plate that are easily
adaptable to different layouts.
3. Interstitial concepts, which seemed promising in the early 1980's, but were mostly
found to be expensive in terms of capital investment, may well return as flexibility
becomes such a vital consideration that these initial capital costs will become
justifiable.
st

4. Other structural strategies that maximize flexibility and adaptability will be
used. Floor systems will have to allow for multiple penetrations for plumbing
and electrical lines, column spacing will need to be optimized so that
departmentalredesignis not crampedby existing structural constraints.
5. Other strategies for maximizing flexibility will include the deliberate specification
of “swing” space to allow temporary relocation of departments during
renovation,and to allow greater flexibility in adapting to changes in patient
population.Low- tech departments can be zoned in 'soft” spaces adjacent to
“high-tech”spaces.
6. Finally, some facilities may require the development of “universal floor plans”,
whichcanbe adapted andreadapted to accommodatevirtually any need.
The concept of flexibility will extend beyond what the architect designs to the architect
him- or herself. The architect will provide a range of services beyond the traditional
architecture and engineering (A & E) tasks, including strategic business planning,
evaluation of lease-versus-build options, financial planning, mechanical and electrical
systems evaluation, space planning inventories, furniture inventories, long-range
planning and master planning. Once the building has been completed the architect
will remain in contact with the owners for the life of the facility, providing a full range
of services on a contractual basis. These services will include ongoing evaluation and
planningfor expansion,contractionand adaptationto changing needs.
It is a mistake to think of the hospital architect only as a technician whose role is
primarily organizing detail. He has an aesthetic as well as an organizational and
conceptual
contribution to make. He is often the major - if not the only - participant in the
development of a hospital in a position to see it as a whole. This is seen in the attention
paid by him to the aesthetics of the exteriors and the interiors of the building. The
typical, somewhat forbidding, hospital facade of the past has given way to more
interesting configurations of building shapes which are based on the functional aspect
of interior communication and traffic requirements. There is also an increasing
awareness by hospital administrators and designers of the value of good graphic
design and art as part of the hospital environment. In good hospital architecture, the
Aestheticin hospitaldesign
52 SCHC

aesthetic and functional unite to contribute to the well-being of both patient and staff.
It has a beneficial effect on both. A pleasant environment increases efficiency and
quality of work. It helps the tolerance level in meeting the pressures of very
demandingduties.
At the same time it should be kept in mind that primarily the hospital is a place for the
care of the sick where conditions may at times seem unattractive to the active and
healthy. To be aesthetically convincing the hospital must be itself and not an imitation
of something else. The patient needs most of all to feel that he is in the presence of
scientificcompetenceaswell assympathetic attitudes.
A critical look at modern hospitals shows that they are designed for ease of
maintenance rather than human comfort. They seem to be resistant to human imprint -
a definition of an institutional environment. The architecture, instead of embracing
and welcoming inhabitants, seems to alienate and intimidate them. They resemble a
Kafkaesque labyrinth of corridors - endless in their dimly lit pallor and multiple layers
of chipped paint. If we stop thinking of patients as inmates and view them as guests,
hospitals could function more on the order of hotels and restaurants. If the individual
can relate the medical environment to something else that he or she has experienced
with apositiveassociation,muchhasbeenachievedtowardsreducinganxiety.
Psychology-implicationsfor healthcaredesign

THE DESIGN PROCESS
CHAPTER 6
Taste,unlike function,is indefinable.
We haveFlorenceNightingale saying:
“The very first consideration to be sought in planning a building is that it shall be fit for
its purpose. And the very first architectural law is that fitness is the foundation of
beauty. The hospital architect may feel reassured that, only when he has planned a
building that will affordthe best chanceof speedy recoveryto sick and maimedpeople,
will hisarchitecture andthe economyheseeks berealized.”
Of course her heart is the right place. She was responsible for naturally well-lit and
ventilated wards, the well-known “Nightingale” ward. Do you see the convergence
with I.M.Peiand hisproposalfor theUCLAMedicalCenter, somany yearslater?
Thenwe havethat connoisseurofarchitecture, HRHthe PrinceofWalessaying:
“Mammoth hospitals, built like dreary office blocks on a devastatingly functional
basis,depressthespirits, howevergoodthecare is.”
We agree. Taste may be indefinable, but let us hear Sir Norman Foster (RIBA Gold
MedalWinner)on thesubject:
“Architecture is also about the spiritual needs of people as well as their material needs;
it has as much to do with optimism, joy and reassurance; of order in a disordered
world; of privacy in the midst of many; of space in a crowded site; of light on a dull day;
it isabout quality.”
Quality need not be defined to be apparent. A building that is functional and pleasing
to those that use it, a building that sits easily in its surroundings, a building that is a
pleasureto behold, sucha buildingis not abuilding at all!Itisarchitecture.
The production of architecture starts with a concept. Here suffice it to be said that
concepts are usually presented in the form of drawings, with a written or verbal
commentary.
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Some explanation of terminology common to drawings developed during
architecturaldesign workmay be helpfulat this point.
1. PLAN : Theplan isthe topview.
2. ELEVATION : Theelevation isthe sideview.
3. SECTION : The section is similar to an elevation, but it shows what
remains after an imaginary slice (section) has been cut
through theobject.
4. PERSPECTIVE : Perspectiveis athree-dimensionaldrawing ofan object.
5. RENDERING : A rendering is a finished architectural perspective
drawing indicating materials and the effects of light,
shade and shadow to help explain form or shape. Plans,
elevations and sections are also referred to as
whenmaterials, light, shadeand shadoware shown.
6. PLANSECTION : The term “plan” is used interchangeably to refer to a top
view and to what is actually a plan section. A plan
section is a horizontal (rather than vertical) section of a
building. It shows the top view of what remains after
everything abovethe slicehasbeen removed.
After conceptual layouts have been approved (“signed off”) by the client, the architect
incorporates more detailed planning criteria into the drawings, the end product of
which is a schematic drawing. It is not done in isolation. All the various members of the
design team participate in giving inputs, comments, critical assessments and the
schematic drawings are the product of what may be a time-consuming and difficult
process, it may involve heated discussions, hopefully followed by “working”
compromisesbetween allkinds ofdesign factorsandcostconstraints.
These schematic drawings would include exterior elevations (quite likely rendered),
and fairly detailed sections, showing vertical stacking of functions. It may include
perspective views (nowadays increasing prepared and rendered on a personal
computer) and may also include a “walk-through”, a series of computer generated
images giving the illusion of a video clip starting maybe with the approach to the
building and going all the through the main entrance into the lobby and possibly
beyond,dependingon thetime andmoney spentmaking it.
“rendered”

Usually such rendered perspectives, scale models of the building and the walkthrough
are commissioned and paid for by the client at actual cost, falling outside the normal
scopeofservicesof thearchitects.
After the schematic drawings have been approved, the architectural design
developmentstage begins, whichis moretechnicaland detailed.
By this time the survey, soil investigation and utility information should be
done. If not, it needs to be done ASAP. This information will support
development of initial studies in foundation and structural framing, sanitary
and storm sewer systems, site development and grading, and electric power
and energy services. Access of traffic to the building entrance, separation of
emergency and service traffic elements and provision for parking are further
studied at this time. The site survey and soil investigation are usually paid for
by the client along with whatever legal services may be necessary in securing
required easements,changein landuse,etc.
Architectural development includes further study and decisions regarding
materials, windows, exterior finishes, architectural treatment and detail;
refinement of space layout within the facility, selection of finishes and
materials in keeping with maintenance and durability requirements; and
comparative cost studies of methods and materials for partition systems and
exterior walls,ceiling andwindows.
Further development is also required on concepts of air handling, air
conditioning, electrical distribution-lighting-communication-data systems
and medical gas, plumbing and piping systems. During design development
these systems are worked out sufficiently to allow cost studies and basic
interfacing decisionsto be made. Drawings are normally single-line indications
of piping or ductwork. Total services requirements for electrical power, natural
gas or fuel oil, sanitary and storm sewers, water, and solid waste disposal are
nowestablished.
Hospital planning requires careful attention to the fixed and movable
equipment that will be needed to implement the operational program. Early in
design development, equipment and room detail interviews are held with
medical and staff personnel. In these sessions, equipment requirements are
documented. The information is used in coordinating room sizes, utility
Site:
Building:
Engineering:
Equipment:
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services, lighting and workflow. Documentation usually takes the form of
room-by-room equipment lists, or room data sheets, and are submitted for
administrative, medicalstaff anddepartmentalreview aftercompilation.
: Complex systems of various types are often incorporated, in concept form, in
schematic design. Functionally, these include communications, data
transmission, storage and retrieval, materials handling, security, food
preparation and others. Each system that is to be incorporated must be studied
in detail and interfaced with equipment common to other building systems;
space and structural requirements are often extensive. Justification of systems
is critical,sinceinitial andmaintenancecostsare usuallyhigh.
Design development drawings normally show considerably greater detail
than do schematic drawings. Major equipment and furniture are shown in the
plans in order to facilitate engineering coordination of utilities and lighting.
Plans show wall thickness, door and window function and more detail
regarding vertical circulation and materials. Sections and elevations at a larger
scale depict relationships between materials. Outline specifications, to
supplement the drawings, are compiled for each material, system and element
of work. A room-by-room equipment list, or room data book, is included to
recordequipment requirements.
A design development is desirable to provide summary discussion of
operational concepts, materials, special equipment, and environmental
systems. When design development documents are completed, a cost estimate
is prepared and presented with the drawings, outline specifications and
equipment information for hospital review. The estimate provides a current
checkon projectscoperelated to budget.
After approval, design development documents provide the basis for the
working drawing or contract document phase of the project. The design
development phase sets the detailed operation of each room and leads to
approval of all systems, fixed equipment, material types and building
construction.
This is the most important part of the administrator's role on the team, as it sets all of
the ideas, programs, needs and designs into the final building plan. All anticipation of
future needs are now fixed, as the following phases only detail and construct what is
nowthe final designproduct.
Systems

TheProductionPhase:
1. TheOwner-Contractor Agreement
2. TheGeneral Conditionsof Contract
The “production phase” of a health care facility is much more than just the construction
of the physical plant; in fact, it begins and ends with the execution of legal activities.
From the production and execution of the owner-contractor agreement, to the final
inspections and acceptance of the completed structure, the hospital administrator and
board will find themselves involved with complex and critical legal documents and
activities. In addition to these clearly legal activities, a new kind of architectural
drawing must now be produced: the working drawings. The working drawings, along
with the written specifications, are in themselves a form of legal document as they
describe in pictures and in words what the contractors have legally agreed to build and
the purchaserhaslegally agreed to pay for.
Given these considerations, it is as important that the hospital administrator and the
board members understand these documents and activities, as it was that they
understoodthe earlierdesign documentsandactivities.
The contract documents consist of the owner-contractor agreement, general
conditions, specifications, bill of quantities (BOQ) and drawings. At the time of signing
the agreement, a work order is issued, containing all addenda issued before execution
of the agreement, which is also signed by the client and contractor. The owner-
contractor agreement and the work order are considered the basic contract documents
because they are the only ones that require the signature of both the owner (client) and
the contractor and they incorporate all other documents referred to in them. The
agreement provides a statement of the contract sum, identifies the nature of the project,
establishes the time of commencement and completion, and describes the manner
wherein thecontractorwillbe reimbursedforwork performed.
Thesetof documentsareasfollows:
This is a legal document on stamp paper that sets forth the terms of agreement between
the ownerandthe contractor.
Thegeneral conditionsset forththe legal andregulatory requirementsofthe contract.
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3. TheSpecifications
4. TheBill Of Quantities(BOQ)
5. Drawings
6. TheWork Order
ReadingtheWorking Drawings:
Thesecontaingeneral specificationsundervariousheads,suchasRCC,Masonryetc.
Thesecontainadditionalspecificationsforvariousitemswith their rates.
Thedrawingsare graphicrepresentations ofthework to be performedandcontain
informationabout design,locationanddimensionsof theelementsof theproject.
Theworking drawings,together with theBOQ and Specifications,are calledthe
contractiondocuments.
Thework ordercontainsallthe addendaissuedbefore execution oftheagreement.
In smaller projects, if mutually agreed by the client and contractor, no agreement may
be signed, the only document that is signed by both being the work order. In this case,
if adisputeoccurs,the recourseisonly to arbitration, andnot acourt oflaw.
At first glance, working drawings are formidable, especially those of a typical hospital
project. Yet, if it is remembered that these documents tell the contractor exactly how
the building is to be built, they become like a foreign language; the more one learns
about them, the less mysterious they become. Taking part in the development of these
drawings, from schematics to working drawings, for a single hospital project would
provideacompleteeducation,but it wouldtake fromtwoto fouryearsonthe average.
Essentially, each consultants drawing is meant to complement the others. The
architect is responsible for coordinating the different consultants drawings, while the
general contractor is charged with coordinating the work of subcontractors. In
addition, the specifications require that all contractors study the work of other
contractors as defined by the working drawings and specifications. The better
architectural firms require composite drawings that lay out the major elements of the

plumbing, mechanical and electrical systems. Such drawings not only force the
engineers to coordinate their work in the field, but dictate the order in which system
components are to be installed. Following completion, these drawings serve as as-
built drawings, and are turned over to the client to become a valuable record of
construction. This enables the in-house engineering personnel to more easily repair
and control the systems. Should future alterations or additions be needed, these as-
built recordswillbe extremely useful.
Competitive bidding is the most widely used method of obtaining construction prices.
When using competitive bidding, it is wise to pre-qualify the contractors who will be
involved. That is, the architect designs a form that asks each interested contractor to
submit references and data on experience, financial conditions and ability to be
bonded.
An invitation to bid, as described above, outlines the time, place, scope and location of
the final plans and the actual bid. The sets of plans and specifications are distributed to
the general contractor. The bidding contractors should be allowed 10 days to 3 weeks
to come up with their final price, depending on the size of project. When so may people
are looking at a set of plans and specifications there are bound to be questions. The
architect should issue clarifications to each bidder, as well as any item changes. The
architect analyzes the final price submittals, and advises the client as to technical
accuracy.Thecontractcanthen be awarded.
Once the bids are received and the contracts signed, the client has very little control
over the selection of subcontractors. The client can however require that a list of
subcontractors be submitted. Whatever prices the general contractor used to
formulate his total, he can now negotiate each item: any savings that result will not be
available to the client. The contractor must, however, meet the quality and quantity as
describedin thedrawings andspecifications.
The general conditions defined the liabilities and role of all general contractors and
subcontractors. The contractor must also understand hospital operations in order to
disrupt hospital routine as little as possible. Construction touches special nerves of the
administrator and hospital staff. The administrator will be blamed for the noise, site
confusion and distractions. These things are part of normal construction, but they
BiddingRequirements andProcedures:
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place an unfamiliar burden on the hospital's normal operation. Day-by-day
construction seems like endless delay and problems to the layman; it is a way of life for
the architect and the contractor. I think they have to both understand each other's
problemsandfocusonbuilding anexcellent facility.
One way to save the client some of the headaches mentioned above is to employ a clerk-
of-works. This person represents the client; he is experience in construction and is
hired by the client to check daily progress. Although the architect acts as the client's
representative during construction, he only performs inspection as it is required; he
will not be on site every day. The architect's duty here is to check shop drawings (detail
of each item specified and submitted by the manufacturer for approval), verify the
contractor's invoices to the owner, and see that quality and design are met. The
architect does not tell the contractor how to build the building: he defines the size,
shapeand quality ofthebuilding.

PLANNING OF INPATIENT WARDS
CHAPTER 7
PatientHousing Systems:
Classificationof Wards
Patient housing systems, typically known as wards are a key element of the hospital
building and may occupy thirty-five to fifty percent of the hospital built up area. The
current trend of corporate hospitals is making it necessary for promoters to think
towards improving the traditional way of laying out these wards. These areas are
becoming more comfort oriented from the customer's point of view. The important
criteriaforplanning the patient hosingsystemswouldbe asunder:
a) Ownership and Bed Mix of the hospital – corporate hospitals may have more single
and double rooms than general wards. The bed mix of the hospital will decide the
numbers in each category of beds. As per current practice approximately 20-25%
beds may be planned in the critical beds and another 20-25% beds in general
wards.
b) Age and Gender distribution – hospitals may need to have separate floors or ear
markedareasforpediatrics,male,andfemalecategoriesofpatients
c) Specialty based distribution – this classification may be required more in large
hospitals imparting medical education wherein one would need to plan for
separate departments for surgery, medicine, orthopedics, obstetrics & gynecology,
pediatrics,ENT,ophthalmologyetc
d) Socioeconomic class based distribution – commonly practiced in all private
hospitals in India wherein the patient wards are segregated on basis of the
socioeconomicclassofthe patient
In-patient wards are classified by their specialty. In a General Hospital the usual ones
are:
theadult general acute
theadult surgical
thechildren'sorpediatric
theoldpeoplesorgeriatric
·
·
·
·
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·
·
·
thematernity
theorthopedic
thepsychiatric
Sometimes there are isolation wards for patients carrying an infection or who for some
reason have suppressed immunity and need to be nursed in a bacteria free
environment. There are also Intensive Care wards for patients needing special nursing
and medical care. Adult wards are likely to be differentiated by sex, depending on the
way they areplannedand thecustomsofthe country.
The efficient and economic running of hospital in-patient services is probably one of
the most difficult problems of all continuously operating services. The organization of
nursing care constitutes a subsystem that very directly aims at achieving the hospitals
overallobjectives.
Over a hundred years ago Florence Nightingale held that thirty-two was the maximum
desirable number of patients in a ward unit. Although there have been revolutionary
developments in medicine and surgery since then, and many changes in the way the
ward has been planned, the number of patients that can be cared for by the ward sister
andher team hasremainedremarkably similar.
Today the preferred number of patients in the general acute and surgical wards may be
some four beds less than Florence nightingales thirty-two but it seems to be universally
recognized that one team should not deal with more. The number of beds under one
sister is likely to vary from about 28 to 30 in general wards, or about 20 to 24 for
children. These numbers may be affected by nursing team arrangements, but in the
interests of flexibility and possible future changes and also for structural and servicing
reasons (particularly in multi-storey buildings) ward units are usually about the same
overall size, varying only in their internal planning. Wards with fewer beds tend to be
those needing additional ancillary accommodation particular to their specialty and the
sizesevenout reasonably.
Inpatientnursingunits
Numberof Beds

Location
Accommodation
The location of wards in relation to other departments of the hospital is rarely critical,
except that surgical wards and those for intensive care are best in close proximity to the
operating theaters. It is an advantage if this connection does not depend on the use of
lifts,although this cannotalwaysbe achieved.
However, all wards need to be easily accessible from the hospitals main supply and
disposal routes and to have convenient communication with the diagnostic and
treatment departments, particularly such departments as physiotherapy which are
visited by ambulant in-patients. In addition all wards should be capable of being
reached by visitors along simple coherent routes from which they are unlikely to stray
into other parts of the building from which they should be excluded, or pass sensitive
areas where there are high risks of cross-infection. No ward should be used as the
principal means of access to another. Even though it may not be entirely on a cul-de-
sac,theentrance to everyward shouldbe capable ofstrictcontrol.
The ward combines clinical and housekeeping facilities with the psychologically
important function of providing the patient with a reassuring home in which he can be
encouraged and supported towards an early recovery. The housekeeping element
used to represent a much larger part of the work of the ward staff than it does today.
This is now much reduced by centralization of the supply of food, linen, drugs and
sterilized articles, so that the ward no longer carries large local stocks of linen, crockery
andmedicines.
Apart from bathing, washing, toilet facilities and day spaces for ambulant patients, the
ancillariesinthe general wardnormallyconsistof:
a treatment room where surgical dressings can be attended to and minor operative
procedures carried out with the minimum risk of cross-infection and without
distressingotherpatients
a clean utility room principally for the preparation of equipment used in the
treatment room
a dirty utility room for emptying and cleaning bedpans and urine bottles, cleaning
othersoileditemsand disposingofmaterials suchasdressings
apantry forthe preparationof beveragesand forwashing anddrying crockery
asmallequipmentstore(mostlyin criticalcareunits)
oneormorenursestations
anoffice(optional)
provisionfor the storageof patientsclothes
·
·
·
·
·
·
·
·
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·
·
a staffcloakroom
a janitorcloset
The treatment room is sometimes placed between the clean and dirty utility rooms so
that sterilized equipment from the Central Sterile Supply Department (CSSD) can be
received and prepared in the clean utility, and after use is passed through another
hatchinto thedirty utility, where it is washedbefore return to the CSSD.
Intensive Care Units (ICUs) are specialty nursing units designed, equipped and staffed
with specially skilled personnel for treating very critical patients or those requiring
specialized care and equipment. Centralizing the acutely ill patients, as is often done, in
contiguous units in an intensive care complex consisting of surgical-medical intensive
care unit, coronary care unit and specialty units such as renal and burn units, results in
multidisciplinarycareand economicaluseof thespaceandequipment.
There is no unanimity among the medical and nursing experts as to where the ICU
should be located. There are two schools of thought. One suggests that the ICUs should
be in a centralized place and be contiguous with, or readily accessible to, one another.
The argument is that patients admitted to the medical-surgical intensive care unit may
have, or suddenly develop, cardiac complications. Having intensive care facilities in a
centralized place allows the specially trained professionals and equipment an almost
instant access to patients in all clinical services when an emergency develops. Such an
arrangement also eliminates the need for duplication of costly equipment and
personnel.
The second school of thought favors that the location should be dependent on the type
of patients. For example, the surgical ICU should be close to the operating rooms while
the medical ICU should be in close proximity to the medical ward to facilitate following
the concept of progressive care, i.e. the patient is moved from the intensive care unit to
intermediate careorstep-downunit, and thento the general patient carearea.
Intensive care units should be close to emergency, O.T. Suite, Respiratory Therapy,
Laboratory and Radiology. Most admissions to ICUs are either through the emergency
department or from the operating rooms following major surgery. They should not be
too far away from general nursing units, as patients may need to be transferred in an
emergency. They should be close to vertical transportation cores. They should be away
from heavy traffic and noise. The electrical influence of equipment like elevator motors
and X-ray equipment on the displays of monitors should be kept in mind. Accessibility
and direct visual contact between patient and nurse is important. The patient should be
IntensiveCare Units

close enough to permit observation of respiration, facial color and other revealing
symptoms.
It is generally recognized that for effective operation, there should be no more than
twelve to sixteen beds per intensive care unit. An intensive care unit of less than six
beds is clearly uneconomical. The beds should be located permanently away from the
wall, to give staff a360degree accessto thepatient.
An Intensive Coronary Care Unit is used to identify the units restricted to patients who
are suffering from cardiac emergency conditions. Patients are transferred from here to
an intermediate care section, which ought to have twice the number of intensive area
beds. A Pulmonary Intensive Care Unit (PICU) is a major key in a comprehensive
pulmonary care program for chronic obstructive lung disease. A laboratory for
around-the-clock determination of arterial blood gases immediately adjacent to the
PICU is required, since these patients are very unstable. Logistic delays due to
laboratory remoteness or unavailable technical assistance is not acceptable.
Neurovascular or stroke cases are admitted predominantly from the emergency
department. In a Burns Care Unit two phases of the burns illness - the shock period and
the healing period - have to be accommodated. Complete reverse isolation can be a
significant factor in the prevention of bacterial contamination of individuals incurring
major burns injuries. For maternity patients with complications and particularly for
those in premature labor a special ante and intra partum unit also referred to as an
obstetric or labor or maternity intensive care unit can be provided. In conjunction with
this, a Neonatal Intensive Care Unit (NICU) can be provided, which is an intensive care
nursery which provides the best chance of saving life and of improving physical and
developmentalstatusfor survivorsof seriousperinatal illness.
The Pediatric nursing unit is concerned with the care of children. It calls for an
understanding of the unique needs, fears and behavior of children. It is generally
accepted that children adjust to hospitalization better when they have the
companionship of other children in the same room. The unit is generally noisy, and
should be located away from the mainstream of hospital traffic. If possible, it should be
locatedadjacentto a terraceto be usedasa play area.
The responsibilities of the Obstetrical nursing unit include prenatal care, observation
and comforting of patients in labor, providing assistance in the delivery room, care of
the mother after delivery and care of the newborn. Ideally the unit should be located on
the same floor as the labor-delivery suites and in close proximity to them. It should also
be adjacentto the nursery
The Psychiatric nursing unit - many general hospitals recognize a responsibility for the
SpecialNursingUnits
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mentally ill and provide facilities to treat them. The unit should be designed with a
non-institutional atmosphere, with sensitive interior design to provide a desirable
therapeutic effect.
All hospitals knowingly or unknowingly admit patients with communicable diseases.
It is the responsibility of the hospital to protect other patients and hospital staff from
these diseases. Barrier nursing and other techniques are not enough. Physical barriers
are necessary. Isolation rooms are therefore provided, and are located within the
individual nursing units. They may also be grouped as a separate isolation unit.
Rooms for specialized procedures such as organ transplants, bone marrow
transplants and burn cases call for special design provisions to meet the needs of
functionalprograms.
Newborn nurseries - they are one of the areas of the hospital where patients are most
vulnerable to infections. They should be located in the obstetrical nursing unit as close
to the mothers as possible. They should also be close to the premature baby or neonatal
intensive care unit. The need for a close, natural adaptation of mother and the
newborn infant to each other right from birth is ingrained in the Indian culture. It is
therefore hardly necessary to have a large nursery for full-term infants as is the
practice in the West. The basic physical and emotional needs of both the infant and the
mother are best satisfied by 'rooming-in', that is, placing them together soon after
birth.

PLANNING OF CLINICAL
DEPARTMENTS
CHAPTER 8
General PlanningConsiderations
Early in the planning process, each department must be sized to accommodate the
functions necessary to accomplish its objectives. Early functional planning must
establish general concepts of operation, space needs, and required room relationships.
As a result, a functional space program can be developed by evaluating activities,
projecting work loads and assigning individual room requirements. In establishing
various work loads, a variety of utilization factors must be considered in light of the
operational procedures within each department. Such procedures vary from one
department to another. Work loads are established by considering such factors as
diagnostic tests and treatment procedures performed, patient visits, prescriptions
dispensed,mealsserved,andpoundslaundered.
After space needs are established and preliminary plans begin, care should be taken in
the development of orderly circulation patterns, focusing on the separation of public
traffic, service traffic, and the movement of goods. It is desirable to have clear patterns
ofcirculationbetween departmentsaswellaswithin eachdepartment.
A constant in the functioning of healthcare facilities is the continuing requirement for
change. Departments should be planned in a manner that supports independent,
open-ended growth and the location of "soft" space adjacent to high-tech functions
likely to grow. In addition, the proper use of modularity, multiuse space, and
changeable walls and systems can enhance a facility's ability to adapt to new
technologicaland carerequirements.
Health facilities operate within a variety of settings, ranging from small community
hospitals to large academic medical centers, storefront clinics to multi-group practice
ambulatory care centers, and children's hospitals to specialty rehabilitation centers.
The quantity and types of ancillary departments are particular to each setting The rest
of this chapter identifies those departments most common in full-service healthcare
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Example of a relationship matrix

THE SURGICALSUITE
Introduction
DepartmentalFunctions
Criteria for departmentsizing
Planning for the surgical suite, one of the most important areas of the hospital involves
various disciplines. The emotional needs of patients must be catered for and also those
of their families. There is no other aspect of hospital care that creates the level of fear
and anxiety than surgery. Therefore, any planning process must involve
administrators, surgeons, anesthesiologists, surgical nurses, representatives of
support areas (housekeeping, pharmacy, central sterile supply, and laboratory) and
individualswhoconsidertheneedsofthe patient andfamily.
The function of the department is to receive patients after diagnosis, to anaesthetize
them either before or after transfer to the operating table, to operate, and to supervise
their post-operative condition before returning them to the wards. The pre-eminent
position of the surgical department in the hospital can be appreciated when one
realizes that in a typical general hospital, surgical patients represent 50% to 60% of the
admissions, and account for an appreciable quantum of the work of and revenue from
ancillary departments. The surgical suite of a modern general hospital and everything
that goes with it make a very complex workshop. The surgical procedures of the
present day, involving more people and highly sophisticated equipment, have
rendered ideas of planning of operating rooms of the past somewhat obsolete. The
majordecisioncenterson thenumberand type ofoperating rooms.
The basic criteria for determining the number of operating rooms are the total number
of procedures and number of minutes expected annually for the target year.
Calculations are made to determine the total volume of expected surgical operations.
The total number of procedures performed in a given period of time is measured
against operating room capacity, including procedure and clean-up time. Surgery
generally takes place in a seven-to-eight hour, six-day-a-week period beginning at 7.00
a.m. with emergency and some elective surgery occurring during the weekend. When a
shortage of operating rooms occurs, it is not uncommon for surgery to take place in the
evenings and on weekends. As a thumb rule you can calculate one OT for every fifty
beds.
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Composition of theDepartment
Flow of Various Individuals
The department consists of one or more operating suites that share ancillary
accommodation such as staff changing and rest rooms, arrangements for the reception
of patients, and facilities for the disposal of soiled material. The general OT's should
have a desirable clear area of 400 sq. ft. (minimum 360 sq. ft.) with 20 ft. clear dimension
(minimum 18 ft.) between fixed cabinets and built -in shelves. Rooms for cardio-
vascular, orthopedic, neurological, and other special procedures shall have a desirable
minimum clear area of 600 sq. ft. (minimum for orthopedic is 360 sq. ft. and for
cardiovascular and neurological is 400 sq. ft.), with a desirable clear dimension of 20 ft.
(18 ft. for orthopedic). A room for surgical cystoscopic and other endo-urologic
procedure should have a desirable area of 350 sq. ft. (minimum 250 sq. ft.) with a clear
dimension of 15 ft. The suites may also share a unit for the supply of sterile material and
instruments. Each operating suite normally consists of a theater, an anesthesia room, a
sterile store and a scrub-up. The orthopedic OT shall have enclosed storage space for
splints and traction equipment, which may be outside the OT, but must be
conveniently located. The space occupied by the operating rooms is only about one
fourth of the surgical suite - the supportive services and functions account for the rest
ofthespace.
Although the requirements of theaters can be met by an entirely internal placement,
from the point of view of staff that spends long periods in the department, some
natural light can be a valuable asset. This should be provided for some of the ancillary
staff rooms. The department should be on a cul-de-sac so that access to it can be strictly
controlled (there should be no non-related traffic through the suite). The Intensive
Care Unit should be preferably adjacent. X-rays are normally taken with the help of
mobile machines. The cleansing and the supply of sterile goods is done in a separate
Central Sterile Supply Department (CSSD) that can serve the whole hospital, or a
Theater Sterile Supply Unit (TSSU) which can serve a larger number of theaters via a
smallsterilestoreattachedto eachofthem.
Workflow in the surgical suite must be considered in relation to several different
groups: patients, visitors, medical staff, nursing staff, and logistical support. Patients
enter the suite from inpatient nursing units, the same day surgery area, or emergency.
Inpatients generally go to a holding area for surgical preparation, then to their
assigned operating rooms. Outpatients are transported to their assigned operating
room. After surgery, patients are transported to the PACU for recovery. Next, they go

to their assigned patient rooms, or to phase 2 recovery. Visitors wait during surgery in
the family waiting area. In some facilities, inpatient family members or visitors wait in
the patients' private room. Outpatient and same day surgery visitors wait in the
preoperative waiting area until after the surgery, when a limited number of visitors
may be allowedto attend to the patient whileheorsheisin the phase2recoveryarea.
All surgical staff members change into sterile clothing in dressing areas and enter the
surgical suite through a lounge. They can consult the surgery schedule for room
assignments. All those participating in the surgery scrub and gown prior to entering
the operating room. After each surgery, the surgeon speaks with the patient's family in
a consultation room. Between surgical cases, physicians can take a break in the surgery
lounge. There they can utilize the physician dictation areas to record the
proceedings/outcomeofthe surgery.
Asurgicalsuite flowdiagram
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ReducingRiskof Infection
Of prime importance in the design of the department is the need to reduce to a
minimum the risk of infection at the operating table. Ensuring the sterility of
instruments and other apparatus is relatively simple, but no less important is the
reduction of the risks of airborne infection. This depends upon management
procedures and the physical arrangement of the department and of its ventilation
system. The physical arrangement should ensure that not only are these procedures
facilitatedbut that asfaraspossiblethey areinescapable.
A surgical department could be divided into zones, where the quality of the
environment would conform to the cleanliness policy adopted by the individual
hospital.
The general zone - in this zone the requirements for cleanliness correspond to the
usual hospital cleanliness standard. This zone includes waiting areas for relatives,
catastrophe and triage areas, plaster rooms, offices, record rooms, laboratories,
storesfor non-sterilematerial, stafflounge-refreshments,toilets changingrooms.
The clean zone - this provides for the surgical department reception and holding
area, anesthesia rooms, delivery rooms, Endoscopy rooms, stores for blood,
medicine, parenteral solutions etc., stores for tubed medical gases, the sterile service
area, thegeneral post-anesthesiaarea, X-rayapparatus stores,andclean bedstores.
The super clean zone - this accommodates scrub-up and gowning areas, operation
theaters, sterilestores,sterilelinen stores,andthoracicpost-anesthesiarooms.
The ultra clean zone - is determined by a circle with a one meter diameter from the
wound.
Theasepticzone-is limitedto thearea ofthe incision.
To minimize the risk of infection the method of artificial ventilation should ensure
that within each suite there is a supply of pure air sufficient to reduce the bacterial
count below a critical level. There should be a positive pressure in the theater and
sterile store to provide a flow of air from the clean to the less clean areas. Each theater in
the department should have its own self-contained ventilation system in order to
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reduce the risk of cross infection. There should be no movement of air from one suite to
another.
Schematic Diagram of OT Suite Airflow
OtherArea Requirements
A holding area is needed at the entrance of the department where patients are
transferred to a theater stretcher. Whether a separate anesthesia room is provided or
not, the anesthetist needs a wide variety of equipment, instruments and drugs which
calls for considerable storage space. In addition, equipment used in the department,
some of them bulky items such as the C-arm and portable X-rays need to be stored in
alcoves. After the operation the patient is transferred to a recovery area for recovery
from the anesthesia, and then either to his own ward or the ICU. The Post-Anesthetic
Care Unit (PACU) (Recovery) area needs to be easily supervised and readily accessible
from all the theaters. it should contain a medication station; hand-washing facilities;
nurse station with charting facilities; clinical sink; provisions for bedpan cleaning; and
storage space for stretchers, supplies and equipment. It would be desirable to have 80
sq. ft. for each bed in addition to the above spaces and a clearance of at least 4 feet
between beds and between beds and adjacent walls. The thumb rule for sizing is one
andahalf to twobedsper operating room.
The procedures carried out in the surgical suite are probably the most precise and
critical of all the functions performed in a hospital. The suite itself makes the most
exacting demands upon detailed design and is frequently the most remote form the
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average designers direct experience. Ventilation and lighting are probably open to
more refined improvement than in any other part of the hospital building. For these
reasons there may be much to be said for a design approach that anticipates future
flexibility and change instead of attempting precise original design with materials and
equipmentthat maybe difficultto alterlater.
Thefollowing serviceareasshallbe provided:
Acontrolstationlocatedto permit visualobservationofalltraffic intothe suite
Asupervisor'sofficeorstation
Asterilizing facility forimmediateoremergencyuse
Amedicationstationfordistribution ofdrugs androutinemedicine
An enclosed soiled workroom for the exclusive use of the surgical suite, for the
collectionand disposalof soiledmaterial
A clean workroom or clean supply room, where clean materials are assembled
priorto useorfollowingthe decontaminationcycle
Medical gas storage facilities, in addition to the main storage, separate storage
ofreservegas cylindersnecessaryto completeat least oneday'sprocedures
An anesthesia workroom for cleaning, testing and storing anesthesia
equipment, withspacefor anesthesiacarts
Anequipmentstorage room
Staffclothing changeareas,containing lockers,showersand lavatories,space for
donningsurgicalattire, with aone-way traffic pattern, from'dirty' to 'clean'.
Stafflounge and toilet facilities
Dictation andreport preparation areas
Outpatient recovery
Changeareasfor out-patients andsame-dayadmissions
A space for patient examination, interviews, preparation, testing and obtaining
vitalsignsof patientsfor out-patient surgery
Storage areas for portable X-ray equipment, stretchers, fracture tables, warming
devices,auxiliary lamps,etc.Theseareasshallbe out ofcorridorsandtraffic.
Housekeeping facilities
Anarea forthe preparation andexaminationoffrozensections
Provisionsforrefrigerated bloodstorage
Where applicable, appropriate provisions for refrigeration facilities for
harvested organs
Provisions for pathological specimens storage prior to transfer to pathology
section
Services, except for the soiled workroom and housekeeping room may be shared with
the obstetrical facilities if the functional program reflects this concept. Service areas,
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when shared with delivery rooms, shall be designed to avoid the passing of patients or
staff between the operating roomandthe delivery roomareas.
There are several operational issues that affect surgical suite design for example,
integrated versus independent outpatient facilities, perimeter work corridor versus
interiorwork core,and integrated versusseparate centralsterilesupply.
The consideration of an integrated versus independent outpatient facility addresses
the question of the outpatient service location. Outpatient surgery can be an integrated
part of the inpatient surgery suite or separated in an independent outpatient suite that
includes both preoperative areas and operating rooms. These areas may be located on
or off campus. The appropriate location of this service will involve the medical staff
and hospitaladministration.
A perimeter work corridor layout circles the operating rooms. The layout provides a
single corridor system that is used to transport patients, physicians, nursing staff and
clean and soiled supplies. Closed clean and soiled case carts and double bagging of
waste products are used to maintain sterile conditions. An interior work core separates
clean distribution from the soiled distribution system. Placed between two rows of
operating rooms,theinteriorwork coreis usedforsterilesuppliesand instruments.
The issue of an integrated versus separate central sterile supply (CSS) is whether
central sterile supply is placed adjacent to surgery or on another floor: if it is placed
directly above or below the surgical suite, it is linked by elevator or dumbwaiter.
Although the surgical and CSS staff normally prefer an adjacent relationship, physical
building constraintsoftenhavea bearing on thelocationofcentral sterilesupply.
Operational Relationship
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A diagram of a surgical suite's perimeter corridor concept
A diagram of a surgical suite's interior work core concept

Trends
IntensiveCare Units
Introduction
Location
Surgical facilities will continue to separate outpatient cases from inpatient cases. The
trend is, however, toward integrating outpatient with inpatient surgery for greater
efficiency in the use of staff and instruments and cost reduction. This trend puts
additional pressure on the surgery staff to maintain outpatient standards of care
within the inpatient hospital setting. Outpatients will continue to require direct and
convenientmeansof entering theoutpatient area.
Pain management services will expand as new and better means of reducing pain are
developed. The preoperative patient areas will continue to be key locations for pain
management services. The integration of invasive imaging (cath lab) within the
surgical suite will increase as a means of delivering invasive imaging in a surgical
environment. A developing trend is to combine surgery with magnetic resonance
imaging. Each of these trends carries with it the promise of improved surgical services
andbetter care forthe patient.
Many people – caregivers, architectural and design professionals, and patients, regard
intensive care (critical care) units as the heart of the hospital. Here a seriously ill patient
can expect the maximum of care: the very best the hospital has to offer in terms of
personnelandtechnology.
Intensive Care Units (ICUs) are specialty nursing units designed, equipped and staffed
with specially skilled personnel for treating very critical patients or those requiring
specialized care and equipment. Centralizing the acutely ill patients, as is often done,
in contiguous units in an intensive care complex consisting of surgical-medical
intensive care unit, coronary care unit and specialty units such as renal and burn units,
resultsinmultidisciplinarycare andeconomicaluseofthe spaceand equipment.
There is no unanimity among the medical and nursing experts as to where the ICU
should be located. There are two schools of thought. One suggests that the ICUs should
be in a centralized place and be contiguous with, or readily accessible to, one another.
The argument is that patients admitted to the medical-surgical intensive care unit may
have, or suddenly develop, cardiac complications. Having intensive care facilities in a
centralized place allows the specially trained professionals and equipment an almost
instant access to patients in all clinical services when an emergency develops. Such an
arrangement also eliminates the need for duplication of costly equipment and
personnel.
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The second school of thought favors that the location should be dependent on the type
of patients. For example, the surgical ICU should be close to the operating rooms while
the medical ICU should be in close proximity to the medical ward to facilitate
following the concept of progressive care. That is, the patient is moved from the
intensive care unit to intermediate care or step-down unit, and then to the general
patient carearea.
Whatever its location and adjacencies, the intensive care unit must exclude through-
traffic.
Intensive care units should be close to emergency, Operation Theater Suite,
Respiratory Therapy, Laboratory and Radiology. Most admissions to ICUs are either
through the emergency department or from the operating rooms following major
surgery. They should not be too far away from general nursing units, as patients may
need to be transferred in an emergency. They should be close to vertical transportation
cores. They should be away from heavy traffic and noise. The electrical influence of
equipment like elevator motors and X-ray equipment on the displays of monitors
should be kept in mind. Accessibility and direct visual contact between patient and
nurse is important. The patient should be close enough to permit observation of
respiration,facialcolorand otherrevealing symptoms.
It is generally recognized that for effective operation, there should be no more than
twelve beds per intensive care unit. Twelve beds is seen as the upper limit of what an
ICU nursing staff and station can adequately monitor. An intensive care unit of less
than six bedsis clearlyuneconomical.
This guideline of twelve beds maximum will become decreasingly significant as ICU's
incorporate bedside computers that enable “paperless charting” and direct recording
of vital signs through monitoring devices. Such technology will encourage
“decentralized nursing” which will allow nursing staff to spend less time at a central
nursing station and more time in patient rooms and at mini-work stations directly
adjacentto theserooms.
As to the rooms themselves, the American Hospital Association (AHA) minimum is
150 square feet per room. This may be adequate for non-critical patients, but it is too
small for patients on life-support and monitoring equipment. The task force on
Guidelines of the Society of Critical Care medicine recommends 150 to 200 square feet
in open units, while private patient rooms should contain 225 to 250 square feet. The
ICUpatient roomshouldbe plannedto facilitate operationsin theevent ofacrisis.
Relationshipswithother Departments
SizingConsiderations

The beds should be located permanently away from the wall, to give staff a 360-degree
accessto the patient.
It is alarming to review the substantial literature that now exists on intensive care units
of the recent past devoted to how the environment of the intensive care unit can
adversely affect patient health while simultaneously increasing stress and fatigue
among the physicians, nurses, and nurses, and others who work in these areas. The fact
is that many ICU'sandICCU's –areliterally –sickening.
In most ICU's, the focus is not so much on the patient as it upon a disease or disorder, as
if the procedures necessary for sustaining life in the physical sense were somehow
incompatible with simultaneously sustaining emotional well-being. The assumption
seems to be that the ICU patient is either unconscious and unaware of his surroundings
or too sick to care about them. The issue is that emotional health cannot be neatly
isolated from physical health. The machinery makes many patients feel invaded and
helpless. The sense of claustrophobia created by packing monitoring equipment,
respirators, and IV delivery equipment into a small space can dramatically increase
anxiety levels.
Windows are all too often absent from intensive care unit design. Not only does this
heighten the sense of claustrophobia inherent in these technology-packed areas, but a
number of studies have demonstrated that patients in windowless rooms are subject to
temporal dislocation and even subject to “ICU psychosis”, which is characterized by
delirium,hallucinationanddelusions.
Harsh lighting, especially from fluorescent fixtures often aggravates the disorienting
effects of having no windows, and by lighting that is not dimmed to correspond to the
body's circadian rhythms. Sleeplessness is a common problem in intensive care units,
and it is not only due to lighting, but also to the remarkably high level of noise that
prevails in manyofthe olderunits.
Excessive noise is particularly stressful for cardiac patients, who exhibit increased
cardiac workloads and arrhythmias in noisy environments. In addition, pain
perception is heightened by the presence of excessive noise. There are more diffuse
negative responses reported by patients, including a sense that they could not “escape”
their environment; a general and anxiety-provoking sense of unrelenting urgency in
the environment; sensory deprivation; crowding; and loss of privacy. Many related
feelings also affect those who work in the critical care unit, leading them to
depersonalizepatients.
Alloftheseresponsescanat leastbe mitigated by designsolutions.
Technology andHumanity: DesignPriorities
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Technology andDesign:AchievingaBalance
SpecializedIntensiveCare Units
While emphasizing the human aspects of ICU design, the intention is not to denigrate
technology. Not only does medical machinery save lives, it has the potential of actually
humanizing the relation of caregiver to patient by saving staff time, for example in the
automatic recording of data, enabling the time freed to be used to be in contact with and
treating patients. The development of “bedside laboratory” technology can be
employed to assess blood gases, electrolytes, glucose, and hemacrit using a very small
bloodsample– 0.5ml–in lessthanninety seconds.
Good design can do much to accommodate the machinery while keeping it out of the
way. Particular attention should be devoted to the headwall, which, especially in the
intensive care environment, bristles with connections for medical gases, suction,
electrical power, and terminal hook-ups. Consideration must be given as to whether
the hook-ups should fan out from the patient to the headwall, whether they will
converge at a power column, or run to an overhead rail system. In general medical-
surgical patient rooms – and even in some critical care facilities – attractive casework
canbe usedto hideall orsomeof thehook-upsin the headwall.
The choice of headwall, power column or rail system is in large part determined by the
layout of the room (especially the orientation of the bed), which, in turn, is a function of
overall unit design and the need to balance the demands of technology, accessibility
and privacy. The starting point for the layout of the room is the orientation of the bed.
From the point of view of the nurse, the bed should be situated to allow ready
observation of the entire body, especially the head. Tradition dictates that the head of a
bed be against a wall, and certainly, headwalls accommodate readily to this approach.
However, in a crisis, it is often essential to have access to the patient from all four sides.
Certainly, the bed can be pulled quickly out from the wall, but tubes and monitor leads
may continue to inhibit access or may even present a trip hazard. Some architects have
proposed a partial solution to this in non-square rooms or rooms with one angled wall,
meant to increase clearance around the bed (and to give the room greater sensory
interest to thepatient). However,asimilarapproachis to treat the bedasanisland.
An Intensive Coronary Care Unit is used to identify the units restricted to patients who
are suffering from cardiac emergency conditions. Patients are transferred from here to
an intermediate care section, which ought to have twice the number of intensive area
beds. A Pulmonary Intensive Care Unit (PICU) is a major key in a comprehensive
pulmonary care program for chronic obstructive lung disease. A laboratory for
around-the-clock determination of arterial blood gases immediately adjacent to the
PICU is required, since these patients are very unstable. A logistic delay due to

laboratory remoteness or unavailable technical assistance is not acceptable.
Neurovascular or stroke cases are admitted predominantly from the emergency
department. In a Burns Care Unit two phases of the burns illness - the shock period and
the healing period - have to be accommodated. Complete reverse isolation can be a
significant factor in the prevention of bacterial contamination of individuals incurring
major burns injuries. For maternity patients with complications and particularly for
those in premature labor a special ante and intra-partum unit also referred to as an
obstetric or labor or maternity intensive care unit can be provided. In conjunction with
this, a Neonatal Intensive Care Unit (NICU) can be provided, which is an intensive care
nursery which provides the best chance of saving life and of improving physical and
developmentalstatusforsurvivorsofseriousperinatal illness.
Theseandotherspecializedunitsare discussedin greater detail below:
After the surgical-medical ICU, the intensive coronary care unit (ICCU) is the most
commonly found critical care unit in the hospital. The central design issue in the ICCU
is finding a strategy to promote tranquility and even relieve visual and acoustical
isolation. So-called “ICU psychosis” is a shocking enough symptom of poor critical
care design. In the case of an ICCU, noise and visual clutter have a readily
demonstrableadverseeffect on heartrates, arrhythmias,and bloodpressure.
The respiratory care unit has developed as an alternative to the traditional ICU in
response to the constraints of managed care and cost containment. Studies show that
35% of surgical and medical intensive care patients were admitted to these costly units
strictly for the purposes of monitoring and did not require any active intervention. The
patients were not suffering from any immediately life-threatening processes. The
studies suggested a rationale for providing more cost-effective intermediate care units
for those patients in need chiefly of close monitoring rather than aggressive
intervention.
Cost savings are achieved in part through reduction in the amount and nature of
required equipment and, in even larger part, through reduced staffing needs. Whereas
the nurse to patient ratio in the ICU may be 1:2 or even 1:1, in the respiratory or step-
downunit the ratiocansafely be setat 1:3or1:4.
Until some time back, most buildings were standardized on the model of a thirty-year
IntensiveCoronary Care Unit
Respiratory Care andStep-DownUnits
CriticalCare of theElderly
82 SCHC

old healthy male user or occupant. Increasingly, however, architects and planners are
designing for a seventy-year-old woman who is in less then optimum health. While no
radical steps need to be taken to design special critical care facilities to accommodate
older patients, certain design features can be incorporated into general ICU's to make
themfriendlierto the aged.
Gerontologists speak of an “environmental docility hypothesis”, which holds that as
competence decreases, the probability that behavior will be influenced by
environmental factors increases. We know that critically ill patients often feel at the
mercy of their environment. This seems to be even more compelling among the
critically illelderly.
Some of the design areas discussed earlier, especially noise control, light and color, are
particularly important in designing with the elderly in mind. Noise reduction should
be a high design priority. Because of diminished visual acuity in the elderly, lighting
should be planned to avoid glare. This also means keeping highly reflective surfaces to
a minimum. Color discrimination also deteriorates with age. Differentiating among
dark shades and among pastels is a particular problem. Thoughtful use of contrast to
emphasize planes and corners aids orientation. However, the elderly person should
notfeel dominatedby the colorsin hisenvironment.
An array of neurological conditions may require intensive care. Many of these
conditions can be treated appropriately in the general surgical or medical ICU, but the
monitoring and treatment of intracranial pressure (ICP) in particular has been cited by
many authorities as ample rationale for creating specialized neurological intensive
careunits.
Probably the best model for the neurological ICU is the Intensive Coronary Care Unit
(ICCU), which focuses on continuous and sophisticated monitoring in order to achieve
early detection of developing problems. Increasingly sophisticated monitoring
devices will have to be accommodated in neurological critical care, and these must be
addedto a fullarray ofrespiratoryand ventilationequipment.
Perhaps the single greatest design impact of the neurological ICU is the issue of
adjacency.Itis desirableto locate thisunit near diagnosticfacilitiesasMRIand CT.
BurnsUnit
Another specialized intensive care facility found in larger, often regional hospitals, is
the burns unit. Some hospitals, most notably the network run by the shrine of North
Neurological IntensiveCare

America (Shriners), are devoted entirely to the treatment and rehabilitation of burn
victims.
For design, the single most important clinical factor in treating burns is creating
structures that minimize the risk of infection. Burns unit critical care patient rooms
shouldbe private, rather than anopenward,to minimizetherisk of cross-infection.
The ICU at Shriner's Hospital Galveston Burns Institute (HDR Inc. were the architects)
features patient rooms that are fully enclosed with glass to allow maximum visibility
while providing for isolation. The HVAC system was designed to surgical operating
room standards, and positive air pressure as well as HEPA filtering promotes surgical
suite airquality.
The Galveston ICU patient rooms also include radiant heat systems above each bed.
These are linked to thermal sensors mounted on patients who lack an insulating
epidermal layer, and, in this way, heat loss is perfectly compensated for by the radiant
panels. Environmental control extends to the maintenance of high relative humidity as
neededto helpprevent damagedskinfromdryingout.
In addition to meeting the demanding clinical conditions required by the advanced
treatment of severe burns, the burns unit ICU should project as much of a non-
institutional sense of well-being as possible. Severe burn injury is not only physically
painful, but is especially depressing and anxiety provoking. Patients suffering from
disfiguring injury benefit from maintenance of contact with the outside world.
Tragically, it is also the case that a great proportion of burn victims are children. The
focus of the Shrine-sponsored institutions is pediatric. But all advanced burns units
shouldbe designedwiththe younger patient in mind.
In discussing the burns ICU we have touched upon the issue of isolation to prevent
infection. Patients admitted to an intensive care unit have a higher risk of nosocomial
infectionthan otherhospitalizedpatients.
Most authorities believe that design for isolation is primarily a matter of ventilation,
filtering, and maintaining positive air pressure in the patient room, for patients who
are immuno-compromised. For patients who themselves are a source of infection,
negative air pressure is maintained, other safeguards remaining the same. It is
assumed that nursing the patient in a one-patient room with the door (or pair of doors
with anair-locklobby) closedisthe best safeguardagainst infectionin intensivecare.
TheIssueof Isolation inIntensiveCare Units
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TheNeonatal IntensiveCare Unit
THENEONATALINTENSIVECARE UNIT(NICU)
1. DesignIssuesfor NeonatalIntensiveCare Units
2. DesignGuidelinesfor Neonatal IntensiveCare Units
DesignIssuesfor NeonatalIntensiveCare Units
Thisisdiscussedseparately asadepartment.
The design and planning issues with respect to a neonatal intensive care unit
(NICU)are sufficiently unique to warrant a separate discussion, apart from that of
intensive careunits ingeneral, whichare separately discussedabove.
Thediscussionwill be undertwo broadheads,Thesetwo headsare:
Themodernneonatalintensive care unit isthe productof twofactors:
1. The development of an understanding that the pathophysiologic phenomena
associated with the newborn are so distinctive that they require an appropriate
setting where thecritically ill infant canbe effectively managed,and
2. Convergent advances in electronics and biochemistry, which made such a setting
feasible.
Theseadvancesinclude:
1. Methods for continuous evaluation of numerous parameters of neonatal (and fetal)
illness.
2. Methodsof continuousmonitoring ofcardio-respiratoryfunction.
3. Micro-techniques for the rapid biochemical determinations from minute blood
samples.
4. Servo-controlledradiant-heat incubators.
These advances, coupled with improved methods for controlling infection, prompted
the development of the NICU: a common area where all medically and surgically ill
infantsare treated,premature andfullterm,infectedandnon-infected.
NICU'sperformthefollowing functions

1. Observe criticalinfants
2. Monitorcritical infantselectronically andbio-medically
3. Carry out advancedtherapeutic procedures
4. Promotematernal-childcontactto the fullest extent possible
The last functions is because it is realized by now that maternal handling as well as
sensory stimulation (but not over-stimulation or inappropriate stimulation) are crucial
in the neonate's earliest hours and days – even if the infant is critically ill. Thus
designers of NICU facilities are faced with a set of requirements that are, in many
points, contradictory. One the one hand, there is a call for a common technically
sophisticated space, while, on the other, there is a call for a humane environment that
facilitates maternalcontact.
A number of studies have suggested that humanizing the NICU may be more of a
clinically urgent matter than merely a desirable goal. Some authorities have suggested
that continual exposure to bright lights may contribute to retinopathy of pre-maturity
(ROP), a leading cause of blindness in premature infants. Another effect of continual
high-level illumination is disruption of diurnal patterns at this earliest stage of
development. Monitoring of cardio-respiratory function demonstrates that these vital
signs tend to be more stable when infants are exposed to cycled lighting that mimics
diurnalpatterns.
Also, when light levels are high, noise levels are commensurately high. When light
levels are dimmed, noise levels also decline. Indeed, noise in traditional NICU's is
often at a distressingly high level. Alarms and incubators are the biggest mechanical
noise producers. These not only elevate levels of arousal, there is evidence that
protracted exposure to incubator noise levels in excess of 70 decibels may contribute to
actual cochlear damage and subsequent hearing loss. As in the adult ICU, sensory
overload is also a threat to professional staff. In a more recent development,
undertaken in part to minimize the ill effects of the traditional NICU unit, architects
have moved away from the warehouse style NICU, designing instead smaller units of
fourto six bassinets.
The only humanizing architectural element that most authorities argue against
including in the design of the NICU is windows, primarily due to their thermal effects,
which can cause potentially harmful dips or spikes in ambient temperature. In settings
where fully enclosed incubators are used, it is even possible that too much sunlight can
causeexcessivewarmingdue to agreenhouseeffect.
NICU's should incorporate muted colors, since babies especially under stress, do not
86 SCHC

respond well to bright colors. Lighting suggested is true-color fluorescent and indirect
cove lighting. To maximize efficiency, place the nurse workroom immediately
adjacent to the NICU, to enable nurses to monitor the unit more closely. A parent room
should be provided close by to accommodate well parents who wish to be close to their
baby. Lighting levels can be automatically cycled to promote the babies regular sleep
schedule, and finishes throughout the facility should be more traditional than
institutional. As far as possible, the NICU should maintain the homelike setting that
predominatesthroughout the familybirth unit.
The creation of formal planning guidelines for newborn intensive care units (NICU's)
occurred in 1976 in the USA, and since then, the American Academy of Pediatrics
(AAP) and American College of Obstetricians and Gynecologists (ACOG) have
published a number of their comprehensive Guidelines for Perinatal Care, among
otherdocuments.
The purpose of this document is to provide health care professionals, architects,
interior designers, health care facility regulators, and others involved in the planning
of NICU's with a comprehensive set of standards based on many years of clinical
experience.
These recommendations are planned to be upgraded on a regular basis, incorporating
new researchfindings,experiencesandsuggestions.
While many of these standards are minimal, the intent is to optimize design within the
constraints of available resources, and to facilitate excellent medical care for the infant
in asetting that supportsthecentralrole ofthefamily andthe needsofthe staff.
Thelatest revisionofthesestandardscanbe foundonthe website:
Theseare the:
RecommendedStandardsforNewborn ICUDesign
Reportof theFifth ConsensusConferenceonNewborn ICUDesign
January2002
Clearwater Beach,Florida
DesignGuidelinesfor Neonatal IntensiveCare Units
www.nd.edu/~kkolberg/DesignStandards.htm

MATERNITY /OBSTETRICSDEPARTMENT
Introduction
TheMaternity Department
The maternity department, also referred to as the obstetrics department, is usually the
setting for a natural process as opposed to a pathological one. This department differs
from most other departments in a hospital because it is designed to house a happy
event, also called a “wellness' event. It is dealing with a continuous process, maybe
from insemination (if clubbed together with IVF) to pregnancy through delivery to
post-natal care of both mother and child. It is not so much concerned with curing an
illness but with the fulfillment of a natural act. It is important, therefore, that the design
ofthedepartment shouldnotbe in any way be suggestive ofill health.
It is a good design response to keep this department separated from the rest of the
hospital, it need not necessarily be on another site, but can certainly have it's own
entrance and image distinct from the facility it is a part of, to foster the concept of a
“wellness” place. If connected to a multi-specialty hospital, it could share support
services such as food and laundry, as well as diagnostic and other services the
“patients”may need.
Thedepartmentis dividedlargely intotwo parts:
Theoutpatient clinics.
Theinpatient accommodationsconcernedwith delivery andpost-natal care.
The outpatient clinics can be a part of the hospital's outpatient department or may be
provided separately. These same rooms could also accommodate post-natal
examinations,familycounselingandgynecologicaloutpatients.
The delivery suites have a lot in common with the operating theaters. There are
similarities in the ways they are located and controlled. In laying out the labor and
delivery suite, the designer should consider the functional areas comprising the
department such as the preparation room, labor room, delivery room, recovery room
and support services area. We recommend that there be a provision of an operation
theater in the department where major obstetrical surgery can be performed. If this
does not work within the area or budget constraints one of the delivery rooms should
be designedandequipped to servethispurpose.
Antenatal patients are usually seen at the time of booking, at about the thirty-sixth
week of pregnancy, and then weekly until admission for delivery. This clinic should
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preferably be accessed separately from the center's main entrance, and will comprise of
a waiting space, rooms for history taking and examination, urine testing room and
lavatory, and office and record space. Easy access to the clinical laboratory and
imagingsciencesis advantageous.
The layout of the department is dependent on the type of delivery envisaged by that
particular facility and the number of projected deliveries. There are three main
deliverymodelsin obstetrics:
This is a process in which the patient moves through different rooms and areas during
the various stages of giving birth. The patient is admitted to a triage area and
transferred to a labor room. The patient is then transferred to a delivery room for the
birthing process. The patient is transferred again to recovery post-delivery. The
postpartum unit is the final stop for the new mother. The infant is placed in a nursery
adjacent to or within this unit. Of the three models, this one involves the most
movementof thepatient.
These are oversized single-occupancy patient rooms that are used for all the three
processes of labor, delivery and recovery. These are an established feature of the
healthcare industry in the West but have been introduced in India only in the early
2000's. They consist of a well-designed room that offers the expectant mother the
advantages of a family-oriented birthing process in one room, other than when the case
is a high-risk one. They are designed like a residential bedroom, with obstetrical
equipment tucked away, out of sight. These rooms can be quickly converted to high-
tech procedure rooms as the delivery progresses, with the necessary equipment
brought in. This provision offers would-be mothers the best of both worlds - the
comfortsoftheir housein the setting ofa hospitalsetting withcompetent medicalcare.
Although the trend in the West was to use these rooms as postpartum beds as well, this
practice has changed there because of several issues: inefficiency in room utilization,
difficulties with nurse cross-training, and patient preferences to continue recovery in a
quieter setting. Consequently, many postpartum beds are located adjacent to LDR
areas, in their own quiet rooms, frequently with newborns rooming-in with their
mothersand withdoublebedsprovidedfor thefathers.
This facility consists of a single room used for the entire stay of the patient in the
1. Traditional.
2. Labor/Delivery/Recovery (LDR).
3. Labor/Delivery/Recovery/Postpartum (LDRP).

hospital. The newborn may stay in the room or in the nursery for full or partial care. In
thesethreemodelsofbirthing, thisone occasionsthe least movementofthe patient.
Specialty care units like a maternity department or a comprehensive woman's care
facility can provide valuable marketing opportunities for the hospital they are attached
to notonly through theservicesthey providebut through their designaswell.
Maternity units can constitute an effective marketing “niche” in today's times. They
can be designed with a focus on “high touch”, and given a residential, non-institutional
image. The unit can be designed to have a non-clinical atmosphere and can be a setting
in which expectant mothers can meet, which can be desirable especially in new
communities.
It could be a good marketing strategy for a healthcare facility based in a large
community to reach out to it's primary market area by combining a birthing center with
other diagnostic and treatment functions. This configuration can create a satellite
ambulatory care center with integrated physician office practices with both affiliated
andnon-affiliatedphysicians.
The intention should be to create in the patient's mind a positive associative image of
the hospital. This can be achieved by providing amenities not usually found in
hospitals. These may range from attractive façade design and entrance areas, lounges
located on the floor (for patients and families) to small reading areas, Internet access,
and access to an electronic library, which can be educational. The ambiance in these
units should be one that aids healing and produces tranquility, the very anti-thesis of
institutional environmentsin hospitalsof thepast.
An easy and clearly indicated entrance for patients is an important design requirement
because of the urgency of the labor and delivery process and the stress and anxiety that
may accompany it. Patients come to the maternity department from a number of
places, such as the women's center main entrance, the emergency department
(especiallyafterhours),and thedoctor'soffice.
Today most healthcare facilities in the West direct patients through a central triage
area. At this point, physicians decide whether to observe or advance a patient to an
LDR/LDRP room or patient room or to a cesarean section room for immediate
delivery. The area may be adjacent to or shared with a cesarean section recovery area
for staffing efficiency and flexibility in assigning patient beds. Immediate proximity of
thisarea to thecesareansectionsuite is essentialforefficient transport time.
Marketingopportunitiesfor themainfacility
PatientandWorkFlow
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Patients in active labor are transferred to a labor room, an LDR room or a LDRP room,
where family members may join them. The LDR/ LDRP design concept incorporates
locating rooms around the perimeter of the facility for day-lighting and should allow
direct access from triage, the cesarean section area, resuscitation, and the neonatal
intensive care unit (NICU). Adequate patient and family amenities ensure a successful
labor anddelivery area.
In the LDRP model, staff flow begins with patient contact at the reception area, then
continues to the triage area, labor and delivery/recovery areas, and postpartum or
discharge area. In an LDR/LDRP concept, the patient will experience the same nursing
staff throughout the labor/delivery process. Staff will move clean equipment into the
roomfordelivery andremovepost-deliveryequipment forcleanup.
After post-delivery assessment, the infant often remains with the mother during
recovery before being transported to the nursery for further assessment, cleaning and
gowning. Infants in stress are transported directly to a transition nursery or an NICU if
directed by the neonatologist. After a delivery occurs in the cesarean section room, the
mother is transferred to the recovery area. At that point, the baby is observed in a
resuscitationareaora transition nurseryadjacentto the deliverysuite.
Physician and staff gowning facilities should provide a one-way flow into the cesarean
section suite, as in the surgery department. Physician and nurse work areas should be
decentralized and located closer to the patient areas to improve patient care and staff
efficiency.
The obstetrics area is the focal point of a comprehensive women's center. There are
some departments and services that have strong ties with the women's center. The
neonatal intensive care unit (NICU) should be contiguous because of the frequency
andpriority ofthe newborn being transferredto thisfacility.
The postpartum/ obstetrical inpatient unit and well-baby nursery require easy
accessibility, separated from public traffic and with horizontal or vertical access to
obstetrics. Emergency and surgery departments require easy access; cases might come
infromemergencyorgo to surgery.
In recently designed facilities in the West, the trend is to combine all services necessary
for comprehensive women's care, including perinatal services, pediatrics, breast
health services, and education centers, in addition to labor, delivery, recovery and
postpartumfacilities.
Relationshipswithother Departments

SpecialPlanningandDesignConsiderations
CLINICALPATHOLOGY
INTRODUCTION
There are a number of special planning and design considerations for obstetrics, as
enumeratedbelow:
1. Make the unit easily accessible to visitors, but separate patient and support traffic
fromvisitortraffic. Thisisnecessaryto protect thepatient'sprivacyand dignity.
2. Thedesignof the unit shouldbe sensitive to the needsof the familiesofthe patients;
the colors, materials, furnishings and the overall ambience should be appropriate
to the activities and mood. The use of artwork in harmony with the overall interior
design scheme can help create positive distractions and peaceful imagery desirable
inthe context.
3. The focus should be on creating an ambience of “wellness”, offering views of
nature,landscapescenery,andwateris very desirable.
4. In the inpatient areas (Rooms, LDR's, LDRP's), the design objective should be to
give patients and their families control over their environment through permitting
them to set lighting levels and the temperature to their comfort, providing
adequatestorage space,andTV/VCR/musicwith thecontrolsat the bedside.
The essential function of the department is to carry out diagnostic tests on specimens
from in-patients and outpatients. It may also be concerned with work for clinics, health
centers, local practitioners and the public health services. Within the department the
main divisions are those for histology and morbid anatomy, which involve the
microscopic examination of tissues and cells; hematology, the study of blood;
biochemistry, the study of living tissues and fluids, cytology, the study of body cells for
malignancy etc. and microbiology, the study of micro-organisms. Each of these
divisions may require sub-departments, their extent depending on the context and
policy of the laboratory. Larger hospitals may have a separate unit for blood
transfusionservices(a bloodbank).
In addition to those originating from outside the hospital specimens will be delivered
from the wards, the operating theaters, the mortuary, the outpatient department and
from the accident and emergency department. Some specimens, particularly blood
and urine, will be obtained from outpatients on the spot, and for this a sample
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collection center is needed. Nearly all specimens will pass through a central reception
and sorting office before distribution to the appropriate laboratory divisions. Small
ancillary units are often sited in the ICU (for speedy blood gas analysis) or in the
emergency unit. Planning for future expansion is important, as space requirements for
laboratoriestend to doubleevery 10years.
Laboratory requirements are inevitably complex, variable and confusing, and it is
essential that the brief should be comprehensive and precise if the resulting design is to
be successful. A bad brief is more likely to result in an unsatisfactory design than is
usual. The brief can usually be obtained in two stages, which correspond to the stages
in which the design team requires information to progress the scheme. The first is that
needed to produce the initial sketch designs; the second is that needed to produce the
detaileddesigns,fromwhichthe productioninformationcanbe prepared.
Thefirst stage brief consistsofaccommodationrequirements.Thisshouldinclude:
accommodation schedule-aroom-by-room list giving name, area and
occupancyofeach;
room relationship statement - guidance on rooms that need to be grouped in close
proximity orensuite;
operational policy statement - a general explanation of how it is proposed to
operate the facility, e.g. how the facility will be supplied, how waste will be
disposedof,hoursofoperation;
general environmental conditions - whether mechanical ventilation or air
conditioningisrequired inspecificareasorthroughout;
non standard requirements - identification of any rooms or areas in which out-of-
the-ordinaryspace,servicingorotherdemandswillaffectthe building form.
The second stage brief consists of detailed requirements. This should include room-by-
roomdetails of:
engineering services requirements - e.g. power supplies, water supplies, special
gases;
environmentalrequirements-ventilation, temperature, humidity,lighting;
fittings and equipment-e.g. benching, cupboards,fumecupboards,equipment;
finishing's-floor,wall andceiling finishes.
Information on the second stage is best gathered by means of room data sheets, on
which the detailed requirements and content of each room are recorded on a
standardizedproformafor theproject.
LOCATION
The following factors should be borne in mind when considering the location of a
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pathology department:
· It should be easily accessible from the OPD, accident and emergency and
maternity departments; surgical wards; operating theaters and intensive care
unit. Medical wards and other clinical departments should also be within easy
reach ofthesediagnosticfacilities.
· There should be a close link with the main hospital routes for ease of distribution of
laboratory specimen containers, reports and blood to the wards and other hospital
departments; ease of transport of specimens from these to the pathology
department andeaseofaccessfor medicalandotherhospitalstaff.
· The function of the hospital mortuary is closely linked with that of the pathology
department, in particular the histopathology departments activities and
personnel.Themortuary shouldbe easily accessibleto pathology staff.
· The whole department should be planned as an integral secure area. In particular,
the total number of entrances from the exterior should be minimal, to deter
unauthorized access. In addition, there should be no corridor traversing the
department which could be used as a link between other departments or constitute
a fireescaperouteexcept forusersofthedepartment.
· The receipt of bulk deliveries of laboratory supplies and large items of equipment
may influence planning decisions on the size and number of stores, positions of
lifts,hoists,corridorsanddoors.
· Laboratory areas are considered to be potential sources of infection and high fire-
risk areas. For these and for aesthetic reasons, proximity to staff accommodation
and to thoseareasfrequentedby thepublic isinadvisable.
· Goodaccessmustbe available forfire brigade vehicles.
· Exhausts from ventilation systems servicing the pathology department must be
discharged safely to avoid ingestion by neighboring supply ventilation systems or
entry into adjacentwindowsofnaturally ventilated spaces.
· Convenient access will be required to an incinerator for the safe disposal of
laboratory waste.
· Easy accessto external storesofgases andflammablematerialsis desirable.
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Specifications
ChemicalPathology Department
Automated testing:
Semi-automated or non-automated techniques:
· Lighting- Laboratory work requires a higher level of illumination at the
workbench, generally 500 lux, and to conserve energy it is best to have light
colored walls, ceiling, floor and furniture surfaces. High efficiency luminaires
withmirrorlouversandelectronicballastsare recommended.
· Walls and Ceilings-They should be impermeable, non-porous and smooth for
easycleaning.
· Floors- Laboratory floors should be level. If there is a particular requirement to
wash down the floor as in, for example, an autopsy laboratory, floor waste gully
traps will have to be installed. Floor coverings should be pre-finished sheet vinyl
or equivalent material manufactured specially for the laboratory use with welded
joints, taken 0'-6” up the walls. Abrasive-surfaced materials should not be used as
they are difficult to clean. However, some laboratories such as for autopsy are
washeddownandneednon-slipfloors.
· Workbench Surfacing- When selecting bench surface materials, the design team
should obtain samples of materials from the suppliers. The client can then apply
the chemicals and test the stain removal procedure recommended by the
suppliers. Other tests by the client may include heat, impact, cold (liquid nitrogen)
andabrasion.
Chemical pathology involves the detection and measurement of chemical and
biological substances in body fluids, mainly blood, serum and urine. Quantitative
changesgive anindicationofthe progressof diseaseorresponseto treatment.
Ingeneral there arethree types ofactivity that take place:
· high proportions of the most commonly requested tests are
automated, with some equipment having a high capacity. Instruments may be
linked to both data input at reception and download results to a laboratory
computer.Ingeneral instrumentsare freestanding.
· these cover a wide range of
techniques such as flame atomic absorption, chromatography, electrophoresis and
immunoassays, some of which utilize radioisotopes. The latter require a separate
room conforming to statutory regulations regarding radioactive substances.
Chromatographical techniques may require inflammable solvents and

electrophoresis,high voltage.
· A separate emergency laboratory must be located in a
position that allows inputs of urgent specimens at all times. It is advisable to have
the emergencylaboratory next to, orpartof,the automatedlaboratory.
Hematology
Hematology is concerned with diseases of the blood and blood forming tissues. A
hematology department should provide a comprehensive laboratory and clinical
service for patients with blood disorders and provide hematology and blood
transfusionsupportforclinicianscaring forpatientswith otherdiseases.
TheHematology departmentwill normallyincludethefollowing sections:
· General Hematology: Core investigations such as full blood count, differential
white cell count, erythrocyte sedimentation rate etc., are carried out in this area.
Most routine estimations are performed using complex automatic analyzers, some
of which utilize robotic sample handling and closed blood sampling. In many cases
microscopic examination of a blood film or bone marrow smear is part of the
diagnosticprocess.
· Special Hematology: The more specialized hematological investigations, such as
clotting tests, test for the control of anticoagulant therapy and Vitamin B12, Folate
andFerritin assaysamongstothers, arecarriedout here.
· Blood bank: This section handles the receipt, storage and issue of blood and blood
products for therapeutic use. Blood grouping and antibody screening and
identification tests are performed and where necessary blood matching is done for
donorandrecipient.
Provision for antenatal and postnatal serology will be required if the hospital has a
maternity unit.
Histopathology department
Histopathology is the study of tissues removed from the human body. This
department willnormallyincludethe followingsections:
· Histopathology: The majority of specimens are received in formalin from
operating theaters, out-patient clinics, post-mortem rooms and general
Emergency laboratory:
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practitioners, but items may also arrive in a fresh state. Some of the latter may
require examination as frozen sections. Specimens are examined and selected
portions of large, or the whole of small specimens, are passed through automatic
tissue processing machines, before embedding in paraffin wax or resin blocks.
These blocks are cut into sections that are transferred on to slides, stained,
protected by a cover slip and labeled. Medical staff will then examine the section
microscopically and make a report. Tissues remaining after the
specimenhasbeen cut up are stored for at least 4 weeks after the section has been
reported.
· Cytopathology: Cytopathology is the study of individual cells collected by
scraping from the surface of an organ, from a secretion or excretion, or by needle
aspiration from an organ or body cavity. A proportion of the specimens received
may already be fixed on slides. Others will be in suspension in fluid and
willneed either to be spread directly or first centrifuged before they are mounted
and processed for staining. Some specimens may require handling in a
safety cabinet. Subsequently cytopathology staff examines the stained slides and a
reportis made. Allslidesare usuallystoredformany years.
Provisionshouldbe madeforthe following:
1. The reception of specimens; their examination and dissection; dictation of
findings; and photographing of specimens. The tissue is processed using
automated systems and embedded in paraffin wax. Some tissue requires resin
processingand embedding. Space is required for storage of gross specimens for
avariable time during and after processing and for mounting of
preparedtissuefor demonstration purposes.
2. The cutting of tissue sections from cold wax blocks. These are mounted on
microscope slides, de-waxed and stained by automated or manual systems using
routine or special techniques. Frozen section investigations, involving freezing of
selected portions of unfixed tissue and cutting sections are required for some
examinations of specimens from operating theaters and for some
immunohistochemical techniques. These are then dried or fixed and stained. All
stained slides are placed in trays for dispatch to the pathologist for
microscope examination.
3. Special histopathology procedures, which include resin work comprising section
cutting, staining and mounting; histochemistry techniques or immunochemistry;
immuno-fluorescence; and crystallography where slides prepared in the general
laboratory are treated with antisera and dyes prior to microscopic examination. In
most, but not all cases, these techniques would be performed in teaching hospitals

rather thangeneral hospitals.
4. Cytopathology work which includes a processing area where slides are prepared
and ascreeningarea where they areexaminedmicroscopically.
MicrobiologyDepartment
Medical microbiology is the study of microorganisms that cause human infections,
and is dependent on the provision of suitable laboratory facilities for the isolation and
identification of bacteria, viruses, fungi and parasites from clinical specimens. Samples
such as blood, urine feces and swabs are examined by a combination of techniques,
including microscopic examination and culture of organisms. Detection of antibodies
in serumsamplesmay be undertaken. Bothmanualandautomated methodsarein use.
RADIOLOGY &IMAGINGSCIENCES
DiagnosticImaging
In the last two decades, the pace of advancement in imaging technology has drastically
accelerated. This is due to the development of digitized information technology—the
recording of images via electronic rather than film media. The first development with
widespreadclinicalapplicationswas computerizedaxial tomography, orthe CTscan.
Developments in digital technology will continue, making imaging more accessible
and cost-effective. There are various ways in which a signal is created; for example,
images are created with the use of isotopes generated by a cyclotron in positron
emission transmission. Magnetic resonance imaging (MRI) also uses digital imaging
technology. Not only does this afford a better way of imaging soft tissue, which does
not have to be made radio-opaque, it portends the development of spectroscopy
techniquesallowing chemicaldiagnosisof thebody without taking specimens.
Context
Imaging Facilities can be located in many places: the traditional hospital radiology
department, the ambulatory care center, freestanding imaging centers. In smaller
facilities, one department typically contains all modalities. In larger facilities,
inpatient and outpatient modalities may be separated. For example, there may be a
separate nuclear medicine department or MRI facility. In some instances, imaging
modalities can be collocated with other diagnostic/treatment facilities to create
healthcare centers of excellence (various technologies to focus on a specific organ or
patient type), suchasmammographyandultra-sonography in awomen'scenter.
Many modalities can also be provided through portable devices. This allows
procedures to be performed at the point of care in a patient's bedroom, in an
examinationroom,orin othertreatment areas,suchasthe operating room.
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Patient andwork flow
Patients may receive more than one procedure per visit, so it is important to quantify
the numberandthe average durationof proceduresa patient undergoes.
Patients can arrive at an imaging facility from a number of sources. Wheelchair or
stretcher-borne patients may come from inpatient units or other treatment areas, such
as emergency. Ambulatory patients may arrive—scheduled or without
appointments—at a reception desk. Typically, departments are configured to separate
the flowofthesetwo types ofpatients.
Another key consideration in patient flow is the requirement for changing— that is,
donning a hospital gown in preparation for a procedure. Historically, patients were
separated by gender and waited, gowned, in waiting areas. More recent departmental
designs provide individual dressing rooms adjacent to the procedure room, where
patientscanchangeand wait withgreater privacy.
The flow of patients through the department intersects with the process of image
generation, interpretation, and results reporting. Historically, this was a sequential
processthat involved.
1. Exposingthe film,usingthe appropriatemodality,
2. Developingandchecking thequality ofthe filmimage,
3. Repeating the exposureifnecessary,
4. Viewing andinterpretation by aradiologist,
5. Dictation andtranscription of the interpretation and forwardingthe report
to therequesting physicianorsurgeon,
6. Filing boththe filmandthe written report.
This process required the radiologist's location to be central to the patient and work
flow in order to expedite the interpretation of the film. With the development of
digitizedimagestorage systems,this needhasdwindled.

Relationships with otherdepartments
The imaging department interacts with a large number of other departments. Both
outpatients and inpatients can be referred to Imaging for diagnostic studies; however,
certain departments have stronger relationships with imaging. The emergency
department, for example, is frequently positioned adjacent to imaging because of the
large proportionof emergencypatientsrequiringpromptradiologicalstudies.
Other special situations include casting facilities, women's diagnostic centers, and
nuclear cardiology. Casting facilities, for resetting broken bones, may be placed in
emergency departments or in specialty clinics. These facilities require radiography to
ensure that broken bones have been set properly. This is usually achieved by providing
radiographic capabilities in or adjacent to cast rooms. Otherwise, the casting area
should benexttoimagingfor confirmingtheappropriatenessof bonereduction.
Women's diagnostic centers require mammography, ultra-sonography, and bone
d nsitometry to test for osteoporosis. Satellite imaging facilities are often incorporated
within these centers. Alternatively, women's imaging may be incorporated as a "sub-
department"of imaging,withaseparateentranceandwaitingarea.
Nuclear cardiology is a unique crossover of services providing cardiologic diagnosis
via imaging technology. The process involves introducing a radioactive medium into
the vascular system. The effectiveness of the patient's cardiovascular system is then
observed by monitoring the movement of the medium through the body while the
patient is "stressed" through exercise. Because this service treats cardiology patients,
the usual preference is to perform such studies in cardio-diagnostic areas (e.g., in a
noninvasivecardiaclaboratory).
e
An Imaging Departments Interrelationship Diagram
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Space summary
Generalfluoroscopy room
Radiography room Radiography is the simplest form of radiology, relying on direct
exposure of film (or a digital image processor) with an X-ray-emitting device called a
tube. This is most useful for creating images of X-ray absorbing tissues such as bones.A
variation of radiography is tomography, which uses a rotating tube source and film
carrier to create a two-dimensional image of a "slice" of the body. Although the
equipment is slightly different, the room requirements and considerations are essentially
thesamefor both techniques.Alltypesof radiographyrooms requirelead-linedwalls.
Recommended dimensions: 17 ft x 15 ft; making the room 20 ft x 16 ft renders it capable
of conversion to a radiography/fluoroscopy room, should that later be
desirable.
Ceilingheight:9ft 6in.
Key designconsiderations:
C o n f i g u r e t h e s p a c e t o a l l o w a
s tretcher to be maneuvered
intotheroomwit minimum turns, typically
by placingtheaxis oftheX-ray tableperpendiculartothe wall with the door by
whichthepatientwillentertheroom.
Place the control console opposite the door with direct access to the vertical work
core.
Special equipment: Table and tube, wall bucky (a device that holds film in a position
during exposure), control console, sink and casework, and transformer and power
cabinet(thelattermaybeplacedoutsidetheroom).
Individualsupportingspaces:None.
Fluoroscopy makes use of radio-opaque media that may be introduced int! the body to
create images of tissue that would not otherwise show up well on an X-ray. Because the
radio-opaque material is typically barium introduced through the mouth or the rectum, it
is importanttohaveatoiletroomdirectlyaccessiblefromtheprocedureroom.
Recommendeddimensions:20 ftx 16ft
Ceilingheight:9ft 6in.
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Configure the space to allow a stretcher to be maneuvered into the room with
minimum turns, typically by placing the axis of the X-ray table perpendicular to the wall
withthedoorby whichthepatientwillentertheroom.
Placethecontrolconsoleoppositethedoor withdirectaccesstothework core.
Theseroomsoftenserveas radiograhyrooms as well.
Attac thetoiletroom directlytothefluoroscopyroom.
Bariummaybepreparedintheprocedureroomor anearby"kitchen.''
Special equipment: Fluoroscopic X-ray tube and table, image intensifier, cine or "spot"
film camera, video monitor, wall bucky, control console, sink and casework, and
transformerand powercabinet(thelattermaybeplacedoutsidetheroom).
Individual supporting s aces: Patient toilet, barium
preparationarea.
Chest X-rays typically constitute the largest single category of diagnostic procedures.
They are often performed as a screening tool in conjunction with hospital admission or
invasive procedures that will require general anesthesia and suppression of respiration.
Many radiography or radiography/fluoroscopy rooms are equipped with wall buckies
for chest imaging. However, because chest imaging can constitute a high proportion of
this department's activity, a large department can justify dedicating a room or rooms
solely to chest imaging. Because such rooms are designed specifically for this purpose,
they are typically more operationally efficient than multipurpose rooms. Even greater
effic̴enci es can be achieved by incorporating film processing with
equipmentthatautomaticallyfeeds dir̻ctlyintothefilmprocessor.
Recommended dimensions: 12 ft x 11 ft (widiout in-room processing), 16 ft x 14 ft
(with in-roomprocessing)
Ceilingheight:9ft6in.
Keydesign considerations;
To maximize efficiency, the equipment control console is typically incorporated
directlyintotheroom.
Thefocallengthof thetubeassemblyis fixedandmustbemaintained.
h
p
Chest room
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? If in-room processing is utilized, chemicals and equipment must be
accommodatedoutsidethepatientarea.
In larger rooms, it is possible that a stretcher-borne patient will be X-rayed. Thus, the
room should have a door large enough to accommodate a stretcher and be configured to
allowmaneuveringofthestretcher.
Special equipment: Tube assembly, changer and stand, console control and transformer
in room without processing; the same equipment, plus auto film transport, auto film
processor, silverrecovery, andchemicalmanifoldinroomwithprocessing.
Individualsupportingspaces: None.
Mammography is a specific type of radiography that employs low-level radiation to
identify tumoral calcifications and to characterize palpable lumps and unpalpable cysts
or lumps in breast tissue. The mammography room is single-purpose room with a X-ray
unit. Using a specialized type of mammography, the stereotactic room provides the
radiologist with a three-dimensional view of the breast for localizing neoplasms for
biopsy.
Recommended dimensions: 10 ft x 12 ft for an upright 18 ft
stereotactic
Ceilingheight:8 ft
As this is a smaller room and the patient will be disrobed, reverse swinging doors and/or
cuũtainsareusedto preventexposureof thepatient.
Special equipment: Mammography unit, film illuminators, and sink in a mammography
room;stereo-tacticbiopsy table,operatorsconsoleanddigitizerinastereo-tacticroom.
Individualsupportingspaces:None.
Ultrasound or sonography operates on the principles of sonar and records size and shape
by tracking reflected sound waves. Typically, a hand-held transducer emits regular
pulses of high-frequency sound and translates the received "echoes" into images.
Because tissue density affects sound reflectivity, the returned sound wave's amplitude
allows graphic depiction of different tissues. This procedure is especially beneficial
when theuse of ionizingrayscouldbeharmfulto tissue,such aswhen afetus ispresent.
Mammography room
unit, ft X 12 for a prone or
unit
Ultrasound room

Recommendeddimensions:11 ftX 14 ft
Ceilingheight:8 ft
Key design considerations: Because this is a smaller room and the patient may be
disrobed, reverse swinging doors and/or curtains are used to prevent exposure of the
patient.
Special equipment: Ultrasound unit (console typically placed to the patient's right side),
stretcher, filmilluminators.
Individualsupportingspaces:None
A computed tomography (CT) room provides an X-ray source that rotates rapidly
aroundapatient,generatingdigitaldata.
Recommended dimensions: 16 ft x 19 ft for a procedure room, 10 ft x 12 ft for a control
room,and7 ftX 10ft foran equipmentroom.
Ceilingheight:9 ft6 in.
Key desigȀ considerations: The patient access door should be positioned to minimize
stretcherturning becauseof the lengthof the equipment.At the same time,the view from
the control room of the patient on the table while positioned in the opening of the unit
must be at least partially preserved.At times, a video camera is used to supplement this
capability.
Special equipment: CT gantry and table in the procedure room. The control room
includes operator's console, video monitor, injector control, laser imager, and
physician's viewing or diagnostic station. (The last two items may be placed remotely in
amultiunitsuite.)An equipmentroomhouses thepowerand computerequipment.
Individual supporting spaces: Control and equipment rooms. These may serve more
thanoneprocedureroom.
Magnetic resonance imaging (MRI) is performed by placing the patient in a powerful
magnetic field that aligns the magnetic spin of atomic nuclei. Radio frequency energy is
CTscanning room
MRI scanning room
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introduced, which disturbs the alignment of the nuclei. Different atoms respond at
different radio frequencies, thus providing a distinction between tissue types. This
powerful tool does not utilize ionizing rays and can create detailed two-and three-
dimensionalimagesof bothhard andsoft tissue.
Recommended dimensions:Varies with strength of magnet; generally, about 20 ft x 26 ft
for procedure room with a mid-strength magnet; along with a 10 ft X 12 ft control room
and an 8 ft x 18 ft adjacent equipment/computer room. With lower-strength magnets,
the room can be as small as 12ftx 16 ft with a 9 ft x 12ft equipment room and the control
stationin theopen. (Refertomanufacturer's specificationsfor specificmodel.)
Ceilingheight:Varies.
The MRI magnet creates a field whose strength diminishes with distance. Magnetic
field strength is expressed in units of measure called gauss. More recent
generationsof MRI unitscontainthe5-gauss linewithintheprocedureroomitself.
As MRI's use radio frequencies to generate images, they are susceptible to
electromagnetic interference from outside sources. To shield the room it is often
wrappedwith acopperfabric.
Because the patient is placed into a unit approximately 8 ft in length and 2'/2 ft in
diameter, claustrophobia can be a problem. New-generation magnets have
mitigated this problem with ultra-low field strength magnets designed with open
architecture. Still, procedure room interior design should take into consideration
exteriorlighting(or theimplicationof it)andotherdevicestoaddress thisissue.
Special equipment: MRI unit, patient couch, and coil storage in procedure room.
Control room includes operators console and video monitor. Equipment room houses
thepowerand computerequipment.
Individual supporting spaces: Control and equipment rooms. These may serve more
thanoneprocedureroom.
Unlike radiography, which transmits radiation in the form of X-rays, nuclear medicine
introduces a low-strength, short-lived, radiation-emitting isotope into the body. The
emissions are captured by a camera and translated into Images. By introducing the
isotope or radio-pharmaceutical into specific tissues and organs, radiologists can
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Nuclearmedicineroom

capture images that would otherwise be unattainable. A recently developed type of
nuclear medicine camera—single photon emission computed tomography, or
SPECT—has gained wide acceptance and application. It combines a nuclear medicine
or gamma camera with digital image acquisition and interpretation capabilities to
generatetomographicportrayalsofblood flowto thebrainandheart.
Recommended dimensions: 18 ft X 16 ft for a single camera room. Because nuclear
medicine does not involve the use of X-rays, multiple cameras may be placed in a single
roomwith adequatespace.
Ceilingheight:9 ft
Keydesignconsiderations:
Because nuclear medicine involves the use of radioactive materials, special
provisions must be made for their containment and disposal. Most of these are
injectable substances. However, some are gaseous pharmaceuticals, such as xenon
gas for ventilationstudies,whichmust bespeciallycontainedandexhausted.
Special equipment: Control console, computer workstation, collimator, collimator
stand, wholebodyscintillationcameraandtable,andxenon deliverysystem.
Individualsupporting spaces:
A hot lab where radiopharmaceuticals are prepared, equipped with cabinets and
work counter, lead-lined containers for storing and working with radioactive
substances, lead-lined refrigerator, 100 percent exhaust radioisotope hood, and
approvedsystemfor radioactivewastecollectionand disposal.
Dose room, where patients are injected with radio pharmaceuticals.The inclusion of
this roomenhancesprocedureroomproductivity.
In the positron emission tomography (PET) scanning room, physicians introduce
radioisotopes by injection or inhalation. The isotope attaches to the body's own
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molecules, becoming a tracer as it moves throughout the body. Typically, the isotope is
very short-lived and must be generated on-site with a cyclotron. This makes PET an
expensive,buteffective,diagnostictool.
Recommendeddimensions:15 ft x20 ftfor scannerroomalone
Ceilingheight:10 ft
Keydesign considerations:
Ideally, the scanning room is placed adjacent to the radiochemistry lab, which itself
must be adjacent the cyclotron. When this is not possible, a pneumatic tube system
canbeused todelivertheradiopharmaceuticaltotheclinicallab.
Specialequipment:Scannerandpatientcouch,computer. Individualsupportingspaces:
Cyclotron room of 500 sq ft with 10 ft ceiling. Because of the weight of these units
(approximately120,000 lb),a gradelevellocationshould besought.
Radiochemistry lab of 600 sq ft where the actual pharmaceuticals are prepared.
Ideally, itis locatedadjacenttothecyclotronroom.
A control room, where computer equipment for data acquisition and processing is
housed.
Patientpreparationrooms withstretchersor chairs.
Special radiography/fluoroscopy procedure rooms Special radiography/fluoroscopy
procedures include techniques that employ radiographic or fluoroscopic imaging
equipmentfor guidanceduring complexexploratoryandinterventionalprocedures.
Although the procedures performed in these rooms may vary, they have in common the
introduction of a catheter and the use of large and complex equipment, including one or
two fluoroscopic C-arms. Because the introduction of a catheter invades the body, some
minimallysteriletechniquesmustbe observed.
Recommendeddimensions:28 ft x22 ftfor theprocedureroomalone
Ceilingheight:10 ftKey designconsiderations:
The equipment should be arranged to allow visibility of the patient's head from the
controlmonitor.
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Many procedures occur while the patient is awake and acutely aware of his or her
surroundings. Therefore, measures should be taken to create a soothing
environment.
Because the procedures require a semi-sterile environment, extraneous traffic should
be limited.
Radiographic/fluoroscopic arm(s), one or two, depending on whether the unit has
biplane capabilities; video monitors, patient table, injector, surgical lights and back
tables,andcatheterstorage.
Individualsupporting spaces:
Control room 22 ft X 12 ft, containing control console, multi-format camera or laser
imager,scrub sink, andstoragecabinets.
Equipmentroom10 ftX 22 ft,housing electronicscabinets.
Patientpreparationand recoveryarea.
Staff gowningandchangingfacilities.
The following list summarizes supporting spaces typically included in diagnostic
imagingdepartments:
Waiting/receptionarea
Gowned waitingareasfor departments
Dressing areasfor gowned waitingor individualprocedurerooms
Toiletrooms for patients
Specialequipment:
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Darkroomfor processingconventionalfilms
Daylightprocessingarea
Digitalimageprocessing area
« Lightroom/qualityassurancearea
Imagereadingor interpretationarea
Viewing/consultationareas" Filmfilesarea
Cleansupply room
Soiledutilityroom
Staff locker/lounge/toilets" Storagealcoves
Historically, films have moved from the procedure rooms to a processing, checking, and
assembly area that serves several rooms.Although conventional film processing is less
prevalent, this "work core" design is still one of the most staff-efficient configurations
for a department. Typically, procedure rooms encircle a work core, with staff access
fromwithinthecoreandpatientaccessfromtheperimeter.
In larger departments, like modalities are grouped around these cores to create pods or
clusters. For example, radiography and radiography/fluoroscopy rooms are typically
grouped.
Mammography and ultrasound may be grouped to serve women patients. Most
departments are made up of groups of clusters aggregated around common or
complementarymodalities.
The pods or clusters organized around work cores are the clinical heart of the
department. Typically, they are interposed between the public access areas— reception
and waiting—and the staff areas—personnel facilities, storage and utility rooms,
radiologist offices, and reading areas. It is important to organize the department to allow
future expansion in key corridors. If any spaces are placed in the path of this expansion,
theyshouldbe "soft" or easilyrelocatedareas.
Workcoredesign
Departmentorganization

Departmental organization must recognize the potential use of mobile technology. This
usually requires providing a sub-waiting area with access to the trailer in which the
mobile device is contained. Depending on the climate, access may be via a covered,
open-air, or pneumaticallyenclosedstructure.
Interior design considerations An imaging department requires high-technology
equipment for diagnosing and treating individuals who may already be in a heightened
state of anxiety. Thus, it is most important to create environments that are friendly and
non-threatening. In addition to the appropriate furniture, fabrics, and colors, positive
distractions may be included, such as artwork, views to the outdoors, and aquariums, to
relievestress and anxiety.
Lighting is also used to create a more soothing environment. Particularly important is
the use of reflected lighting in areas where patients will be lying on their backs on
stretchersor proceduretables.
Imaging is clearly one of the areas most affected by developing technology, particularly
digitallybasedequipment.
Special diagnostics services typically include noninvasive testing of the human body's
cardiovascular or neurological performance. The tests principally use electronic,
sonographic, or scintillation counter technology to monitor the body's anatomy or
physiological activity. These procedures produce measurements that are recorded over
time in hard copy or digital storage media for physician review and reference. Most
measurements occur over periods of 5 to 45 minutes, although durations of 24 hours are
usefulin somestudies.
Noninvasivediagnostictestingof thecardiovascularsystems includesthefollowing:
Electrocardiograph)/(ECG).
Observationof cardiacperformancethroughelectronicphysiologicalmonitoring.
Echocardiography (Echo ECG)-Observation of cardiac performance through Doppler
ultra-sonography monitoring coupled with physiological monitoring. Transthoracic
echocardiography is the basic study, and transesophageal echocardiography (TEE) is a
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SpecialDiagnostic Departments
Functionaloverview
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commonprocedureusing thesametechnology.
Exercise stress testing. Observation of cardiac performance through physiological
monitoring while the patient is subjected to varying levels of exercise demand by
treadmill or exercycle. Tilt tables may also be provided in this area for identifying
reflex-inducedproblems.
Nuclear scans. Observation of cardiovascular performance through physiological
monitoring and gamma camera or SPECT (single photon emission computerized
tomography) camera imaging of absorbed substances tagged with radioactive isotopes.
Patients are typically subjected to varying levels of exercise demand via treadmill or
exercycle during these studies. Nuclear scans combined with computerized
tomography, known as PET scanning (positron emission tomography), are also useful
but remain cost-prohibitive in most cases.Thus, this technology is generally found only
inteachinginstitutionstodate.
Holter monitoring. An ambulatory ECG recorded continuously over a 24-hour period
via portable magnetic tape media to monitor electro-physiological data related to
cardiacbehaviorandperformance.
Pacemaker verification. Periodic and routine testing of pacemaker devices inserted to
assist inregularizingthebehaviorof theheart.
Peripheral vascular studies (PV). Noninvasive testing of the arteries, veins, and
lymphaticsysteminthebody extremities,using Dopplerultra-sonography.
Noninvasivediagnostictestingoftheneurologicalsystemutilizesthefollowingstudies:
Electroencephalography(EEC).
Observationofbrainactivitythroughelectronicphysiologicalmonitoring.
Sleep studies. Extended observation via camera and microphone, along with electronic
physiological monitoring via EEG and EKG, through normal (8-hour) or short-term
periodsof sleep.
Special diagnostic services are typically found in hospital settings within departments
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including cardiology, cardiovascular, cardiopulmonary, neuro-diagnostic, or electro-
diagnostic services. These services are often centralized for inpatients and outpatients,
although most inpatient ECG and EEG studies are conducted at the patient's bedside.
Stress testing, echo ECG, peripheral vascular (PV) studies, and isotope scans are
usually centralized owing to equipment requirements. Outpatient ECGs are completed
mainly in physicians' offices, except when required for hospital preadmission testing
records. Holter monitoring, pacemaker verification, and sleep studies are entirely
outpatientservices.
Planning for special diagnostics is based on projected work load volumes for inpatients
and outpatients. The work loads are categorized by average procedure time and
distribution between inpatient and outpatient volumes (see table above). The
percentage of inpatient services is important, because many procedures are performed
in the inpatient's room, thus reducing demand for diagnostic space within the central
areaof theservice.
Key capacity determinants The variety of special diagnostic services requires many
distinct procedure rooms to separate functionally incompatible activities, facilitate
efficient work flow, and avoid excessive waiting time for patients. Some procedures,
such as exercise stress testing, require strenuous physical activity by the patient.
Doppler equipment used in echocardiography studies may generate noise. Risk of
exposure to radioactive materials used in nuclear scans must be carefully controlled.
Sleep and EEG studies require quiet areas without significant audio stimuli. The
number of these rooms required is based on an 8 hours per day, 5 or 6 days per week
(excluding holidays) schedule. The service is available on a 24-hour basis in the acute
caresetting,but principallyfor emergencyneedsafterregularhours.
Patient and work flow Easy patient access to special diagnostic procedure rooms is
paramount. These rooms are designed for outpatient convenience. Scheduled
appointments dictate that adequate parking, clear ambulatory care entrance points, and
simple way finding to the reception and waiting areas be available.Ambulatory patients
should have direct access between the waiting area and procedure rooms without
passing through staff or physician work areas. Easy transfer of inpatients, as required, to
procedure rooms is also a factor in design. Clear access to inpatient areas that keeps
patientsor staff frompassingthrough publicspacesis preferable.
The technician staff requires workroom space close to the procedure areas, to Inpatient
accesstotestingareasmustbeavailablewithouttransportthroughpublicareas.
Centralized staff work areas, where charting is performed outside testing rooms,
Keyactivityfactors
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provide for quick room turnaround.These work areas must be close to the procedure
spaceto minimizetraveldistance.
Physician reading areas must be nearby, but separated for EGG (hard-copy review),
echo EKG and peripheral vascular (video monitor review), and EEG (hard copy
review)functions.
A central location is required for observation of multiple EEG, sleep lab, and
multiplestress testingstations.
The healthcare technology industry will continue to explore alternative imaging and
physiological testing modalities that are faster, less intrusive, and more reliable than
currently used tools. Efforts to simplify the patient care process and to minimize the
specialized expertise required of staff will stimulate the development of smaller, more
portable, and more rapid measurement devices capable of use at the point of care.
Where such devices still require centralized use because of cost or lack of portability,
the establishment of quick diagnostic centers will absorb many of these services into
convenient areas of care where common testing required for outpatients and
preadmissiontestingofinpatientsareco-located.
Oncology therapy is treatment for cancer patients. Two common forms of cancer
treatment are chemotherapy and radiation therapy. Chemotherapy is the intravenous
admission of chemicals that attack cancer cells. Radiation therapy is the exposure of
cancer cells to radiation. This radiation can be introduced to the body either through
direct implantation—called brachytherapy—or by means of a beam of radiation from a
linear accelerator or a screened radioactive source. Because radiation is not selective
regarding the type of cells it kills, treatment planning for radiation therapy is quite
complex. Both chemotherapy and radiation therapy require patient preparation and
recovery. Most chemotherapy and radiation therapies are provided in an ambulatory
care setting. Because of the difference in treatment modalities, the two therapies can be
separated from each other. However, 30 percent of cancer treatment regimens involve
both chemotherapyandradiationtherapy.
Patient examination and treatment, as well as treatment planning, are key activity
factors. The number of patients being treated and the type of healing environment
needed determine space requirements. In radiation therapy, equipment requirements
are extensive, as are requirements for shielding. In both chemotherapy and radiation
therapy, properstaff supervisionis criticaltotheefficientutilizationof space.
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Oncology

Chemoterapy is administered in a non-technical area designed as patient-friendly space.
The process is traumatic, stressful, and lengthy. The amount of space required depends
on the total patient volume and type of desired treatment. Separate patient rooms and
individual cubicles provide privacy, while open treatment bays encourage interaction
with other patients. Creating a healing environment is the design goal for the
chemotherapyfacility.
Radiation therapy is performed in an area housing highly technical equipment, operated
by highly specialized staff.The therapy is usually administered by linear accelerators.A
shieldmustconfinethedangerousbeamof radiationcreatedby thelinearaccelerators.
The flow of oncology patients is very predictable, because patients undergoing either
chemotherapy or radiation therapy are usually ambulatory and regularly scheduled.
Facilities are needed for those patients who are weak and nauseous following
treatments. Radiation therapy involves initial examination and consultation with the
patient, treatment planning by the staff, treatment simulation using diagnostic x-rays to
confirm the treatment and then the radiation treatment. Both therapies usually consist of
morethanone treatment.
Oncology therapy has few relationships with other departments because most cancer
patients are ambulatory. A key factor is direct exterior access to chemotherapy and
radiation therapy, respecting patient privacy. Oncology does need access to emergency
facilities, but not directly to the emergency department. Chemotherapy requires a
connectiontothepharmacyforpreparationsof administeredchemicals.
The equipment and shielding requirements for radiation therapy are the most significant
for any area in oncology. Linear accelerators aim and focus a beam of high-level
radiation. To confine the effects of the beam to the treatment vault itself, substantial
radiation shielding is required. Although lead and steel are highly effective shields,
concrete is more commonly used because of its lower cost. Eighteen to 20 megavolt
linear accelerators produce a beam that can be shielded by approximately 8 ft solid
concrete.
To aim the beam, the linear accelerator must be capable of 360 degree rotation. In turn, a
room with a 10 ft overhead clearance and a 360 degree shield along the sides requires a
significant amount of floor area and building height. Because of the permanency of this
kindof construction,carefulplanningforplacementis imperative.
Flowof patients
Keyspaces
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Typicalroomsizes forradiationtherapyareas follows:
Therapyvaults—highenergy 600sq ft
Therapyvaults—lowenergy 500sq ft
Controlareas 130sq ft
Equipment 100sq ft
Entrymaze 140sq ft
Simulator 300sq ft
Treatmentplanning 200sq ft
Dosimetrist's office 120sq ft
Moldroom 250sq ft
Patienttoilets 60sq ft
Sub-waitingareas 20sq fteach
Familywaitingareas 18sq fteach
Brachytherapy is the implantation of a radioactive source in or near the site of a
cancerous mass. Implantation can be implemented surgically or by catheter. A patient
must be monitored during therapy, usually in a patient room that is specifically shielded
to preventexposuretootherpatients.
Typicalroomareasfor chemotherapyareasfollows:
Opentreatmentbays 60sq ft
Treatmentcubicles 60—80 sq ft
Treatmentgroups 100-150sq ft
Nurses' station 150+sq ft
Patienttoilets 50-60sq ft
(ADAcompliant)
Familywaitingareas 15sq ftperperson
Examinationrooms 120sq ft
The stress and anxiety felt by many cancer patients can be eased somewhat if there is an
opportunityforcamaraderiewithotherpatientsin mutualsupport.
The design of the facilities for oncology therapy should provide opportunities for such
interaction. Because of the effects of therapy on the physical appearance of patients,
privacyand discretionarekeydesignconsiderations.
The need for staff to supervise patients during and after their treatment influences all
design solutions. Treatment planning is a staff function that is screened from patients
physically and audibly. A hot lab houses radioactive substances that are prepared for
Keydesign considerations

brachytherapy implantation. The room must be shielded and located adjacent to the
room where implantation takes place. Preparation in the pharmacy for chemotherapy
requireslaminarflowmixinghoods toensure thesterilityoftheadministeredagents.
Physical medicine and rehabilitation (PM&R) offers services to individuals who are
physically disadvantaged, with the purpose of returning them to their maximum
physical capabilities. These services may include physical therapy, occupational
therapy, speech pathology, audiology, and specializedprograms; they may be supported
with the development of orthotics and prosthetics to assist in their functioning. Physical
medicineandrehabilitationareprovidedon aninpatient,outpatient,or in-homebasis.
Physical therapy concentrates on gross neuromuscular and skeletal activity, with
emphasis on regaining movement, circulation, and coordination of body and limbs.
Typical components of the physical therapy service are treatment areas, a gymnasium,
and a hydrotherapy area. Treatment areas may be individual cubicles or rooms. A
number of therapies can be administered in these areas, including thermal therapy,
electrical stimulation, massage, and manipulation. A gymnasium is generally
configured with equipment for several functions located in a common space, such as
mats, platforms, gait training stairs, parallel bars, and weights, as well as other resistive
equipment and orthotic and prosthetic training services. The gym can also serve as a
multipurpose space, supporting other uses such as sports events (e.g., wheelchair
basketball) and community activities. In long-term rehabilitation facilities, the physical
therapyprogrammaybe expandedintorecreationaltherapyfor patients.
Hydrotherapy is a treatment with warm to hot circulating water in tanks. The tanks are
used either for the extremities, such as the legs and arms, or for full-body submersion.
Hubbard tanks, which are configured to allow each limb to be fully extended, are also
used. The warm to hot water circulating around the body or parts of the body stimulates
blood circulation, promoting healing and reduction of pain. Larger therapy pools allow
patients to exercise while suspended in water, thus reducing the impact of body weight
during therapy. The humidity of these areas should be carefully controlled through the
mechanicalventilationsystem.
Occupational therapy focuses on optimizing a patients independence while
concentrating on finer physical movements. Activities of daily living (ADL),
vocational training, and, in some cases, a work-hardening program are used to
rehabilitatethepatient.
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The activities of daily living are routine tasks that individuals are required to perform.
The area provided for this therapy includes a mock bedroom, kitchen, and bathroom.
These areas provide the patient with an opportunity to learn the basic essentials of
cooking,hygiene,anddressing withthebenefitof anattendingtherapist.
The vocational training area houses a variety of equipment, including word processors,
computers, cash registers, and telephone switchboards, simulating a work
environment. The area may also include wood and metal workshops. Some
occupational therapy services include work-hardening programs, which simulate an
industrial environment, providing both education and therapy for a more rigorous work
setting. Patients learn to perform work tasks and to protect themselves from further
injury. Because of the noise made by equipment, it is important to address acoustics in
thevocationaltrainingarea.
Apatient's injuries or disease may result in communication disabilities. These are most
commonly related to cerebrovascular (stroke) and head trauma. The purpose of therapy
is to assist a patient in regaining control or adapting to a specific communication
disability, which may include cognitive retraining. Communication disabilities include
problems with speech and/or hearing. Audiology is most effectively supported
diagnostically by two-compartment sound-isolated booths. In the booths patients are
accurately tested for hearing loss, as well as the effectiveness of prescribed hearing
devices.
Specialized programs Many providers have specialized programs in physical medicine
and rehabilitation. These may include a pain clinic, cardiac rehabilitation, sports
medicine, and hand therapy. Specialized areas may be required for these programs.
However, many are similar in configuration to the areas for the services already
described.
Physical medicine and rehabilitation services may be housed in a variety of settings,
including hospitals, ambulatory care centers, and comprehensive specialty
rehabilitation facilities. Care is provided under several physician specialties such as
physiatry, orthopedics, neurology, cardiology, and others. The specialty centers may
include rehabilitation treatment for cerebrovascular/stroke, spinal cord injury, head
trauma, amputation, developmental disabilities, neurological degeneration,
complicatedfractures,cardiacconditions,orgeneticdisorders.
Operational considerations The size, internal relationships, configuration, and location
Speech pathology and audiology
Settings

of physical medicine and rehabilitation services are dependent on their work loads.
Work load is determined by the number of inpatient or outpatient visits and treatments
received within the operating hours of the services. Capacity is determined by such
factors as the number of treatment cubicles, mats, therapy positions or stations,
cognitiveretainingrooms,and hydrotherapytanks.
Patient and work flows shape the design of the PM&R area. Because of their various
disabilities, patients require convenient access to the services. In hospitals, the PM&R
services are often located near the elevators at grade. This location is easily reached by
inpatients and outpatients. Patients must be visible and accessible to staff. Satellite
therapy areas may be located on nursing units for the convenience of less mobile
patients.Many initialtherapiesoccurinthepatient's room.
PM&R services are related to other departments and services within a hospital. The
most common relationships are with nursing units, such as orthopedic, cardiac,
neurological, and other units. These services should also be accessible to outpatient
entrances,withadedicatedentrancenearconvenientparking.
Thefollowingaresuggestedsupport areasfor PM&R:
Lounge,personallockers,toilet,and, possibly, aplacetoshower
Meetingspacefor continuededucationandtraining
Clean workroom, soiled utility, housekeeping, equipment storage, wheelchair and
stretcher storage Larger facilities may also have an orthotics and prosthetics
department. The department supplies, manufactures, and fits devices to assist
patients' mobility and dexterity.These devices may include artificial limbs, assistive
appliances,braces,crutches,andwheelchairs.
According to the AIA 1996-1997 Guidelines for Design and Construction of Hospital
and Health Care Facilities, typical physical medicine and rehabilitation services
includefivemajorareas:
Administrative/work
Physicaltherapy
Occupationaltherapy
Speechpathology/audiology
Support areas
Spaceneeds
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Support/staff
Thefollowingareareastypicallyrequiredin thedepartment:
Receptionandwaiting(outpatientor stagingofinpatients)
Administrativeofficeand clericalspace
Patienttoilet
Wheelchairandstretcherstorage
Housekeepingcloset
Access toconferenceroom
Physicaltherapy
Individualtherapytreatmentareaswithaminimumof 70 sq ft
Hand washingarea
Exercisearea(gym)
Cleanlinenstorage
Equipmentandsupply storage
Soiledutility
Patientdressingareas,showers, andlockers(if required)
Hydrotherapy(when required)
Occupationaltherapy
Patientwork areas
Hand washing area

Equipmentandsupply storage
Activitiesof dailylivingareas
Speechpathologyandaudiology
Evaluationand treatmentarea
Spacefor equipmentandstorage
Orthoticsandprosthetics
Work space
Spacefor fittingandevaluating
Spacefor equipment,supplies,andstorage
These areas should be planned in a manner that encourages quality patient care,
appropriatespacefortheproposed work load,andstaff efficiency.
An overriding issue in PM&R is accessibility for patients with restricted mobility. In
treatment areas, space must accommodate not only the patient and therapist but also the
transportation modalities used to get the patient to therapy— such as a stretcher,
wheelchair, or walker. Slip-resistant floor surfaces should have no tripping hazards and
mustacceptwheelchairsandwalkingaccessories.
Heating, ventilation, and air-conditioning systems should address several demands in
the PM&R department. Humidity control is required in hydro-therapy and therapy pool
areas. Orthotics and prosthetic manufacturing areas require special consideration of
acousticalneedsandcontrolof fumesanddust.
Physicalmedicineandrehabilitation
services will be performed more often in outpatient and home care settings. These
services will also be more and more decentralized within the community for
convenience and ease of access. There is a trend toward the development of specialty
centers of excellence for certain rehabilitation services such as those provided for spinal
cord injuries, head trauma, stroke, and development rehabilitation. However, physical
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medicine and rehabilitation will continue to play an important role in the continuity of
care—frominpatienttohomecare—inboth medicaland surgicalspecialties.
Renal dialysis is the simulation of kidney functions for patients in chronic end-stage
renal failure or temporary acute kidney failure. The simulation may be performed by
two primary methods— hemodialysis or peritoneal dialysis. Hemodialysis is the
filtering of an individual's blood to remove the uremic toxins and water typically
removed by the kidneys. The process is implemented by a machine connected to the
body's veins through large-bore needles and plastic tubes. These needles may be placed
in surgically created fistulas or artificial implants. These are more commonly located in
the arm, but the needles may also be placed in the neck or leg regions. The blood is
circulated through a membrane filter whereby toxins and water are removed.Alarms on
the machine monitor biophysical parameters such as the patients body temperature,
relative blood volume, and hematocrit and electrolyte balances. This procedure may be
required three days a week and varies in duration from two to four hours. Home dialysis
withthismethodispossible, butlimitedby costand caregiveravailability.
Peritoneal dialysis is the removal of uremic toxins and water from the body through the
peritoneal cavity around the abdominal organs. This is performed by perfusing specific
warm, sterile chemical solutions through the cavity. An artificial opening is surgically
created in the abdominal wall for this procedure. Dialysis by this method is typically
performed several times daily, depending on the size and weight of the patient— which
may also limit its practicality. Peritoneal dialysis is considered a less efficient method
thanhemodialysis;however, itis themost commonhomedialysistreatment.
Renal dialysis may occur in a variety of settings, including hospitals, physician's
offices, and freestanding dialysis centers, as well as in the home. These settings vary in
sizeandconfiguration,dependingon typesof inpatientsandoutpatientsserved.
A renal dialysis unit or center is designed around several operational considerations.
The number of patients treated, the hours and frequency of treatment required for
patients, and the hours of operation are all items for discussion. Capacity is determined
by thenumberof dialysispositions.
Patient and work flow through a dialysis unit includes several components. The patient
is weighed upon arrival. Following this evaluation, the hemodialysis patient is
connected to the dialysis machine. The machine is set to operate for a set amount of
time. The patient is disconnected from the machine and reweighed, and fluid loss is
Renal Dialysis
Settings
Operationalconsiderations

recorded.An inpatient may return to his or her room and an outpatient may return home.
Portable machines are becoming more popular in hospitals, allowing patients to remain
in theirroomsfor treatment.
The treatment area can be open or partially enclosed, yet permitting visibility for
nursing and technical staff. The nurses station is centrally located, allowing visual
observation of all patient treatment stations. Treatment positions are at least 80 sq ft
(7.43 sq m) and at least 4 ft from other positions. Privacy should be addressed in the
layout and design of the treatment position. Isolation positions may also be required for
infectious cases. Tables may be placed beside recliners and stretchers as a convenience
for thepatients.
When a facility for renal dialysis is combined with the physician's office, the
nephrologist may schedule an office visit at the same time a renal dialysis procedure is
scheduled. The appointment may include not only a visit with the physician, but also a
visit with a dietitian or social worker to address specific issues regarding nutrition or
personalresources.
Inpatient renal dialysis services should be closely related to inpatient units for
convenience and ease of access. After undergoing a renal dialysis procedure, a patient
may be weak and faint. Therefore, outpatient services should have immediate access to
theparkinglot.
Anumberof supportareasareprovidedfor thedialysispatientduringtreatment:
Nurses' station
Medicationpreparationanddispensing station
Examination room of at least 100 sq ft (9.29 sq m) If home training is provided, a
separateroomof120 sq ft
(11.15 sq m) shouldbe available.
Cleanworkroom
Soiledworkroom
1
Support areas
?
?
?
?
?
122 SCHC

?
?
?
?
?
?
?
?
Separatereprocessingarea
Nourishmentstations
Housekeepingcloset
Generalstorageandstoragealcoves
Watertreatmentand dialysispreparation
Patienttoiletandpersonalstorage
Appropriatestafffacilities
Inanoutpatientsetting,a waitingareaandsupporting offices
needs
According to the AIA 1996-1997 Guidelines for Design and Construction of Hospital
andHealthCareFacilities,atypicalrenaldialysisserviceshould includethefollowing:
Waitingandreception(inoutpatientfacilities)
Treatmentpositions
Isolationtreatmentposition(ifrequiredby theprogram)
Nurses' station
Medicationstation(ifrequired)
Hometrainingroom(if required)
Examinationroom
Cleanworkroomandlinenstorage
Soiledworkroom
Reprocessingroom(ifrequired)
Space

Nourishmentstation
Housekeepingcloset
Equipmentrepair(ifrequired)
Storage
Centralbatchdeliverysystemandwatertreatment
Patienttoilet
Patients' personalstoragespace
Supporting officesandstaff facilities(ifrequired)
It is important for the designer of a renal dialysis service to be sensitive to the patient's
situation during treatment. Typically, a patient is in a recliner or on a stretcher, which
makes lighting and ceiling treatments important. During the actual connection to the
machine, adequate lighting is required. After the connection, a more indirect light is
desirable. Many centers provide shared television sets for patients' entertainment.
However, it is difficult to find television programs that interest everyone. Thus,
individual television sets are preferable. Acoustical considerations are also important,
especiallyforpatientswho prefertosleepduringtreatment.
End-stage renal failure is affecting a larger percentage of patients because of the
continued aging of our population. As a result, the growth of renal dialysis centers will
continue. Outpatient centers are being developed by major providers nationally. The
trend toward consolidation of major national and international dialysis providers is
expected to continue. Currently, close to 50 percent of patients in the United States
receive treatments from ten major national providers. Home dialysis is also expected to
grow as theprocedurescontinuetobesimplifiedbynew machines.
Respiratory care is the care of the respiratory system—primarily the lungs. There are
two distinct areas of activity. The first is inhalation therapy, involving a variety of
techniques ranging from simple oxygen supplementation to assisted breathing with the
use of respirators or ventilators. Diagnosis, by calculating the respiratory system's
Trends
RespiratoryCare
4 SCHC

effectiveness through pulmonary function studies and arterial blood gas analyses, is the
secondactivity.
Although the two activities have traditionally been grouped together, they are very
different. Inhalation therapy is typically rendered at the patient's location—on nursing
units, in outpatient treatment areas and physicians' offices, and even in the home.
Increasingly, inhalation therapy is being decentralized to the hospital nursing areas such
as critical care, pulmonary units, and neonatal units, which require its support. In many
cases, inhalation therapists are integrated into nursing teams or nurses are cross-trained
as inhalation therapists. The study of pulmonary function has remained a discrete
activity, requiring specific equipment for diagnosis of pulmonary capacity and status, It
may constitute a single department or be combined with other diagnostic activities in a
multifunctiondiagnosticcenterwithinahospitalor ambulatorycarefacility.
Activities and capacities The key activity factor or work load measure for inhalation
therapy is number of procedures or hours of therapy. However, because these
procedures occur outside the department—rather than in a procedure room—the key
capacity determinants are the number of therapists and pieces of equipment. The key
activity factor or work load measure for pulmonary function is the procedure. The key
capacityfactoris thenumberofprocedurerooms.
Patient and work flow For pulmonary function testing, patient and work flow is similar
to that of other diagnostic departments. The patient arrives, checks in, waits briefly,
undergoes the procedure, and departs. The results of the testing are recorded,
interpreted,andfiled.
For inhalation therapy, the process is more complicated. As noted earlier, the therapy is
typically rendered at the patient's location, with staff and equipment coming to the
patient. However, following the procedure or treatment, the therapist must record
observations on the patient. Traditionally, this was done within the department at
charting positions. With the development of computerized records and specialized
hand-held devices for recording inhalation therapy activity, this occurs on the nursing
unitor atthepointofcare.
Another necessary process is the returning of equipment to a ready-to-use this trend can
beexpectedtocontinue,separatingthisactivityfrompulmonaryfunctiontesting.
Biohazard waste disposal Because inhalation therapy equipment may acquire infectious
materials during the treatment process, care must be taken in disposing of these
components. Containment and disposal of such waste is coordinated with the
Context

SUPPORT SERVICES IN A HOSPITAL
CHAPTER
FOODSERVICE DEPARTMENT
Suitable food well cooked and presented is an important part of the patients' treatment.
Hospitals have long recognized the public relations value of the food service
department. Unfortunately, criticism of the food is one of the most frequently heard
complaints in any hospital. The food service department is responsible for all activities
involving food, nutr ition and beverages. The department's primary function is to
provide nutrition and dietetic care to both inpatients and outpatients. Ancillary services
include the operation of dining facilities for employees, visitors and physicians, catering
and vending services, meal service for childcare centers and satellite facilities, and
providing education in nutrition for all campus facilities, clinics, and long term care
units.
Economics and convenience dictate the setting for the food services department.
Ambulatory care centers, long- and short-term facilities, hospitals and surgical day
clinics may all include an in-house food service department. The size and complexity of
the operations are contingent on cost. A food service may also be operated as a satellite
from a remote or centralized facility, although such operations have unique equipment
andproceduralrequirements.
The departments work load hinges upon the number of meals served; operational factors
such as food production methods, menu selection, staffing, and hours of operation play a
key role. Capacity determinants may include food production methods, the size of
production equipment, dry/refrigerated storage space, and the number of dining rooms,
floorpantries,and warming kitchens.
126 SCHC

Work flow also affects an operations work load and capacity. Cross-traffic, double
handling of good, and poor controls impact costs, efficiencies and food quality.
Generally, productsshould flow asfollows:
1. Receivingarea
2. Prep area
3. Cookingline
4. Finishedproductassembly
5. Tray assembly
6. Dish washing
To ensure an optimal work flow and efficient service, the food service department and
supportingspacesmust adheretoparticularadjacencyrequirements,as follows:
Locate near the loading and unloading dock for quick, safe food
receiving.
Locate near the servery, conference/meeting rooms, service elevator to
patientsrooms,and auxiliaryservices,such as vendingandcatering.
Locateneartheserviceelevatorcore.
Locate next to the employee/visitor's dining facility, to accommodate late
service,andatotherstrategicpointsthroughoutthefacility.
Locatenextto theserveryand diningroom.
Locate adjacent to the kitchen and food production area.
The seating area should be placed next to the servery, providing easy access to foot
traffic.Guest's needquickaccesstothevisitor's parkinglot.
Locate offices for management and supervisors near the appropriate
productionareastofostercommunicationwithlineworkers.
Several methods are in use for delivery of meals from kitchen to wards. They differ in
the method of processing, the palatability, the means of transport and the amount of
labor that is necessary. Food may be transported to each ward in a bulk container by
Receiving area.
Kitchen.
Floorpantries.
Vending.
Physician's dining.
Employee/visitor's dining.
Offices.

heated trolley and served on to plate by the ward staff. This method has for a long time
been the normal method and is simple and effective; it allows for immediate adjustments
in the quantity given to individual patients but is relatively labor intensive in the wards.
More recent methods are for individual meals to be portioned and plated up in the
kitchen or served there on to insulated and compartmented trays, and delivered
complete by trolley or conveyor. Alternatively and more rarely food may be cooked
centrally, then frozen, and finally reheated in the ward kitchen, or even prepared
centrallyandcookedin theward kitchen.
There is an increasing use of bulk frozen foods, with consequent implications on the
storage requirements, and also of the bulk purchase of ready-made frozen meals from
commercial sources. The catering may be run by the hospital or contracted out to
external organizations. The different methods are reflected in the size, equipment and
planning of both central and ward kitchens. The washing up of crockery and utensils has
in the past done in ward kitchens. This is now usually centralized in the main kitchens,
with the advantages of more efficient steam sterilization, less work for the ward staff and
less noiseintheward itself.
Akitchen in the basement is certain to have a deleterious effect on the quality of food and
efficiency of the department. It is likely to be dingy, dark and poorly ventilated.Aground
floor location is preferable, and is also convenient for delivery of supplies. The storage
area should be in close proximity to the unloading dock. Easy access to the vertical
transportation system serving in-patient units is important to facilitate delivery of
patientmealsandreturnof used trays andutensils.
Delivering safe, high-quality food is paramount to the dietary services department.
Efficient, cost-effective, and safe food production is based on a continuous system, with
specific methods for raw product flow, preparation, cooking, assembly and dispensing.
To prevent cross-contamination, clean and soiled areas and products must be
segregated.Thesefunctionsrequireadequatespaceanda designatedflow pattern.
Cross-contamination must also be addressed in the receiving area. Boxes and containers
may contain living organisms and so must not be directly loaded into the production
kitchen holding coolers. Sufficient space is needed for receiving, weighing, and storing
products to ensure product safety, strict inventory controls, and the proper rotation of
goods.
The design and physical facilities of the food service department have an important
bearing on the standard of food service, labor costs and the morale of the employees. For
example, storage rooms far removed from the work area, poor arrangement of the
preparation and production area for work flow, and long traveling distance for prepared
food lower the level of efficiency and increase unnecessary steps for employees
resulting in increased costs. In the general layout, the most important factor to be borne
128 SCHC

in mind is the logical workflow that is, receiving supplies, storing and refrigerating
them, preparing and serving food, returning trays and washing dishes. The space and
facilitiesshould beadequate.
For decades, a simple concept dominated cafeteria service: recreate an army mess hall,
with a long line of serving stations supported by an oversized kitchen or commissary.
The demands of younger patients, staff, and visitors accustomed to a variety of dining
options and the increasing need to find new revenue streams have spurred more flexible,
innovativedesigns.
One of the latest developments is the food court and market designs, similar to those
found in high-end food outlets and shopping malls. Employees, visitors and outpatients
are able to move freely through food displays or boutiques, which are either self-service
or staffed. The atmosphere promotes social activity and helps relieve stress. The variety
offood offeringsalsosatisfiesmorediscriminatingcustomers.
On the production side, new technologies and equipment have allowed kitchens to
consolidate functions. These advances have enabled healthcare facilities to prepare
products for inventory, rather than for immediate consumption, capitalizing on
economiesof scale.
Ahospital consumes a large quantity of new material that needs sterilization before use.
It also processes other material that has to be cleaned and sterilized before it can be used
again. Central Sterile Supply Department (CSSD) is a service whereby medical/surgical
supplies and equipment – both sterile and non-sterile – are cleaned, prepared, processed,
stored and issued for patient care. Hospital acquired infection remains a serious problem
in health care today. The purpose of a sterile services department is to concentrate the
skill and the responsibility for the supply of sterile material and to reduce the risk of
error.
TheprimaryactivitiestobeundertakenwithintheCSSD are:
1. Cleaning and disinfecting processes for instruments, trays, utensils, containers and
otherreprocessableitems.
2. Preparing and packaging contents of trays and packs and where appropriate, single-
use itemsandothermaterialsas supplementarypacks.
3. Sterilizing trays and packs and disinfecting those items acceptable for patient use in
thiscondition.
CENTRALSTERILE PROCESSING

4. Storingnon-sterilematerialscomponents.
5. Storinggoods processed inthedepartmentandpurchasedsterilegoods.
6. Distributingprocessedandpurchasedgoods tousers.
Sterilization of instruments, operating packs, trays etc., is performed is performed by
heating them with pressurized steam or by gas sterilization. Steam sterilization is called
autoclaving. However, certain items such as rubber, plastic and delicate instruments
cannot be autoclaved and so have to be sterilized by using ethylene oxide or similar
gases. Gas sterilization requires certain safety precautions such as aeration prior to use
and special exhaust ventilation. Under both systems, sterilization is performed on
cleanedinstrumentswrappedinspeciallinen.
The department receives clean material from a laundry and new material from
manufacturers and suppliers. It also receives for re-use, dirty articles from within the
hospital. Clean and dirty materials require separate delivery points, the clean one
serving a bulk store for new materials such as towels and masks, and the dirty one
serving a clean-up room where all re-usable goods including instruments and syringes
are washed, cleaned and dried. Rubber gloves may require a separate glove room for
treatment.
The department is divided into three zones to accomplish the functions of
decontamination, assembly and sterile processing, and sterile storage and distribution.
Thesezonesincludethefollowing:
1. Decontaminationzone
2. Assembly/sterilizationzone
3. Storageanddistributionzone
The work flow for central sterile processing is centered on the processing of soiled
instruments through the four zones. A distinct separation must be maintained between
the soiled and sterile areas. The technical staff works on either the soiled side or the
sterileside andcannotcross fromone sidetotheother.
Reusable equipment and soiled instruments and supplies are
received from surgery, labor/delivery and other departmental areas for initial or gross
cleaning. These items are cleaned and decontaminated by means of manual or
mechanical processes and chemical disinfection.The exchange cart is cleaned in a pass-
through cart washer and readied in the assembly zone to carry items back to the
departments.Itemsof equipmentused inthis areaincludethefollowing:
Decontamination zone:
130 SCHC

Biohazardouswastemanagementsystems
Washer/Decontaminator– usedto cleanheat-tolerantitems
Ultrasonic Washer – used to remove fine soil from surgical instruments after manual
cleaningandbeforesterilization
Healthcare decontamination systems (pass-through washer sterilizers or tunnel
washers) –used tosterilizeinstrumentsin perforatedor mesh-bottomtrays
Cartwashers – used tocleancartsand othertransportvehicles
After the instruments have been cleaned and inspected,
they are typically assembled into sets or trays, according to detailed instructions. Each
set or tray is wrapped or packed in a non-woven textile pouch or a rigid
package/container system for terminal, or final, sterilization. At that point, the sets are
prepared for issue, storage or further processing.After assembly, the instruments receive
final sterilization. The cleaned instruments are issued to the sterile storage area until
issued.Equipmentused mostcommonlyinthis zoneincludesthefollowing:
High-pressuresterileprocessingsystems (steamor electric)
Low-pressuresterileprocessingsystems
ETO (EthyleneOxide)gas sterilizerandaerators
ETO gas aerators
Chemicalsterilizationsystems
Microwavesterilizationsystems
Following the sterilization process the instruments are
stored in sterile storage or sent to the appropriate department. Other functions of this
zone include case cart preparation and delivery; telephone or requisition order filling,
anddeliveryof patientcareequipment.
It is advisable to have one high-speed autoclave, preferably in the surgical suite, as a
standby in the event of a CSSD breakdown. Flash sterilization is performed in the user
departments, particularly the operating rooms, to re-sterilize the instruments needed
Assembly/sterilization zone:
Storage and distribution zone:

immediately or those that have been dropped accidentally. Flash sterilization is
autoclavinganinstrumentwhen itisunwrapped.
The department should be in the hospital service zone to simplify the reception of goods.
Proximity to the boiler room is an advantage if steam is raised there. Good
communication routes to most of the other departments of the hospital are essential.
However, it has a relationship primarily with the Surgical Suite, and can be placed next
to it. It can also be located above or below the Surgical Suite. This requires elevators or
dumbwaiters to provide direct access for both clean and soiled materials to and from
surgery. In some facilities, central sterile processing is collocated with materials
management.
The size of the central sterile processing area depends on the number of surgical and
obstetrics cases treated in a given period and the amount (cubic volume) of sterile
storage required. In addition the number of open heart and/or orthopedic cases treated in
a given period must be considered. Key capacity determinants include the number and
type of sterilization instruments, the exchange case cart distribution system, and
instrumentholdingandequipmentcleaningintheCSSD department.
The trend is for central sterile processing to move into total integration with surgery.
This move is in response to physicians' continued concern regarding the handling of
surgicalinstrumentsandtheneedfor nurses to preparethecasetraysfor sterilization.
132 SCHC

THEPHARMACY
The pharmacy serves the whole hospital. It stores pharmaceutical products
manufactured elsewhere and may also store dressings. It usually manufactures some
sterile and non-sterile products in bulk and dispenses prescriptions, sometimes direct to
outpatients. It supplies all wards and other departments, often on the basis of daily
deliveries. For smaller hospitals, the function of the department may be restricted to
storage and distribution. It is one of the few areas where large amounts of money are
spent on purchases on a recurring basis. It is also one of the highest revenue generating
centers.
As a department, it provides prescription medications, intravenous (IV) solutions, and
investigational drugs for clinical research, as well as other related products for patients.
Therearethreeprimaryservicesof thehospitalpharmacy:
1. Receiptandpreparationof prescriptions
2. Dispensing
3. Clinicalconsulting
Pharmacists receive orders or prescriptions from physicians. These prescriptions are
prepared and dispensed to the patient by the pharmacist. In a hospital setting,
medications may be dispensed in a variety of ways.They may be prepared in a central or
satellite pharmacy and delivered to the patient care unit for administration by a
physician, nurse or other caregiver. Moreover, automated vending systems may be
positioned as satellites in high-use areas such as critical care, emergency and similar
locations. A vending system allows the caregiver to administer physician directed
medication and drugs using pharmacy-pre-stocked products in a high-use area.
Pharmacists are commonly encouraged to consult clinically with the patient on the
administration of a medication. This assists the patient in learning the risks and possible
effectsof themedicine.
Because supervision of drugs is essential and security is of first importance,
manufactured goods are sometimes received direct by the pharmacy rather than via the
hospitals main stores. The basic workflow in the department is reception of goods,
unpacking and checking, then storage either in a dressings store or a drug store, and
finally dispensing and distribution. Some of the products (poisons and dangerous
drugs) require special security measures. Others need refrigeration, and some
flammable liquids may demand particular precautions against fire or explosion
involvingstorageoutsidethebuilding.

From the drugs store, goods pass to the dispensing section either direct or via a bulk
preparation room. In the dispensary they are broken down into correct quantities and
from there distributed to the hospital or collected direct at a counter on prescription by
outpatients. In many of our Indian hospitals, inpatients too are required to buy their
medicine directly from the pharmacy on a cash 'n' carry basis. In this case a separate in-
patient pharmacy may be needed. Ancillary accommodation includes staff offices, a
laboratory, and a suite for the manufacture of sterile products, comprising preparation
room, wash-up, autoclavesandaroomfor inspection,labelingandstorage.
An inpatient pharmacy (in the Western model) is typically located near material
management functions for convenience in receiving bulk items. It can also be located
near inpatient care units for dispensing medications or at a central location, such as near
elevator banks. Outpatient dispensing is provided in the hospital for outpatients
requiring discharge medications and prescriptions. Outpatient dispensing should be
convenientlylocatedfor servingdepartingpatients.
The pharmacy department should have secure access control. Entry points should be
limited, if possible, to receiving and dispensing. Ideally, both entry points are under the
pharmacist's visual control. Space should be available to allow separate workflows for
the preparation of prescriptions and IV solutions. Dispensing and storage areas must be
located near these two flow areas. The IV preparation area and the fume hood should be
near the bulk storage area and IV dispensing. Satellite pharmacies are integral to critical
care, surgery and other areas. Automated materials movement systems, such as
pneumatic tube stations, are desirable and efficient; A 6 inch pneumatic tube system is
idealfor movinglargeritemssuchas IVbags.
Space determinants include the kind of drug distribution system – either centralized or
decentralized – as well as the workload generated by the patients. The patient work load
mayincludebothinpatientandoutpatientdemands.
Flexibility within the pharmacy is paramount, especially during a facility's growth and
change. Modular casework provides the flexibility of configuration and layout that is
desirable in any pharmacy. Lighting should be adequate for reading small labels and
finding medications in banks of shelves. Fume hood, to provide a sterile work
environment for the admixtures and IV preparations, should be provided. A pass-
through window, required for walk-up medication dispensing, must be secured.
Securitylocksatallentrancesis necessary.
Pharmacists are becoming active in the clinical administration of prescription
medications in the inpatient and outpatient settings. With this responsibility,
pharmacists are more likely to support a decentralized service encouraging their
availability to the patients. Staffing remains a critical issue in cost control; thus many
facilities still prefer a single centralized pharmacy, augmented with automated
134 SCHC

pharmaceuticalvendingmachinesthataredecentralizedthroughoutthehospital.
The environmental services department is responsible for maintaining a clean and
sanitary environment in die hospital, including floors, carpeting, tile, drapery, windows,
lights, vents, and upholstered items. This department is also responsible for furniture
moves, conference and classroom setups, replacement of patient room furniture, and
trash collection. Environmental services typically contracts with outside vendors or
arranges with the maintenance department for pest control, waste removal, exterior
window washing, furniture repairs, window coverings, and the purchasing of trash
receptaclesandmattresses.
The number of housekeeping rooms or closets is determined by the needs of the facility.
A service sink or floor well with a drain is provided for mops and other cleaning
equipment. Shelves or carts for the storage of cleaning chemicals and supplies are also
required.
Linen services are typically included within environmental services for the collection
and distribution of linens and scrubs throughout the hospital. Linen services are
typically contracted with vendors. However, some hospitals still operate full laundry
services. Linen is stored on shelves or carts. Clean linen storage may be located in clean
workrooms or linen storage alcoves. Soiled linen can be collected in carts in corridor
alcovesor transferredtosoiledutilityrooms for pickup.
Hospital environmental and linen services serve the hospital and satellite facilities,
including medical office buildings, ambulatory care facilities, and other related
campuses.
The environmental and linen services department is staff-intensive and should be near
loading dock, materials management, and engineering/maintenance services, as well as
close to elevators. Larger carts may be circulated throughout the hospital for restocking
housekeeping carts located throughout the facility. Carts can also be delivered to the
central department for restocking. Housekeeping carts are usually kept in the various
housekeeping closets throughout the hospital. Linen carts are located in appropriate
areasandarerestockedon a"par" levelorexchangedfor anewlystockedcart.
Environmental and LinenServices
Settings
Operationalconsiderations:
Spaceneeds
According to the AIA 1996-1997 Guidelines far Design and Construction of Hospital
and Health Care Facilities, the following areas are generally accepted as appropriate
forenvironmentaland linenservices:

Environmentalservices
Linenservices
Housekeepingclosets
Housekeepingstorageand supplies
Bedand equipmentstorage
Administrativeoffices
Vendormeeting
Linenstorage
Receiving,sorting, andholdingareaforsoiledlinen
Centralizedcleanlinenstorage
Soiledandcleanlinencartstorage
Hand washingin soiledlinenstorageareas
Serviceentranceprotectedfrom inclementweather
Laundryor minimumlaundryprocessing roomforemergencies
Storagefor laundrysupplies
Staff facilities
Hospital finishes, furniture, and accessories are designed to withstand the rigors
of constant cleaning and sanitizing. Such measures help to maintain standards of
cleanlinessthatsupport ahealingenvironment.
Outsourcingenvironmentalandlinenservicesis agrowing trendin hospitals.
room
Trends
136 SCHC

Engineeringand Maintenance
The engineering and maintenance department is typically responsible for the entire
physical plant and grounds of the hospital. Services include preventive maintenance,
corrective maintenance, casualty prevention, minor construction, and construction
administration. Work load and departmental needs are directly related to the scope of
thefacilitiesandthecampusfor whichthedepartmentisresponsible.
These services should be convenient and accessible to all areas of the facilities and the
campus. Access to the dock area is necessary for building materials, supplies, and
equipment. Enclosed access to all hospital departments and areas is also desirable. The
department may be responsible for off-site facilities, such as ambulatory care centers
andmedicalofficebuildings,as wellas forthehospitaland grounds.
Engineering and maintenance services are integral to the day-to-day operation of the
hospital. These services are responsible for keeping the facilities in proper working
condition and helping them function effectively. Engineering is responsible for
monitoring the mechanical, plumbing, heat, ventilation, air-conditioning {HVAC), and
electrical systems, as well as preventive maintenance and repair. Supporting shop work
areas, such as carpentry, electrical, plumbing, paint, welding, and HVAC, may be
provided in appropriate areas of the hospital. They may also be located in a separate
outbuilding for better acoustical and dust control. If such shops are located in an
outbuilding,coveredaccessor transportationtothedockareashould beprovided.
According to the AIA
components of engineering and maintenance services
includethefollowing:
CentralEnergyPlant
MedicalGas Park
Dockarea
Administrative offices (plan room, computer-aided drafting and design [CADD] room,
environmentalcontrolsroom,etc.)
Settings
Spaceneeds
1996-1997 Guidelines for Design and Construction of Hospital
and Health Care Facilities,

Appropriateshops (carpentry, electrical,plumbing,paint,welding,HVAC, etc.)
Supply storage
Flammablestorage
Biomedicalworkshop
Externalgrounds maintenanceequipmentstorage
Stafffacilities
Engineering and maintenance services require appropriate electrical and mechanical
systems for shop operations meeting all requirements of the Occupational Safety and
HealthAdministration (OSHA). Specifically, dust control and the storage of flammable
fluids mustbeaddressed.
Safety and security services within a hospital setting provide general security, guard
patrols, preliminary investigations, fire prevention, control policies and training,
disaster planning and training, and other measures for the general safety of staff,
patients, and visitors. Other services include lost-and-found and patient assistance, and
transportationbyvehicle.Thedepartmentoperates24 hours perday, sevendays aweek.
Safety and security has high visibility near entrances and parking areas. It is common to
place this function close to the emergency entrance, inasmuch as this is a 24-hour
entrance to the hospital. The service has relationships to employee health, infection
control,engineering,andrisk management.
This service typically includes a suite arrangement, one component of which is a
command post.At the post, security guards monitor closed-circuit television cameras.A
director's office is usually adjacent to the command post. Storage is required for lost-
and-found and disaster planning equipment. More healthcare facilities are establishing
carpatrolson theircampuses.
Safety and Security
Settings
OperationalConsiderations
138 SCHC

Spaceneeds
Trends
Functionaloverview
Typicalsafetyandsecurityservicesincludethefollowing:
Commandpost
Director's office
Securitysupervisor's cubicle
Storage(lost-and-found,disasterplanningequipment)
Greater emphasis is being placed on safety and security at healthcare campuses because
of a rising perception of more violence and criminal activity. This activity, experts say,
is attractedby the24-houroperationof ahospital.
Materials management is responsible for the acquisition, general storage, daily
inventory, and restocking of most, if not all, of the consumable materials used within a
facility. This service may be provided for several facilities within a healthcare system to
increase efficiency of operations, reduce total space requirements, and maximize
purchasingpower.Thefollowingservicesareprovided:
Management of consumable goods such as medical-surgical supplies and
administrativepapergoods
Receiving,breakdown,andstowageof supplies,inbulk casesandinunits ofissue
Storage of special supplies (chemical reagents, X-ray film; stock intravenous [IV]
solutions,flammableor otherhazardousmaterials)
Receivingandtemporaryholdingof new equipmentor furnishings
Distribution and restocking of supplies to consumer units on a scheduled and on-
callbasis using pre-established(PAR) levels
Inventory management to maintain supply and to secure optimal purchasing
agreementsforoperationaleconomy
MaterialsManagement
·
·
·
·
·
·

· Administration and management of the facility's supply system in cooperation
withthemanagersof consumerunits
Responsibilities of the materials management director may include managing the
central sterile processing service (reprocessing/sterilizing reusable Stems) and
overseeing the linen service. Materials management service excludes food products,
which are managed by the food service department.Also, this department usually relies
on the clinical lab for storage of radioactive materials or special products, such as
reagents,whichrequirerefrigeratedstorage.
A general storage area is required in facilities of all types. If serving a network of
facilities, material management is often centralized at a "hub' facility, with
management and distribution services provided to satellites. Demand for storage space
and staff will be driven by the mix of services and volume of activity at each site. Each
consuming unit in smaller facilities may itself manage material acquisition and storage.
However, this service is typically centralized to achieve economies of scale and to
minimizestaffing requirements.
Planning for this service is driven by the array of clinical services to be supported and
the operational concept for the materials management program. The projected volumes
of patient care services, types of general and specialty supplies required, relative
proportion of inpatient versus outpatient care, and the administrative needs of the
clinical services are components to be addressed in determining demand for materials
management services. More important to space planning, however, is the frequency of
deliveries and the type of supply system—external and internal—as well as the
functional work flow intended for the service. These components make up the
operationalconcept.
Servicelocations
Keyactivityfactors
1
A materials management flow diagram
140 SCHC

Keycapacitydeterminants
Workflow
The extent of centralized versus decentralized storage affects capacity. Inherently,
decentralized storage requires more space. Some decentralization is necessary in all
healthcare facilities for enhanced productivity. Capacity is determined by the on-site
supply reserve and delivery frequency to bulk stores and local storage rooms. Capacity
is driven by the storage system: fixed shelving or high-density movable shelving, the
storage system volume—height in particular— and the extent of compartmentalization
(separate areas for specialty storage, or bulk carton storage versus broken lot "unit of
issue" storage).
In materials management,work flow begins at the receiving service dock. Bills of lading
and product condition are checked in the receiving area.This area must contain space for
weather-protected products and temporary holding. Weighing scales are located in this
area, as is a clerical work space. The dock area must be raised, often with dock levelers
"for receiving materials from tractor-trailer and bobtail trucks, and must have an apron
atgradeforsmallerdeliveryvehicles.
Cartons of received supplies are moved directly into bulk storage areas on pallets or
placed on heavy-duty shelving. Equipment and furniture are moved to a temporary
holding space until they can be installed by engineering or environmental service staff.
Hazardous or flammable supplies are stored in dedicated rooms. These rooms are often
accessible directly from the dock to facilitate exterior access for vendors and to provide
ventilated,safestorageoutsidethebuilding.
From the cartons, daily-replenished supplies are moved onto more accessible shelves
for ease of restocking by unit of issue. The "distribution room" or "clean/sterile supply
area" is the principal storage room from which carts are loaded to restock each consumer
department in the facility. Depending on the inventory management system, before
distribution each item is usually marked with a bar code label to facilitate tracking and
billing.
Bulk stores also hold cartons of prepackaged consumable sterile goods used in surgery,
labor/delivery, or other special procedures areas. These items are distributed daily to the
central sterile processing (CSP) area. The supplies delivered to the clinical areas may
include both consumable and reprocessed goods. For this reason, CSP is often adjacent
to the distribution room of materials management to optimize material flow over
minimum distances. A "break-out" room between the distribution room and CSP
typicallyserves asa vestibule,wheresupplies areremovedfromcartonstoshelves.
The replenishment system for consuming units is an important determinant of necessary
space. There are two basic approaches—replenishment or use of exchange carts. A
hybrid of the two is often employed. Pure replenishment requires a periodic inventory,
by the materials management staff, of items consumed in each consumer area; the
collection of those items from the centralized supply distribution room onto a cart; and
j

the delivery and restocking of those items in the cabinets or on carts in the consumer unit.
These storage areas are typically identified as the clean supply or clean utility rooms of
theconsumerunits.
The pure exchange cart system requires the periodic replacement of the supply cart in
the consumer unit with a cart fully stocked to PAR level, and then the return of the
partially used supply cart to the distribution room for inventory and restocking. A key
difference between these systems is the redundant cart holding space needed in the
distribution room in the exchange cart system. Today's computerized inventory systems
facilitateinstantinformationtosupport thereplenishmentapproach.
Because of their value or special storage requirements, specialty goods, such as imaging
film supplies, lab reagents, and cath lab catheters, may be stored entirely within the
consumer department. These goods are received by materials management and moved
in bulkdirectlytotheconsumerdepartments.
Relationships with other departments Materials management must be directly
accessible from the exterior via a receiving dock area. In planning this department, its
activities should be kept away from circulation routes for the public, ambulatory
patients, and most staff traffic. However, easy access to all consumer departments for
distribution is desirable. The routes of such access should be separate from public
thoroughfares. Central sterile processing should be located nearby for expedience in
daily restocking. For operational reasons—often driven by preferences of surgery
managersandphysicians—CSPmaybeseparatefromor integratedwith surgery.
The design of the materials management scales, 36 to 42 in. deep pallet or deep area
should address thefollowing
considerations:
Direct dock access for receiving, with staging space for checking deliveries prior to
storageor distribution
Breakdown area for unit of issue stock, with convenient waste management
pathways(box baileroraccesstotrash compactors)
Capability to segregate flow of clean and dirty activities at the dock (complete
separation is not necessary); ability to move trash, hazardous waste, and soiled linen
toholdingareasor transportvehicleswithoutconflictingwith cleanincominggoods
Clear and adequate circulation pathways for materials movement equipment such as
forklifts
Keyspaces
Keydesign considerations
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?
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Exterioraccessforselectedmaterialsstorageindedicated,code-compliantrooms,
such as for flammable or hazardous substances and portable medical gas cylinders
ofvarioussizes.
Special equipment requirements may include dock levelers, in-floor industrial carton
storage, forklifts or pallet lifts, 24 in. deep shelving for unit of issue supply holding (in
fixed or movable high-density storage systems), and replenishment or exchange carts
{typically24 by 60in.).
Supporting spaces In addition to basic storage and distribution areas, materials
managementshould includesupport areas:
Staff lounge,lockerswithshowers andchangingareas,andtoilets
Administrativeoffices
Specialdesign considerationsincludethefollowing:
Servicetrafficmustbeseparatedfrompatientvehicletraffic.
Weather protection and environmental control should be available at the portal to the
receivingdock.
Life safety codes require rated enclosures for certain types of storage, as well as
minimum ceiling or sprinkler head clearance vertically above the top levels of
storedmaterials
Apneumatictubestationwithintheordistributionroom shouldbe provided.
Various other types of automated conveyance systems may be considered, but most
are typically too costly to justify. Often, 6 in pneumatic tube transport systems are
effectively used for immediately needed items not in stock on the user unit, and a
station for this system should be provided in the distribution area (unless provided in
adjacentCSP).
The centralization of materials management services will continue or increase, in order
to serve greater numbers of facilities within a system. Various approaches and
applications of "just in time" delivery of supplies will continue to minimize inventory
and requirements for storage space in healthcare facilities.Automation of processes for
inventory, ordering, and restocking will be increased in an effort to minimize staffing
requirements for materials handling. Distribution of supplies to the points of care will
continue to be an expedient way to maximize use of clinical human resources. In
addition, new ideas on achieving care goals without increasing material management
staff requirementswillbe explored.
Specialequipment and furniturerequirements
Trends

THE DISASTER MANAGEMENT
CHAPTER 10
144 SCHC
Introduction:
Hospitals would be among the first institutions to be affected after a
disaster, be it natural or man-made. Because of the heavy demand
placed on their services at the time of a disaster, hospitals need to be
prepared to handle such an unusual workload. This necessitates a well
documented and tested disaster management plan (DMP) to be in place
in every hospital. To increase their preparedness for mass casualties,
hospitals have to expand their focus to include both internal and
community-level planning. The disaster management plan of a hospital
should incorporate various issues that address natural disasters;
biological, chemical, nuclear-radiological and explosive-incendiary
terrorism incidents; collaboration with outside organizations for
planning; establishment of alternate care sites; clinician training in the
management of exposures to different diseases, chemicals and nuclear
materials; drills on aspects of the response plans; and equipment and
bed capacity available at the hospital.
Importance of External Agencies in Disaster Management Plan:
The most important external agencies for collaboration would be state
and local public health departments, emergency medical services, fire
departments and law enforcing agencies like police etc. The key hospital
personnel should be trained to implement a formal incident command
system, which is an organized procedure for managing resources and
personnel during an emergency.
The hospitals should also have adequate availability of personal
protective hazardous materials suits, negative pressure isolation rooms
and decontamination showers.
A hospital's emergency response plan has to be evaluated whether that
plan addresses these issues. The hospitals in abroad are required to
have disaster response plans to be accredited by the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO).
In India and probably in many other countries, there is no statutory
body to regulate and accredit this requirement.

OBJECTIVES OF DISASTER MANAGEMENT PLAN:
ESSENTIALS OF DISATER MANAGEMENT PLAN:
1. While responding to a mass casualty event, the goal of the health
and medical response is to save as many lives as possible.
2. Rather than doing everything possible to save every life, it will be
necessary to allocate limited resources in a modified manner to
save as many lives as possible.
3. When a hospital responds to a large number of victims presenting
over a short time, often without a prior warning, delivering care to
the level of usual hospital standards or benchmarks may not be
possible and "altered standards" may have to be acceptable.
4. The term "altered standards" has not been defined, but generally
is assumed to mean a shift to providing care and allocating scarce
equipment, supplies and personnel in a way that saves the largest
number of lives in contrast to the traditional focus on saving
individuals. For example, it could mean applying principles of
field triage to determine who gets what kind of care. It could mean
changing infection control standards to permit group isolation
rather than single person isolation units. It could mean limiting
the use of ventilators to surgical situations. It could mean
creating alternate care sites in the waiting area, lobby or corridors
which are not designed to provide medical care; minor surgical
procedures in victims in these areas could mean altered level of
asepsis. It could also mean changing who provides various kinds
of care like enhancing the scope of nurses, physician assistants
and hospital paramedics.
5. Secondary triage also may be necessary within hospital, as
demands on the system grow.
6. Hospital DMP should consider the possibility that a hospital
might need to evacuate partially or wholly, quarantine, or divert
incoming patients. For example in the event of flooding, the
ground floor services may need shifting to higher floors or a make
shift operation theatre may be needed. Spare capacities for such
contingencies should be included in the DMP.
1. One of the key components of an effective health and medical care
response is ensuring adequate supplies of a broad array of
qualified health care providers who are available and willing to
serve in a Hospital. This could mean re-allocating non emergency
and non-clinical doctors to emergency area of the hospital and

recruiting retired or unemployed providers for temporary service.
2. The traditional separation between the medical care community
(e.g., hospitals, physicians and nursing homes) and the public
health community needs to be bridged in preparation for mass
casualty incidents. Mass casualties will provide more work than
any organization itself can address.
3. Coordination is the key and the historic separation is a genuine
disadvantage. Several strategies help ensure protection of staff
handling disasters e.g. safety measures including personal
protective equipment, prophylaxis, training specific for different
events, adequate back-up staff for rotation to prevent burnout
and fatigue related errors and care of families of staff.
A wide range of training of hospital staff is needed to ensure an effective
health and medical response to a mass casualty event. Training should
include, but not limited to a general disaster response, including an
introduction to altered standards of care, but can also be extended to:-
a) Legal and ethical basis for allocating scarce resources in a MCI.
b) Orientation to how an incident commands system would work in
a mass casualty event.
c) How to recognize the signs and symptoms of specific hazards and
treat specific conditions.
d) Basic and advanced life support; hazardous materials life
support; decontamination and isolation protocols, triage
protocols; personal protection gears.
e) And use and maintenance of emergency equipment.
Preparedness for disasters is a dynamic process. In addition to having a
well documented DMP in place, it is prudent to have regular drills to test
the hospital's DMP. The drills may be hospital disaster drills, computer
simulations and tabletop or other exercises.
Why to have drills at regular intervals?
In India, hospitals rarely have a documented DMP and even rarely
conduct disaster drills or publish the reports of such drills. The JCAHO
actually requires hospitals to test their emergency plan twice a year,
including at least one community-wide drill. The purpose of the hospital
disaster drills is to train hospital staff to respond to an MCI, to validate
the readiness and effectiveness of the hospital's DMP, to make new
hospital staff to become aware of procedures in disaster response, to
TRAINING REQUIREMENTS:
HOSPITAL PREPAREDNESS-ITS PURPOSE:
146 SCHC

incorporate advancements in knowledge and technology into the DMP
and to use the reports from the drill to reinforce the DMP. Hospital
disaster drills should test various components viz incident command,
communications, triage, patient flow, drugs and consumables stock,
reporting, security and other issues. Survey of some published articles
on disaster drills have highlighted that internal and external
communications were the key to effective disaster response; a well-
defined incident command center reduced confusion; conference calls
were an inefficient way to manage disaster response; accurate phone
numbers for key players were vital and regular updating was necessary;
disaster drills appeared to be an effective way to improve clinicians'
knowledge of hospital disaster procedures; computer simulation may be
an economical method to educate key hospital decision makers and
improve hospital disaster preparedness before implementation of a full-
scale drill; a tabletop exercise can help to motivate hospital staff to learn
more about disaster preparedness and can help to teach staff about
aspects of disaster-related patient care in a way that simulates the
practice setting; a regional exercise involving top government officials
can help to increase awareness of the need for better disaster response
planning; and video demonstrations may be an inexpensive, convenient
way to educate a large number of staff about disaster procedures and
equipment use in a short time.
The hospital's patient care role begins with and follows the disaster. The
hospital's community service role begins long before the disaster as the
hospital develops tests and implements its disaster plan. The objective
is to prepare the hospital through the development of emergency
response systems, staff training and purchase of equipment and
materials so that it can continue caring for its present patients, protect
its own staff and respond to the needs presented by the disaster. Finally,
hospital preparedness can be enhanced more rapidly if standardized
state and national guidelines for model hospital DMP, staff training,
disaster drills and accreditation of hospitals based on DMP are
developed and widely disseminated.
ROLE OF HOSPITAL IN PATIENT CARE DURING DISASTER:

INTRODUCTION TO DISASTERS
1.0 Objectives
1.1 Introduction
1.2 Disaster impacts in some states of India
1.3 Major natural disasters in India
1.4 Definition
1.6 Causes of Disasters
1.7 Effects of disasters
After going through this unit, you should be able to
1.0 Define the terms of disaster
1.1 Explain the classification of Disasters
1.2 Describe the causes of disaster
1.3 Identify the most important hazards and how they affect
society
1.4 Distinguish between natural and human made hazards
Disasters are affecting mankind form ages. The disaster event concerns
every community and no community is immune from it. According to the
Greek Philosopher Empedocles, the universe consist of five elements the
Earth, Fire, Air, Sun and Water from which come the manifestation of
violence such as Earthquake, Volcanoes, Cyclones, Droughts and
Floods.
India with wide range of climatic and topographical condition is subject
to various types of natural disasters. Flood is common natural disaster
during monsoon period. Floods are estimated to affect 6.7 million
hectares of land annually. The statistics of 10 yrs indicates that on an
average in India about 30 million people are affected every year. As
already we are losing land areas to the rising sea, if trend is not checked
15% hospitable land will be under sea by 2020 displacing 30,000
families. It is estimated that if sea level rises by one meter it would
displace more than 7.1 million people in India and suck 5764 sq km of
Structure
1.0 OBJECTIVES
1.1 INTRODUCTION
1.5 Classification of Disasters
148 SCHC

land under water. The eastern coastal region are prone to severe floods
and cyclones (Andhra pradesh, West Bengal Orissa etc) Northern region
of India namely Assam, Meghlaya, Mizoram, Manipur Nagaland Tripura
These regions are hazard prone in Asian countries. The average rainfall
in this region is 1750 mm to 6400 mm causes flood and erosion.
The shocking memories of Bhopal Gas Tragedy of 1984, Latur
Earthquake of 1993, Gujrat earthquake of 2001 and tsunami calamity
of 2004 have killed and incapacitated millions of people and destroyed
the properties in corers. Approximately 20 major disasters strike the
world yearly most common being floods, cyclones, and earthquake.
Global Statistics reveal over three decades the impact of disaster has
significantly increased.
Each year natural disaster takes a heavy toll on human life and
property.
From 1900-1988, 47 million people worldwide become homeless due to
natural disasters.
1.3 SOME MAJOR NATURAL DISASTERS IN INDIA
1.2 DISASTER IMPACTS IN SOME STATES OF INDIA
Yr Type Place Death
2004 Tsunami A.P./ T. N. / A&N
island Kerala
10749, 5460 missing
2004 Flood Assam, Bihar, Gujarat NA
2001 Earthquake Bhuj, Gujarat 16480 killed
1,44,927 injured
1999 Super Cyclone Orissa 20,000
1993 Earthquake Latur (M.S.) 8000 death
14,000 injured
1991 Earthquake Garwal (Uttaranchal) 1000
1984 MIC Gas Bhopal (M P) 3800

1.4 DEFINITION
The term 'disaster' originated from a French word, which is a
combination of two terms 'des' meaning bad or evil and 'astre' meaning
star. The expression of term disaster is bad or evil star. Disaster Means
Sudden or Great Misfortune
A disaster is any human-made or natural event that causes
destruction and devastation that cannot be relieved without assistance.
Disaster has been defined in variety of ways
1. Anything that befalls of ruinous or distressing nature: a
sudden or great misfortune mishap, or misadventure, a calamity. (OED)
2. “Any occurrence that causes damage, ecological disruption,
loss of human life, deterioration of health and health services, on a scale
sufficient to warrant an extraordinary response from outside the
affected community or area.” The present century has added a new
ecological dimension to the definition of disaster: Chemical and nuclear
catastrophes, oil spills, air, water and soil pollution, desertification, the
greenhouse effect and environmental refuses. (WHO)
3. “An occurrence, either natural or man made that causes
human suffering and creates human needs that victims cannot
alleviate without assistance” (AMERICAN RED CROSS (ARC) )
4. “An occurrence of a severity and magnitude that normally
results in death, injuries and property damage that cannot be managed
through the routine procedure and resources of government” BY FEMA
(FEDERAL EMERGENCY MANAGEMENT AGENCY)
5. “A disaster is any event that causes destructions and distress
resulting in demands that exceeds the response capacity of the affected
community. Disaster usually have an unforeseen serious and
immediate effect on health”. (Operational definition)
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1.5 CLASSIFICATION OF DISASTERS
Natural Disasters Man-made Disasters
Earthquake Conventional warfare
Volcanic eruptions N u c l e a r , B i o l o g i c a l a n d
Chemical Warfare
Landslides Vehicular Accident
Avalanches Drowning
Windstorms Collapse of building
Tornadoes Explosions
Hailstorms and snowstorms Fires
Sea surges, Chemical Poisoning
Floods Droughts
Risk:
Hazards:
Risk is a measure of the expected losses due to a hazardous event
of a particular magnitude occurring in a given area over a specific time
period. Risk is a function of the probability of particular occurrences
and the losses each would cause. The level of risk depends on:
v Nature of the Hazard
v Vulnerability of the elements which are affected
v Economic value of those elements
Vulnerability:
It is defined as “the extent to which a community, structure, service,
and/or geographic area is likely to be damaged or disrupted by the
impact of particular hazard, on account of their nature, construction
and proximity to hazardous terrain or a disaster prone area”
Hazards are defined as “Phenomena that pose a threat to people,
structures, or economic assets and which may cause a disaster. They
could be either manmade or naturally occurring in our environment.”
The extent of damage in a disaster depends on:
1) The impact, intensity and characteristics of the phenomenon and
2) How people, environment and infrastructures are affected by that
phenomenon

This relationship can be written as an equation:
Disasters of three types depending upon its nature of occurring
I. Natural Disasters
II. Anthropogenic Disasters
III. Hybrid Disasters
I. Natural Disasters - It is result of natural phenomena. E.g.
earthquake, volcanic eruptions hurricane, tornado, avalanche or flood.
In this loss of life can range from few individuals to thousands of people,
there are plenty of warning signals and man has to regard them and
encourage people to take action.
II. Anthropogenic Disasters: - It is result of man's interaction
with artificial environment e.g. Air borne hazards, nuclear accidents,
Titanic sank in north Atlantic (No life boat available union carbide plant
disaster at Bhopal. All these disasters are caused by human failure)
III. Hybrid disasters: It arise from a linkage of man – made events
and natural events e.g. Air pollution, water pollution, drought, floods
hurricanes, landslide and wildfires.
Depending on time of continuity disasters are divided into-
(I) Rapid onset disasters (II) Slows onset disaster (I) Rapid
Onset Disasters:e.g. earthquake, tsunamis, floods tropical storms,
volcanic eruptions landslides There is sequence of events following
occurrence of rapid onset disaster.
1. The relief phase – is the period immediately following the
occurrence of sudden disaster outstanding measures have to be taken to
search and find the survivors as well as meet their basic needs for
shelter, water, food and medical care.
2. Rehabilitation – actions, decisions to be taken to restore the
normal living condition of the community encouraging the people to
adjust with situation causes by the disaster.
3. Reconstruction – it includes construction of permanent houses, full
restoration of all services as equal to pre disaster state.
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Mitigation – measures includes preparedness and long-term risk
reduction measures preparedness includes minimizing life losses,
damage and effective rescue, relief and rehabilitation.
(II) Slow onset disasters: e.g. drought, famine, environmental
degradation, desertification, pest infection.
– It is process of monitoring situations in
communities e.g. early warning signal is drought, livestock sales,
changes in economic condition. Detection of early warning signal is to
provide quick and effective measure and to be prepared with new action
plan for prevention. Extraordinary measures have to
be taken to support human needs, sustain human needs, sustain
livelihoods and protect property emergency phase is prolong in slow
onset disaster such as famine it is short in earthquake.Rehabilitation –
is action taken after slow onset of disasters, for resettlement of
displaced person arising out of conflict or economic collapse.Other
disaster occurring in international community includes – avalanches,
fog, frost, lighting, snow storms and tornadoes.
1.6 CAUSES OF DISASTERS
1. –Poverty generally makes people vulnerable to the impact
of hazards because they settle on hills that are prone to land slide, along
the riverside where chances of flood are on higher side.
2. – population has a major impact on man made
disaster. This is because more people will be forced to live and work in
unsafe areas. Increased numbers of people will be compete for limited
amount of resources such as employment opportunities, and land
which can lead to conflict; this conflict may result in crisis – induced
migration. Such growth occurs in developing countries, resulting in
disasters.
3. – Rapid population growth & migration are
related to rapid urbanization. It is characterized by rural poor
population moving to metropolitan areas in search of economic
Early warning
Emergency phases:
Poverty
Population growth
Rapid urbanization

opportunities & security. They may not find safe and desirable
places to build their houses which can lead to human made disasters.
4. : - all societies are constantly
changing and in continual state of transition. These include – nomadic
population becoming sedentary. Rural people move to urban areas
these examples of shifting non industrialized to industrialized societies.
Introduction of new construction material – these new materials being
used incorrectly – these technique may lead to house that cannot
withstand earthquake.
5. – Deforestation leads to rapid rain
that leads to flood – creation of drought – poor cropping pattern over
grazing, stripping of topsoil, and depletion of water supply.
6. – protective measures, safe
locations, safe evacuation routes and procedures, where to turn for
assistance in case of acute disaster . This understanding should be
incorporated into any efforts to provide external assistance.
7. War & Civil strife – The changing economy and emergence of
developed countries as supreme powers, terrorism etc have led to
various situations of wars which have led to man made disaster.
The complete disaster management cycle includes the shaping of
public policies and plans that either modify the causes of disasters or
mitigate their effects on people, property, and infrastructure.
The mitigation and preparedness phases occur as disaster management
improvements are made in anticipation of a disaster event.
Developmental considerations play a key role in contributing to the
mitigation and preparation of a community to effectively confront a
disaster. As a disaster occurs, disaster management actors, in
particular humanitarian organizations become involved in the
immediate response and long-term recovery phases. The four disaster
management phases illustrated here do not always, or even generally,
occur in isolation or in this precise order. Often phases of the cycle
overlap and the length of each phase greatly depends on the severity of
the disaster.
Transitions in cultural practices
Environmental degradation
Lack of awareness & information
EFFECTS OF DISASTERS AND REHABILITATION:
154 SCHC

o - Minimizing the effects of disaster.Examples: building
codes and zoning; vulnerability analyses; public education.
o - Planning how to respond.Examples: preparedness
plans; emergency exercises/training; warning systems.
o - Efforts to minimize the hazards created by a disaster.
Examples: search and rescue; emergency relief.
o - Returning the community to normal.Examples: temporary
housing; grants; medical care.
Developmental considerations contribute to all aspects of the
disaster management cycle. One of the main goals of disaster
management, and one of its strongest links with development, is the
promotion of sustainable livelihoods and their protection and recovery
during disasters and emergencies. Where this goal is achieved, people
have a greater capacity to deal with disasters and their recovery is more
rapid and long lasting. In a development oriented disaster management
approach, the objectives are to reduce hazards, prevent disasters, and
prepare for emergencies. Therefore, developmental considerations are
strongly represented in the mitigation and preparedness phases of the
disaster management cycle. Inappropriate development processes can
lead to increased vulnerability to disasters and loss of preparedness for
emergency situations.
Mitigation activities actually eliminate or reduce the probability of
disaster occurrence, or reduce the effects of unavoidable disasters.
Mitigation measures include building codes; vulnerability analyses
updates; zoning and land use management; building use regulations
and safety codes; preventive health care; and public education.
·Mitigation will depend on the incorporation of appropriate measures in
national and regional development planning. Its effectiveness will also
depend on the availability of information on hazards, emergency risks,
and the countermeasures to be taken. The mitigation phase, and
indeed the whole disaster management cycle, includes the shaping of
public policies and plans that either modify the causes of disasters or
mitigate their effects on people, property, and infrastructure.
Preparedness
The goal of emergency preparedness programs is to achieve a
Mitigation
Preparedness
Response
Recovery
Sustainable Development
Mitigation

satisfactory level of readiness to respond to any emergency situation
through programs that strengthen the technical and managerial
capacity of governments, organizations, and communities. These
measures can be described as logistical readiness to deal with disasters
and can be enhanced by having response mechanisms and procedures,
rehearsals, developing long-term and short-term strategies, public
education and building early warning systems. Preparedness can also
take the form of ensuring that strategic reserves of food, equipment,
water, medicines and other essentials are maintained in cases of
national or local catastrophes.
·During the preparedness phase, governments, organizations, and
individuals develop plans to save lives, minimize disaster damage, and
enhance disaster response operations. Preparedness measures include
preparedness plans; emergency exercises/training; warning systems;
emergency communications systems; evacuations plans and training;
resource inventories; emergency personnel/contact lists; mutual aid
agreements; and public information/education. As with mitigations
efforts, preparedness actions depend on the incorporation of
appropriate measures in national and regional development plans. In
addition, their effectiveness depends on the availability of information
on hazards, emergency risks and the countermeasures to be taken, and
on the degree to which government agencies, non-governmental
organizations and the general public are able to make use of this
information.
Humanitarian Action
· During a disaster, humanitarian agencies are often
called upon to deal with immediate response and recovery. To be
able to respond effectively, these agencies must have experienced
leaders, trained personnel, adequate transport and logistic support,
appropriate communications, and guidelines for working in
emergencies. If the necessary preparations have not been made, the
humanitarian agencies will not be able to meet the immediate needs
of the people.
Response
· The aim of emergency response is to provide immediate
assistance to maintain life, improve health and support the morale of
the affected population. Such assistance may range from providing
specific but limited aid, such as assisting refugees with transport,
temporary shelter, and food, to establishing semi-permanent
156 SCHC

PREPAREDNESS
RESPONSE
RECOVERY
RECONST
RUCTION
REHABILI
TATION
DISASTER
IMPACT

Chapter 3
Essentials of Hospital Disaster Plan
1.0 Objectives
1.1 Introduction
1.2 Aim of Disaster plan
1.3 Objective s of disaster plan
1.4 Principles of disaster plan
1.5 Organization of Health services for Disasters
1.6 Facilities and special equipment needed during disaster
1.7 Incident Command System
1.0 Objectives
After going through this unit, you should be able to
1. Understand hospital emergency plan
2. Know aim of disaster plan and its objectives
3. Understand principles of disaster plan
4. Discuss organization of health services
5. List the facilities and equipments needed during disaster management
response
6. Explain the level of incident command system operations
1.1 Introduction
Disaster causes great loss of life and property and creates severe disruption to
human activities, it is essential that disaster management is planned in a
comprehensive and scientific manner. Hospital preparedness is crucial to any
disaster response system. Each
Hospital need to have an emergency preparedness plan to deal with mass
casualty incidents. Hospitals that are ready can meet the unpredictable
challenge of disasters. The capacity building of health managers through in-
service training for emergencies or mass causality incident management is
essential.
1.2 Aim of Disaster plan
The aim of disaster plan is to provide prompt and effective medical care to
maximum possible in order to minimize morbidity and mortality.
1.3 Objective s of disaster plan
1. To prepare the staff & institutional resources for effective performance
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2. To make the community aware of the sequential steps that should be
taken at individual and organizational level.
3. To make great benefits to greater numbers
4. To reduce after shock
1.4 Principles of disaster plan
1. Plan should be simple and operationally functional.
2. Plan should be flexible.
3. It should specify various roles and responsibilities, work relationships
of disaster management team.
4. It should be comprehensive and should consider all the dimensions.
5. It should be multi factorial and multi dimensional and should include
fire brigade, police and administrative machineries.
6. Plan based on realistic assessment of potential problems.
7. Estimates of types of injuries resulting from disasters most likely to
occur in area included.
8. Plan should be brief, concise, and inclusive of all who will be providing
disaster aid.
9. Plan should be in accordance with timeline.
10.Plan should be approved by all agencies that provide authority
endorsement.
11. Plan should be sanctioned by those with power to see that the plan is
updated and implemented.
12.Plan should be regularly tested and revised
13.Progress of the plan should be considered on regular basis.
1.5 Organization of Health services for Disasters
The health services during disasters are critical elements. It requires careful
planning. Following factors are to be considered while planning health
services during disasters
1. Country's overall health care delivery system at central, state and
district level
2. Role of disaster management authority in existing health care system
3. Region wise delegation of responsibilities and organization of
resources within the defined area.
4. Formulation of comprehensive emergency medical care plan.
5. Establishment of focal point of coordination to ensure the optimal
healthcare resources.
6. Organization of pre hospital medical care and hospital medical care
7. Provision of first level care at disaster site including rescue, relief, first
aid and basic life support measures to preserve life
8. Mass casualty management
9. Provision of therapeutic procedures and supply of drugs and medical
supplies.

10. Medical command and control, triage team, first aid team, casualty
evacuation team should be in place
1.6 Facilities and special equipment needed during disaster management response
1.7 IncidentCommandSystem
Incident Command System
LEVELS OF OPERATIONS DURING DISASTER MANAGEMENT:
1. Earth moving equipments
2. Ambulance
3. Drilling rigs
4. Mobile craves
5. Mobile X-ray units
6. mobile trauma care centers
7. Water tankers
8. Wireless sets, Mobile wireless sets etc.
9. Blood bank
10. Labs
11. Fire brigade services
12. Hospital with surgery facility
:
In order to
professionalize emergency response management, it is proposed to introduce the
Incident Command System in the country. This system provides for specialist incident
command teams with an Incident Commander and officers trained in different aspects
of incident management – logistics, operations, planning, safety, media management
etc. Disaster is unexpected, unforeseen event causing damage on large scale. Because
of its sudden nature leading into mass causalities, the health care providers have to
research on site-for rescue operation. Therefore the nurses have greater role in the
managementofdisaster on siteand intheemergencydepartmentor in thehospital.
LEVEL OF OPERATIONS
is assigned to help hospitals and communities
for improving emergency management planning, response, and
recovery activities for unplanned and planned events.
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OPERATIONS
EMS OPERATIONS FIRE OPERATIONS PUBLIC HEALTH
MEDICAL DIRECTION COMMUNICATION SURVEILLANCE IMMUNIZATION
TRIAGE TREATME TRANSPORTATION RESCUE TAGGING

Chapter 4
HOSPITAL PREPAREDNESS
PREPARATION OF EMERGENCY DEPARTMENT FOR MASS CASUIALTY
INCIDENTS:
Mass casualty management committee:
The hospital should have a mass casualty management committee. Its
responsibility would be preparation of the hospital contingency plan,
dissemination and its follow up. It would undertake training of staff. The
committee member should comprise of following authorities:
· Medical administration
· Hospital administration
· Maintenance
· Emergency Department
· Surgical department
· Nursing service
Department-wise preparedness
Incoming patient area:
This is usually the casualty / Emergency department of hospital.
Depending on the size of casualty, this area might be extended to another
area of hospital if patients exceed a certain number.
Areas in the emergency department:
· Triage area in the casualty
· Resuscitation area for unstable patients.
· Area for the beyond salvages patients.
· Area for brought in dead.
· Area for the walking wounded.
· Alternate area / ward where sick patient can be shifted when the
casualty is over crowded.
· Area where post operative patient can be received.
Patient care in casualty: (Triage)
Instead of treating the most sick or most injured first, triage would focus on
identifying and receiving immediate treatment for individuals who have a
critical need for treatment and are likely to survive. The goal would be to
allocate resources to maximize the number of lives saved.
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spectrum of care from the scene to hospitals and to alternate care sites.
Emergency department access may be reserved for patients requiring
immediate care; ambulatory patients may be diverted to alternative care sites.
Needs of current patients such as those recovering form surgery or critical
or intensive care unit should be evaluated; the resources they use will
become part of overall resource allocation.
Elective procedures may have to be cancelled and current in patient may
have to be discharged early or transfer to another settings. Depending upon
the situation.
Nurses may function as physician and physician may function outside their
specialty credentialing of providers may be granted on emergency or
temporary basis.
In patient services by medical staff:
Medical director will coordinate the preparation, notification of inpatient
services.
Will ensure to provide adequate patient care.
Facilitating pending admissions.
Preparation to receive patient
Will ensure care of patient
Nursing services:
Conduct accurate bed count for available medical-surgical beds.
Conduct accurate count of available ICU, Isolation beds.
Contact the director of pre-operative services to assess readiness of
operation theatre and recovery room.
Coordinate with inpatient services for evaluation of patients who can be
discharged on priority basis to make room available.
Ensure the availability of required staff and supplies.
Support services:
The emergency department should have a reserve of essential drugs
including whole blood, medical supplies and materials that can be used in
large scale emergency. It should be stored separately in the one casualty. It
should be easily accessible in an emergency.
Material management:
Four emergency department disaster carts should be brought from central

supply to the casualty. Assign personnel to the emergency department to
bring the required supplies and equipments.
Blood bank
The blood bank is alerted to the disaster activation and will co-ordinate the
distribution of blood and contact outside blood banks if needed.
Pharmacy
Dispatches required personnel and medication to the emergency
department.
Lab services:
Is prepared to receive a large number of samples and prepared for down
time procedures
Internal and external communication
The internal system of communication between the various wards and
departments must be established. Following could be done:
1. Portable loud speaker.
2. Internal telephone lines
3. Two way radios are the possible alternatives; this may also help in
establishing communication with staff outside hospital.
There should be updated list of names of doctors and others support staff,
department wise with their database.
Transportation:
Emergency department clearly indicates the priorities regarding the
use of hospital ambulance and other services vehicles. It should make
provision for fuel, designate staff to be in charge, it should have the basic
and essential equipments and the medication.
For transportation of causalities within the hospital .it is important to have
mobilization of adequate number of stretchers and wheal chairs.
Manuals and operational guidelines:
The administrator, departmental heads should have specific manuals for
each departments / ward as well as instruction on how to establish personal
working groups, and plan of action to be implemented in case of an
emergency.
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At no time the media should be allowed unescorted through any patients
care of treatment area. The office of communication and business
development will handle all news releases, press conference and the
interviews.
Family reception area:
In mass casualty incidents, no visitors will be allowed in to the emergency
department and the hospital visiting hours should be suspended.
Family reception area will be set up in separate lobby; the patient relationship
department will be responsible for notifying families.
Hospital network with other agencies:-
The major emergency requires involvement of all relevant agencies and it is
also necessary to establish network with public and private agencies. The
emergency department must know the operating capacity of other hospitals
in the neighborhood. It should also network with agencies like defense,
police, fire etc.
Patient referral system:
Some cases may require specialized care for which, the emergency
department should make alternate arrangements with other hospitals for
referring patients and provide necessary transport for the same.
Critical incident stress management programs:
The emergency department has to provide short and long term stress
management measures for the health care providers and their families.
References
1. Coping with major emergencies- Who strategy and approaches to
humanitarian action, Geneva, World Health Organization, 1995.
2. WHO (1999). Community Emergency Preparedness: a manual for
managers and policy – makers, WHO
3. PAHO (2000). Natural Disasters, Protecting the Public's Health,
Scientific Publication No. 575
4. Emerton, M.D., Principles and practice of Nursing, 2 ed. , Chapter
18, Prentice Hall of India Pvt. Ltd., New Delhi.
5. Mahoney, R.F., Emergency and Disaster Nursing, 1 ed., Mac Millan
Company, New York, 1965.
nd
st

THE HOSPITAL PROJECT TEAM
CHAPTER 11
In the conceptualization, design, construction and commissioning of any successfully
run healthcare facility project, the services of some or all of the following types of
consultantswillbe required:
In additiontotheseconsultants,thedesignteamwouldalso include:
We thus have eleven individuals / consulting firms or groups of people who would
constitutethe
Starting with the consultants, their fields of expertise and thus scope of services would
beas follows:
1. HospitalConsultant
2. ConsultingArchitect/Architect
3. MunicipalArchitect/LocalArchitect
4. Structural Consultant / MEP (Mechanical, Electrical, Plumbing)
Consultants
5. Construction Manager
6. LandscapeArchitect
7. InteriorDesign Consultant / GraphicDesigner
8. Bio-MedicalEngineer/ MedicalEquipment Consultant
9. The Client/Client'sRepresentative
10. HospitalAdministrator/CEO of Proposed Facility
11. UserGroups / Representativesof Users of theProposed Facility
DesignTeam.
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1) The HospitalConsultant
2) The ConsultingArchitect/Architect
At the start of the project, the hospital consultant's role is to do a market survey and
financial feasibility report to establish what should be the role of the proposed
healthcare facility in the region it is to serve. The consultant's recommendations focus
on the total operational future of the facility, including the service area market financial
future, proposed medical specialties and bed strength. His most important function is to
provide an independent professional opinion and plan based on an unbiased look at the
total operation. This consultant is usually retained to develop a long-range plan (also
known as strategicplan.)
The hospital consultant's role in design and construction is thus that of a programmer.
The consulting architect will help him in this. Once the facility's role in the community
has been established, the operational and functional plans must be established. They
should bebasedon departmentutilizationprojections.
This consultant has a role to play towards the end of construction too. He can offer
services relating to recruitment of staff, setting of tariffs, formulating operating
procedures for the different medical departments, may offer consulting services on the
evaluation of medical equipment to be purchased and may facilitate computerization of
hospital functions. He may formulate marketing strategies and offer TQM / ISO 9000
solutions.
In an existing facility he may advise on turn around strategies, do operational audits,
costing of services and systems study and redesign. He may advise on hospital waste
managementpractice.
Fees arenot regulated,andwillvarydependingon thescopeof services.
Consulting Architects offer specialized healthcare programming and design services.
They may offer these services on a national or international basis.The national firm may
have either many offices throughout the country or a home base and a few regional
offices. It's design expertise includes master planning, layout, and equipment from
projectsrangingfrommedicalcollegesto ruralprimaryhealthcarecenters.
The Consulting Architect may also extend his scope of services to do conceptual
planning and schematic layouts for individual hospital projects. This will then be then
theinputtothenextconsultant,theArchitect.
If theArchitect has the necessary expertise to design and produce construction drawings
and documents for the hospital project himself, and if the scale of the project is within

his design and production capabilities, the consulting architect's services are not needed
for thatproject.
Selecting the consulting architect / architect can be a difficult and tiring process. The
selection committee may sit through four presentations a day, hearing equally good
demonstrationsof expertise.Thefollowingtips mayhelpnarrow thechoice:
a) Find out which member of the firm will handle the job and evaluate his or her
responses. You will be working closely with this person for a long time, and this is
thekeytoafirm's selection.
b) Study the proposed team and it's organizations appearance. Ask about the teams
members' experienceandrequestareferenceofcompletework.
c) Checkthefirm's references.
d) Explain your needs and the goals of your project, such as design excellence,
mechanical systems and functional concerns, and ask questions as to how these can
bemetfor your facility.
e) Relate the fee quoted to the larger costs, those of construction and efficient
operation. Do not pick the lowest fee just because it is low. Once a fee is verbalized,
it greatly influences a committee. However this fee amounts to only a small fraction
of the total amount you will spend for construction, and an even smaller amount of
the total project cost, including land and medical equipment. Money is not saved if
the building does not operate efficiently. Every 3 to 5 years of operations will cost as
much as the initial construction. The building will in all probability operate for
around50 years.Itis importantto inyour selection.
The Municipal Architect is the consultant who will be responsible for obtaining all the
requisite permissions / No Objection Certificates (NOC's) from the concerned
regulatory authorities. This would include approval of the land use, the proposed built-
up area, the open spaces around the building, the provision for parking, any recreational
space / gardens that may need to be provided and the plans showing the individual rooms
with sizes. He would also be responsible for obtaining clearance as to fire-fighting
provisions andmeansof exitsuch as staircases.
trust
3) MunicipalArchitect/LocalArchitect
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If the hospital is being designed by an architectural firm that does not have
representation in the city / town / rural area where it is proposed, a LocalArchitect may
be appointed, who, as his designation suggests is based in the locality of the project. He
may be the same as the Municipal Architect. He would then, in addition to the above-
mentioned functions, supervise the day-to-day activities on site, reporting to the main
architect. He could also provide information on locally available materials and local
methods of construction. He could advise on the traditional architecture of the region, if
themainarchitectsdesireto respondto itin theirproposed aestheticfor thefacility.
Both these architects are better selected by the Main Architect than the client, as the
working relationship between all these architects needs to be based on mutual respect
and hence cooperation. Many a project has come to grief over disputes or differences in
outlook between different firms of architects working on the same project. Creative
professionalscanoftenbeprimadonnas, orbehavelikethem.
Structural and MEP Consultants are engineers. Structural engineers are
moregenericallycalledcivilengineers.
Historically, engineers who worked on non-military projects became known as civil
engineers.Threemaindivisionsof civilengineeringexisttoday:
a) TransportationEngineers
b) StructuralEngineers
c) SanitationEngineers
CivilEngineerscontributetheirtalentstohospitalconstructioninthreeareas:
a) SitePlanning
b) StructuralDesign
c) Construction
Site planning is the art and science of arranging the uses of land. Site
planning is done professionally by architects, landscape architects and civil engineers.
The civil engineer plays a role in readjusting the existing landform through designed
gradingandprovidingforproper drainage.
4) StructuralConsultants /MEP(Mechanical,Electrical,Plumbing)Consultants
Site planning:

Structural Design:
Construction:
Mechanical Engineers
Electrical Engineers
Plumbing Engineers
The structural engineer's role is that of providing the optimum
support for the building. Structural work needs to be coordinated with the architect and
the other engineering consultants; this coordination is absolutely essential in hospital
projects.He willdecideinconsultationwiththearchitectthestructuralsystemto beused.
It is in the preliminary stages of design that the structural engineer can effect the most
savings. He must be appointed at the beginning of the project, and work with the architect
evenduringconceptualdesign.
The civil engineer is responsible for inspection and testing of the
materials used in construction, to make certain the owner gets the quality and quantity
specified.His roleis thatofConstructionManager, dealtwithindetaillateron.
study the conservation of energy and apply it in the most
efficient and economical way. They design the heating / air-conditioning loads for the
hospital, design the system and specify the necessary equipment. He will design the
incorporation of the necessary filters into the air-conditioning system to produce the
desiredsterilityconditionsinthatspace.
design the electrical systems of the hospital and calculate the
electrical loads based on lighting and equipment loads. He should be aware of the public
utility supply and rates to ensure economical power distribution and the required
emergency supply. He will specify the equipment needed. He will design control and
monitoring systems (Building Management Systems) and cater to communications and
dataprocessingrequirements.
are responsible for the processed water supply and liquid waste
disposal throughout the building. They design the capacity of the water tanks (overhead
and underground) required based on occupancy and applicable regulations. They design
the fire-fighting systems required, the sewage treatment plant (if required) and water
purificationplantsfor thehospital.
In it's engineering requirements, each hospital presents a unique problem. There is no
universal solution to the selection of a system even after the problem is defined.There are
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many technical considerations depending on the medical equipment to be housed and
themedicalprocedurestobe performedwithintheproposed facility.
It is important that the MEP design team is hired as early on in the proceedings as
possible, ideally at the start of the project, as they can advise on many decisions that are
often taken without their involvement, presenting them later on with a de facto situation
resultingininefficientdesignand/or construction.
Very often, at the end of the project, few among the consultants and sometimes the client
too are not satisfied with the outcome. Too often the client is heard to say, “ Well, it is not
whatI expectedor whatI wanted.”
This condition of dissatisfaction can be avoided with value management. This performs
thefollowingfunctions:
a) Understandingtheclient's expectations
b) Understandingtheconstraintson theclients
c) Understanding the expectations and limitations of the architect, engineer and
constructionmanager
d) Helpingthedesignteamcommunicatetheirexpectationsandneedsto oneanother
e) Helping the architect and engineer make changes and stay with schedule and
budget
Coordination of the work of the engineering design team and the architectural
design team is of crucial importance. A lot can go wrong if this is not rigorously
done, especiallyin hospital design.

f) Monitoring and reporting issues that seem likely to delay design or cause
dissatisfactionamongmembersofthedesignteam.
g) Preparing and conducting special problem solving sessions to clarify values and
objectives, improve design, maintain or lower total cost, maintain or shorten
schedule,improvelifecyclecosts andimproveenergy design andcosts.
h) Employing the methods and procedures of all problem-solving systems, including
valueengineering,valueclarification,design-to-costand Delphi.
is a set of concepts and methods used to adjust designs to acquire the
best total value. Using definition and analysis of function, value engineering is aimed at
achieving the lowest total cost commensurate with design excellence. Specific methods
include function analysis, brainstorming sessions, matrix comparisons and analysis of
life-cyclecosts.
Construction Management of hospital projects in the West began in the 1960's. By now,
almost all projects include a construction manager to save time. The advantages of
including a construction manager early in the design phase can be great. For example,
theconstructionmanagerisfamiliarwith:
Current building systems that are available on the regional market at a competitive
price.
Current labor and industrial prices, enabling him to establish a proper estimate in the
specificarea.
Sub-contractingtradesthatcanadviseon detail.
Specificationreview.
Value engineering
5) Construction Manager
i)
j)
k)
l)
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m)
n)
o)
p)
q)
r)
Cost consultingand scheduling.
Management.
Inspections.
Insuranceprogramming.
SamplesandTesting.
Shop drawingandCoordination.
This knowledge, if applied in the design phase, can lead to cost improvements, time-
savings and fewer change orders. The expected contingencies now budgeted and used
should be reducible. Many architect-engineer firms offer construction management
services.
The construction manager performs a variety of functions, such as managing general
conditions on site, including start-up and overall supervision. Towards the end of
construction, the construction manager is responsible for drawing up a certificate of
substantialcompletion.
The landscape architect is responsible for the design of outdoor areas, around the
hospital or the spaces in-between buildings on a campus. While the architect usually
does the layouts of motorable roads, the landscape designer suggests the layout of
pedestrian pathways, paved outdoor areas and plantation. He may also suggest water
bodies, fountains, street furniture and lighting and provide detailed construction
drawings for all these elements. He will work in close coordination with the main
architect.
6) LandscapeArchitect

7) InteriorDesign Consultant / GraphicDesigner
Graphic
Designer.
We are in an era in which interior architecture design has become an integral part of the
architectural process; it begins with the earliest architectural concepts and ends with the
client occupying the completed space. In the case of a hospital, it is best that the interior
designer is able to work as a direct extension of the architect and is often hired directly
by the architect to perform work included in the basic architectural contract. The
architects firm may itself contain an interior design division. Such designers are best
qualified to perform the total range of services needed to complete any medical facility
including basic design and functional considerations, durability and maintenance of
product,andcontrolof costs.
Fees vary, based on scope of work. The earlier the consultant is retained, the better.
Listedbelowinchronologicalorderaresome oftheinteriordesignservicesavailable:
a) Preliminaryconsultation,analysisof scopeandarchitecturalreview.
b) Interiordesign materialsandcolorcoordination.
c) Environmentalprogrammingbasedon socialandbehavioralfactors.
d) Operationalprogrammingforefficientuse ofspaceandfurniture.
e) Inventoryanalysisandevaluationfor existingfurniturereuse.
f) Preliminarybudget.
g) Spaceplanningof detailedlayouts.
h) Lightingdesign,coordinationand review.
i) Furnitureselectionor design,budgetandspecifications.
“Corporate image” does not sound like a term that should be applied to the design and
construction of hospitals, but it is an area of design that is of great importance. The
overall concept of a hospital's image includes graphic art and design. The interior of a
hospital should be tied to a graphics program and that requires the services of a
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Two types of programs are of interest to the hospital designer. One is that of directional
graphics, a signage program. A mass of information must be transmitted visually to the
patients, visitors and staff so that time and motion are not wasted. The program develops
a consistent lettering font and style and a directional program. The second is that of the
corporate image of the hospital, the hospital logo and master program for all printed
data. Graphic design should be thought through early in the design stage, allowing
incorporationof thegraphicdesignintothetotaldesignconcept.
The responsibilities of the medical equipment consultant can be limited or quite broad.
Basicequipmentplanningservicesmightinclude:
a) Assisting theclientinmakingequipmentselections.
b) Establishingandtrackingtheequipmentbudget
c) Compiling an “equipment book” including manufacturer's installation data and
“cut sheets” (equipment specifications) and obtaining other relevant data from
equipmentvendors.
d) Developing room-by-room equipment lists and indicating the general location of
equipment.
e) Obtaining from the vendor and forwarding to the architect (via the owner)
installation data necessary to develop architectural and engineering components of
thebuilding.
f) Organizing and directing equipment user group meetings in which the specific
equipmentneeds offacilityusers areidentified.
Additional services, which may go beyond the scope of basic equipment planning
services,mayinclude
a) Assisting the owner in procuring and installing equipment and negotiating a
purchaseagreementwith thevendor.
Although the equipment planner can be quite helpful in this area, many health care
providers may be affiliated with some type of bulk purchasing service and can negotiate
competitive prices themselves.The difference between an aggressively negotiated price
and list price is considerable. Negotiated pricing also should include extended service
contracts,whichinthemselvescaneventuallyaddup toa considerablesum.
8) Bio-MedicalEngineer/ MedicalEquipment Consultant

b) Additionaluser group meetings.
Departmental user group meetings consist of a series of long, intense, interactive work
sessions. In order for these meetings to be conducted in a time-efficient manner, each
department user group should have a general idea about the equipment it is considering
to purchase or reuse.The equipment planner can be an additional resource in describing
some of the specific attributes and requirements of each unit, instead of having to begin
with more basic issues. The equipment planner will bring a more objective viewpoint
thantheequipmentvendor.
c) Coordinating tours to visit facilities where similar equipment is in operation and
presentationsby equipmentvendors.
One good way to learn more about the equipment that currently is in use is to visit
similar facilities that have recently opened. When conducting such a tour, it is best to
select a facility that is similar in scope to the one being designed. It should also have
been operational long enough for the staff to develop more than just first impressions,
but not one that is so old that the equipment does not compare with what is currently on
the market. Equipment vendors may also organize tours of their showrooms and current
facilities showcasing their equipment. Such tours can be both educational and
economical. However vendor organized tours tend to be less objective than those
organizedby thearchitector equipmentplanner.
Trade shows are another good source for learning about current equipment as well as
staffing, management and business issues relating to the operations of health care
facilities.Manyequipmentvendors unveiltheirlatesttechnologyatsuch shows.
As a client or his representative who intends building a new healthcare facility or adding
to or renovating an existing facility, you will be working with the above-mentioned
design team. Long before the first shovel hits dirt or hammer is swung, you will find
yourself committed to many hours of planning meetings with professionals such as the
above.Youwillbean integralpartofthedesignteam.
This is what Vincent Wang, Design Director, Stanhope Properties plc, has to say on the
subject:
“Quality is a state of mind, not an optional extra. It cannot be bolted on. The lead must
come from a strong and committed client and the pursuit of quality must form every
strandoftheprocess”
An essential function you will perform right at the beginning of the project will be to
9) TheClient/ Client's Representative
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state the project goal/s, or 'statement of intention”. This will form a reference point for
policy decisions taken by the design team, which will need to be consistent with this
formulation of project goals or intention. Keep it short and state it with clarity. Weigh
eachword thatforms partof thisstatement.
The whole team will look to you to provide direction and purpose to the whole effort. If
you falter or show signs of indecision this will communicateitself to the entire team, and
if this goes on for an extended period of time, the whole group will come apart at the
seams.You have to project, as Mr.Wang says above, strength and commitment, and lead
from the front. If you are perceived as losing interest in the project, maybe you show the
team that you are more concerned about your other business then it is bad for morale.
You must always communicate keen interest in the project. Make an effort to establish a
rapport with the key members of the design team. Consultants work harder for clients
they like as people; you can't always buy that kind of extra effort with money. (Of
course,youcantryitwon'tdo anyharm!)
Maintain project momentum. If you drag out the process, all concerned will lose
interest.
It is a good move to appoint the CEO of the proposed hospital or the HOD of the
additional department/s being added / renovated right from the design stage. If they are
already working in the existing facility they need to get themselves a hardhat and take
on a part-time job.They will be liaison and interpreter between their staff and the design
team.
My adviceto thisCEO is:
A) You need to be an active member of the planning and design team as early on as
possible.
B) Try to keep a copy of the most up-to-date plans. This way you can keep up with
progress andrevisions.
C) Keep a current plan located in a strategic location so staff and physicians can
becomefamiliarwiththeproject.
D) Take your own project meeting notes. You can double check them with the
architectural minutes to make sure you don't forget anything. You should be on the
mailinglistforprojectmeetingnotes.
10) HospitalAdministrator/CEOof Proposed Facility

E) Involve your staff. Invite key members of your department to architectural planning
sessions.
F) Form a staff planning committee and meet regularly for feedback and plan reviews.
Involve a cross section of staff from different shifts, those that embrace change and
yes, thosethataremostresistant.
G) Create flow charts of critical work processes. Determine what your problems and
issues are with your current plan. How will these processes be supported in the new
plan? Examples of processes to consider include chart flow within a department,
supply flow and storage, soiled / clean linen flow and clean / soiled instrument /
proceduretraypathways.
A little advice on reading architectural drawings: drawings or plans are produced in a
reduced scale. The most common scale is 1:100 where 1 drawing unit is equal to 100
units in reality. This scale is by-and-large the same as 1/ 8 of an inch equals 1 foot. The
other commonscale is 1:50 or 1 / 4 of an inch equals 1 foot. Once you have your first plan
to review, get a scale or architectural ruler to help read the drawings and determine the
plannedsizeof spaces.
On relating plans to space: once you can read the blueprints, relating them to your frame
of referenceof spaceis criticalin planning.Hereareafewquicktricks:
A) Find a room in your current department such as a patient room or supply room.
Measure the size of the room. A room that is close to 8 feet by 10 feet is a good
manageable frame of reference. You can then relate the size of your room to a
comparablesizeroomon theplans.
B) Measure doorways both on the plan and in your department. Doors through which
patients on stretchers are to be moved are usually 60 inches wide, with two equal
shutters. Patient room doorways and doorways for handicapped people are usually
48 inches wide. What is planned to go through the doorway in question will
determineit's width.
C) Acute care hallways and hallways in public spaces should be 8 feet wide (7 feet at a
pinchgoes inIndia).
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D) Compare the new space with what you have. For example if the supply and
equipmentroomsarechangingsizes,comparethenewspacewithwhatyou have.
E) The amount of square footage doesn't always provide a guide for actualusable space.
The two rooms shown here give examples of different shaped rooms that are the
samesquarefootage.
Room A would make for a good equipment room because
of the amount of space in the middle of the room for
equipmentneedingfloorspace.
nottoscale
10'-0”x 12'-0”
120 sq. Ft.
Room B would make a better supply room as the wall space
canbeusedfor shelving.
nottoscale
8'-0”x 15'-0”
120 sq. Ft.
On being a proactive participant: don't let anyone tell you it's too early to start
determining your departments needs. The earlier you have information, the more
appropriateinputyou cangiveearlyon intheplanningprocess.
Internalresources:
A) An essential place to start with is your information services department. When
planning workspaces such as nurse stations and patient rooms, many of the issues
will relate to technology. Discuss technology for your department and facility for the
next 2 to 5 years so your department plans can be designed with enough flexibility to
support change.
B) Meet with key support department heads. Their future plans may impact your
department. Or, you may be considering changing a work process that impacts
another department. In either case, inputs from these departments can provide you
withvaluabledecisionmakinginformationandideas.

C) Visit other departments that have undergone recent construction, renovation and /
or have purchased new equipment. Get their feedback on how the process was
managed and the quality of decisions made. Check with the purchasing department
and facilities department to see what current information they may have from
vendors about new equipment. The internet is also an excellent source of product
information!
D) Depending on the scope of the project it may be practical to build a mock-up room,
for example a patient room, trauma room or an or somewhere on your campus.This
is a great place not only to actually see the proposed size of the rooms but also to
havemock-upproductsand equipmentbroughtinfor staff toseeand touch.
Externalresources:
A) Your peers in other facilities. If you haven't already done so, talk to managers who
have been or are going through their own construction project. Visit their
departmentsandhavethemsharetheirexperienceswithyou.
B) Sales reps. Word gets around the sales community pretty quickly so sales reps may
be contacting you before you think you are ready for them. They are a great
resource for up-to-date information and future trends in their industries and for
references regarding other new facilities. They should have a list of installed or
built sites for you to see or key contacts for you to talk to. Trial and mock-up
products are frequently available to assist you and your staff in making purchasing
decisions.
C) Site and / or factory visits. Many people feel that a site visit to another health care
facility is as good or better use than the traditional factory visit. Some of the
advantages of a factory visit include being able to see the full range of products and
servicesavailabletoyou fromamanufacturerand obtainingcustomerreferences.
D) Professional meetings. Professional meetings that have large exhibit areas provide
the opportunity to see many different kinds of technology and to touch, move and
learn product features and benefits in a short condensed period of time. Registering
at each booth may not only get you a free gift, but also put you in touch with a local
representative.
E) The internet. More and more manufacturers and professional organizations have
web sites that will let you research information and / or shop right from your office.
Professional organizations such as the American Institute of Architects have web
siteswith articleson architecturaltrendsandcurrentprojects.
Many construction projects, especially renovations, are phased construction unless you
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can relocate to another hospital space or temporary building during construction.
Disruption in operations, patient care delivery and compromises of work areas are to be
expected. Working closely with project team members including infection control staff
willensureasmoothprocess.
A) Identify your priorities for the order of phasing and match them with the reality of
constructionconstraints.
B) Get as realistic a schedule as possible, accepting the fact that time lines are bound to
change.
C) Keepyour staff up todateso thereareaminimalnumberofsurprises forthem.
D) Visit the construction site frequently. As the building is being completed it will be
easier for you to visualize what was on the plans. You will also be able to recognize
situations that do not match the plans. It may be something as simple as a missing
electricaloutletor athermostatplacedwherefurnitureor equipmentwillobstructit.
E) When construction is far enough along, usually after the walls are put up, bring your
staff through and start orienting them to the new space.Athree-dimensional space is
verydifferentfromtheflatblueprintsyou havebeenreviewingfor alongtime.
F) Keep your sense of humor! Generally, even if you had to make some compromises,
thenewdepartmentwillbebetterthenwhat youarecurrentlyworkingin.
All in all, the process of renovation or new construction can be challenging and fun if
you are well prepared. You are the key to creating a more effective, functional and
efficient clinical department or facility that supports both staff and patient care. This is
your opportunitytomakea differenceinthis important workand acreenvironment.
As we have mentioned above, in an existing hospital addition or renovation, staff
members of the concerned departments are invited to attend what are called “user group
meetings” in which they, as the eventual users of the proposed facility comment on the
plans prepared by the design team. Their comments can offer insights into the efficient
operations of the proposed facility, helping the design team get in touch with reality.
These could be meetings with physicians, nurses, support staff, anyone who would be
using theproposed facility.
For the design of Inpatient units, patients can be interviewed through questionnaires
relating to their experience in the hospital, and asked for suggestions as to how their stay
could have been made more comfortable. Designing for the patient costs no more
11) UserGroups /Representativesof Users ofthe Proposed Facility

initially, and it will boost public relations for many years. This information can be
obtainedby “patientprofiles”.
Patient profiles represent patient's needs, tastes, and opinions on their hospital stay
directly to the architects and design people. Profiles will not only directly affect the
administrator, as a buyer of hospital products, but will establish the patient and hospital
staff as a partnership that works together to achieve a good professional environment
thatministerstothephysicalandemotionalneedsof thepatient.
With a patient profile system, reported patient needs can be analyzed in order to improve
design standards. Whether a hospital has hired a consulting architect for a completely
new facility or a phased renovation, the patient profile information is a valuable tool in
design. It is time the design profession reflects on the needs of patients themselves, not
on whatwe perceivetobetheirneeds,for “their” needsaretrulyour own.
Community outreach programs are increasingly becoming important for hospitals to
educate the community which they serve about the services they offer, and to get
feedback from the same community as to what additional services they need to provide
or change in the way they provide their current services.When designing a new facility it
is well worth the designers while to present the proposed scheme to representatives of
the community it is located in, to inform and to get feedback. In the United States it can
be mandatory to this in particular cases. For a corporate hospital, it generates important
feedback on the needs of the community, and would help determine which medical
specialties should be their thrust area. Meetings with local physicians who would
possibly refer patients to the proposed facility and asking their opinions on what medical
facilities the proposed facility should offer would be at least a good marketing move,
and mightbeof helptoo.
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