Study Material 2

STRATEGIC OVERVIEW OF INDIAN HEALTH CARE SETTING
• WHAT CONSTITUTES HEALTH CARE INSTITUTION?

Apart from Hospitals, there are many other health care related institutions like
Wellness centres, Health Spa, Hospices, Poly Clinics, Para Medical
institutions, Old Age Homes, Palliative care centres etc. The institutions are
basically divided as Government v/s Non Government, For Profit v/s Not For
Profit, Primary v/s Secondary v/s Tertiary

• NON-PRIORITY FUNDING BY GOVERNMENT
Over the years the government budgets globally have reduced their spending
on healthcare. There has been a concerted effort to privatize the healthcare
business at all levels. In India the percentage GDP spend on healthcare has
been declining on a per annum basis. The government expenditure has been
more on building infrastructure like roads, ports, telecommunication, power
etc and less on social sector essentials like education and health care.

• TIER SYSTEM
The health care institutions are generally planned into a TIER system which
starts with the Primary Level healthcare wherein the basic facility of
outpatient based medical care is combined with limited general surgical set
up. Secondary care centres provide services in all medical and surgical
faculties and has more in patient based facilities. These centres include
advanced diagnostics and critical care facilities with a capability to treat most
diseased conditions. The Tertiary care centres provide all the facilities in a
secondary care centre and also some super specialty services in areas like
Cardiac Surgery, Neuro Surgery, Urology, and Orthopaedics. The tier systems
helps a planner to identify the infrastructural needs of the building to be
planned.

• POPULATION DISTRIBUTION
India been a vast country with agrarian economy, the population distribution
continues to be rural based. The healthcare infrastructure has more bias
towards the developed cities with secondary and tertiary care centres, whereas
the rural belt is left stranded with only the primary care set ups. The referral
system been under developed, the rural masses have very little choice of
treatment for advanced diseases.

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Hospital Planning Dr. Vivek Desai

• AWARENESS PROBLEM AMONGST USERS
Low levels of literacy combined with negligible media coverage has not
helped the healthcare industry in expanding its market base. It only offlate
with the advent of health insurance and promotion of privatized healthcare,
that the media coverage of health care has improved thereby making the
population aware of various issues involved in the delivery system. This trend
will only continue as is evident with the increase on number of publications
targeting the health care markets.

• LACK OF PROPER REGULATION
As compared to any other organized sector, healthcare sector is plagued with
the problem of complete lack of regulation. There is no set standard guideline
to plan and operate a health care facility. Various attempts made towards
developing a standardized document by non governmental organizations and
the government has not been properly channelized. Regulations would be
required for minimum standards for physical infrastructure as well as for
operational procedures like manpower skills/record keeping. Certain
institutions like ICRA and CRISIL have already formed Accreditation norms
and have started rating hospitals. Even the Health Insurance companies have
started to emphasize on the concept of minimum standards for recognizing
hospitals in their network.

• TECHNOLOGICALLY UNDERDEVELOPED
The healthcare organizations in India are as yet not keeping pace with the
technological advances in medical devices and IT. Only the tertiary care
hospitals in bigger cities have recognized the importance of such technology
and have opted for the latest equipment. The major problem in this is most
advanced technology has to be imported which increase the cost of
acquisition. Primary and secondary level instituitions should opt for more
indigenous technology, wherein the cost could be curtailed and servicing also
becomes easier.

• FINANCING OF HEALTH CARE INSTITUTIONS
Financing mechanisms for setting up hospitals is also under developed.
Though the lending rates for capital has reduced from the 15% to around 10%,
it still will need to go further down. The recent budget in 2003 has given a
welcome break for hospitals above 100 beds, wherein the lending institution
will get tax benefit on the interest thereby reducing the lending rate by almost
2%. Such sops will definitely help brining more entrepreneurs in the fold,
especially the medical fraternity. Customs duty rationalizations still remains a
distant dream, which if done will bring big relief to the hospital owners.
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• PURCHASING POWER OF THE CONSUMER
Over the years the purchase power of Indian consumer has witnessed a
upward growth, but still health care expenses remain one of the highest cost of
debt especially in semi urban areas. The fast growth of health insurance will
definitely help in brining in more people into the fold who can afford
institutionalized health care. Corporates have also been a big contributor to the
health care industry wherein most specialized care is been reimbursed for their
employees as medical benefit perquisite.

• INFRASTRUCTURE PROBLEMS (UTILITIES, ROADS ETC.)
As in all other industrial growth in any country, infrastructure problems
related to basic amenities like access roads, electricity, water, drainage, and
telecommunications remain a major problem area for the hospitals. This
deficiency is more pronounced in non urban areas and even in big cities like
Chennai, Bangalore, Calcutta etc. Such deficiency result in high cost of such
infrastructure as one has to rely on their own capacities of generators, water
treatment plants etc, which ultimately increases the cost of the project.

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STAKEHOLDERS IN HEALTH CARE INDUSTRY

Health care sector is one of the few industry which have diverse stakeholders
ranging as under:

! OWNERS

• GOVERNMENT (Central, State, District, and Local Bodies)

• ‘NOT FOR PROFIT’ HOSPITALS (Mostly owned by charitable
Trusts, societies, and multilateral agencies)

• ‘FOR PROFIT’ HOSPITALS (Corporate Hospitals)

! CONSUMERS (PATIENTS/RELATIVES, 3RD PARTY PAYERS)

• PROFESSIONALS (Doctors, Nurses, Para Medical staff, Managerial,
IT professionals, bio-medical engineering, finance etc)

! EQUIPMENT (Medical & Non Medical) AND OTHER VENDORS

! PHARMACEUTICAL COMPANIES

• FUNDING AGENCIES (Financial Institutions & Insurance)

! ARCHITECTS

! CONTRACTORS (civil, electrical, air-conditioning, plumbing, fire
fighting, interior design, data cabling, building maintenance etc.)
! ENGINEERS (consulting as well as contracting)

In view of the above, it is evident that the industry has a very diverse portfolio of
stakeholders and hence affects a large cross section of professionals and businesses.
Thus proper growth of the sector will create more employment opportunities for a
large cross section of population.

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STEPS IN HOSPITAL PLANNING

Any hospital project has five basic steps that one needs to follow:

1. Project Conceptualization
2. Detailed Feasibility Study
3. Architectural and Engineering Services Design
4. Project Management
5. Commissioning of the Hospital

1. PROJECT CONCEPTUALISATION
This is perhaps the most important step as it sets the tone for all future work for any
hospital project. This perhaps is also the most difficult step as the promoters have
many ideas for the project and needs proper filtering of various options to arrive at a
Hospital Concept. This has major implications on the planning process as well as on
the cost of the project.

• PROMOTER’S IDEA/PHILOSOPHY
• MARKET RESEARCH
• FIRMING UP OF THE CONCEPT

2. FEASIBILITY STUDY
• TECHNICAL DETAILS
• COMMERCIALS
• MEANS OF FINANCE

3. ARCHITECTURAL DESIGNING
• CONCEPTUAL DESIGNS
• FUNCTIONAL SPACE PLANNING
• WORKING DRAWINGS

4. PROJECT MANAGEMENT
• CO-ORDINATION AMONGST VARIOUS AGENCIES
• FINANCIAL BUDGETING
• DRAWING UP THE EQUIPMENT PLAN
• PERT-CPM TECHNIQUES

5. COMMISSIONING THE SERVICES
• EQUIPMENT PURCHASE & INSTALLATION
• RECRUITMENT
• SYSTEMS, POLICIES, PROCEDURES
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• TARIFF DESIGNING

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STEP – 1 PROJECT CONCEPTUALIZATION

• PROMOTER’S VIEWPOINT
• INDIVIDUAL/TRUST/CORPORATE/GOVERNMENT
• PHILOSOPHY
• THRUST AREAS PROPOSED
• BUDGETARY ALLOCATION

• MARKET RESEARCH
• RAPID ASSESSMENT V/s DETAILED SURVEY
• PRIMARY DATA V/s SECONDARY DATA
• HOUSEHOLD SURVEY
- SAMPLING
- HOUSEHOLD COMPOSITION & DEMOGRPAHIC DETAILS
- INCOME DETAILS
- SICKNESS DETAILS IN LAST ONE YEAR
- CIRTEIRA FOR CHOOSING HEALTH CARE FACILITY
- REPONSE TO CLIENT’S CONCEPT OF HOSPITAL
•INSTITUTIONAL SURVEY
- FACILITY MIX
- PRODUCTIVITY DETAILS
- TARIFF DESIGN
- STRENGTHS/WEAKNESSES
•DOCTOR’S SURVEY
- SAMPLE SELECTION
- OPINION ON HEALTH CARE DELIVERY SYSTEM
- PATIENT PROFILES & ATTITUDE FOR PAYING
- FACILITIES THAT SHOULD BE DEVELOPED
- SUCCESS CRITERIA FOR THE PROPOSED FACILITY

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PROJECT CONCEPTUALIZED

• FINALIZATION OF FACILITY MIX WITH PHASING IF ANY

• BED MIX (DELUXE, SINGLE, DOUBLE, GENERAL, ICU)

• IDENTIFICATION OF LOCATION

• BROAD MILESTONES FIXED

• TENTATIVE BUDGET PROPOSED

• GO AHEAD GIVEN FOR FEASIBILITY STUDY
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FEASIBILITY STUDY

PART – A
TECHNICAL DETAILS
• SPACE PLAN - DEPT. WISE FUNCTIONAL SPACE PROGRAM
- FLOORWISE AREAS
- PRIMARY/SECONDARY AREAS
- SCOPE FOR EXPANSION
• EQUIPMENT LISTING WITH PRICES
- MEDICAL
- NON-MEDICAL
- FURNITURE AND FIXTURES
- LIFTS

• MANPOWER PLANNING
- SHIFTWISE
- SKILLS WISE
- BUDGET FOR LEAVE/ABSENTEEISM

• UTILITY REQUIREMENTS AND THEIR COST
-ELECTRICAL
-AIR-CONDITIONING (ENERGY SOURCE)
-WATER
-PLUMBING/DRAINAGE
-WASTE MANAGEMENT

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PART – B
FINANCIAL FEASIBILITY

1. PROJECT COST
• LAND & BUILDING
• COST OF LAND & LANDSCAPING V/S LEASE OPTION (BOOT
STRATEGY OF IL&FS)
• AREA IN SQ FT X COST PER SQ FT (split up as cost of
superstructure, façade, & interior work)
• HVAC – Chillers, cooling towers, piping, ducting, insulation, AHU,
grilles, electrical panels etc
• ELECTRICAL – HT, LT, Generators, cabling, wiring, panels,
distribution boards, fixtures, data cabling, telecom, fire detection,
CCTV, nurse call systems, etc
• PLUMBING – water storage, pumps, water treatment, sewage
treatment, boilers, fire fighting, fixtures, piping, reverse osmosis etc
• ELEVATORS
• LANDSCAPING
• ARCHITECT’S & OTHER FEE
• CONTINGENCY @ 5-10%

• MEDICAL EQUIPMENT – DEPTWISE BREAK UP WITH INDEGENOUS or
IMPORTED, CURRENCY/INR, CUSTOMS DUTY ETC.
•
N O N M E D I C A L E Q U I P M E N T – H VA C , C S S D , C O M P U T E R S ,
COMMUNICATION, LIFTS, DG-SET, INCINERATOR
• FURNITURE & FIXTURES
• PATIENT RELATED
• OFFICE

• PREOPERATIVE COSTS (legal, stamp duty, consultants etc.)

• INTEREST DURING CONSTRUCTION

• WORKING CAPITAL (AT LEAST THREE MONTHS)

2. INCOME PROJECTIONS

•ROOM RENTS – CLASSWISE, PROVIDE FOR CHARITY
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•DEPARTMENTAL INCOME
• ASSUMPTIONS – DEPTWISE & SEPARATE FOR OPD/IP,
• CAPACITY UTILISATION
• CHARITY (EXCLUDING PHARMACY/EHS)
• DOCTORS FEE – SEPARATE IT OUT FROM OT CHARGES
• MISCLLANEOUS INCOME – CANTEEN, PASSES, AMBULANCES

3. EXPENDITURE PROJECTIONS
• SALARIES & WAGES (GROSS COST TO COMPANY METHOD
AND KEEP 10% AS PERKS)
• CONSUMABLES – PEG IT AS % OF INCOME OF DEPT.
• UTILITIES – GASES, WATER, POWER
• LAUNDRY & LINEN
• FOOD
• HOUSEKEEPING
• PRINTING & STATIONARY
• COMMUNICATION
• TRAVL & CONVEYANCE
• DEPRECIATION
• REPAIRS & MAINTENANCE
• INSURANCE & AUDIT
• LOAN SCHEDULE (IF APPLICABLE)
• MISCLLANEOUS
• TAX (IF CORPORATE)
4.
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5. PROFIT & LOSS STATEMENT
• SURPLUS/DEFICIT
• PROFIT/LOSS
• DIVIDEND (IF CORPORATE)

6. BALANCE SHEET DERIVATION

7. BREAK – EVEN ANALYSIS (cash/book loss)

8. SENSITIVITY ANALYSIS
• PROJECT COST ESCALATION BY ----%
• LESS CAPACITY UTILISATION
• RECURRENT EXPENDITURE CHANGE
• DEBT : EQUITY RATIOS (LIBOR/INR LOANS, FLEXI-INTEREST)

ARRIVE AT MEANS OF FINANCE & ITS STRUCTURING

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ARCHITECTURAL DESIGN

HISTORY OF HOSPITAL ARCHITECTURE
•
• SELECTION OF ARCHITECT
• Previous experience – health care/hotel
• Indian/western design concepts
• Inhouse capabilities – cad/jr.arch/str. Engg./HVAC/electrical/
plumbing consultants
• Flexible approach

• SITE SELECTION
• Site contours for shape of bldg
• Accessibility
• Soil testing
• Foot print of building & fsi
• Availability of utilities in proximity
• Parking areas

• PREPARATION OF ARCHITECT’S BRIEF
• Space allocation
• Traffic flows and peak loads
• Functional intricacies of departments
• Location of services
• Sterility requirements
• Technical requirements – clinical – ot, icu,lab, casualty,
wards, ct-scan, cathlab, support-laundry, kitchen, cssd
• Specific civil requirements
• Mention of a/c, electrical, plumbing, vertical transport
requirements
• Possibility of expansion
• Residential quarters requirement
• Local rules

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• CONCEPTUAL DESIGNING
• Building shape (vertical/horizontl)
• Future expansion
• Stack plan
• Types of designs (refer notes)
• Vastu shastra
• Light, wind, rain beating
• Ventilation and air circulation
• Centrally air-conditioned or selective

DECIDING ON COLUMN GRID

FINALISATION OF GRID MATRIX
AFTER SATISFYING ALL REQUIREMENTS

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BASIS FOR ALL FUTURE DESIGN  
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SCHEMATIC DESIGN:

• Most important stage wherein there is lot of iterations with the client
& user groups
• Block diagrams are converted into individual spaces
• Departments are broken down into smaller spaces with furniture
layouts
• Wall Thickness, Doors, windows are shown
• Important engineering elements are put into proper places like
basins, plug points etc
• At this stage the drawings are ready to be circulated between
various consultants for finalizing locations of engineering services
• Other consultants also commence their schematic design for the
engineering services
• By the end of this stage, we are ready for tendering the project in
terms of the civil works

WORKING DRAWINGS

• Details with measurements for contractors to construct the
building
• Columns & beams details with specifications for use of raw
material
• Equipment layout in consultation with vendors and users
(doctors)
• Doors, windows schedule
• Plumbing & drainage details with type of toilet in terms of
sunken slab/suspended piping
• Electrical details with type of points and their heights
• Reflected ceiling plans
• To be signed by architect as ‘good for construction’ and
stored for future use
• Similar Working drawings will be made by all engineering
consultants for their respective systems

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INTERIOR DESIGN PROCESS:

• Internal spaces have to appropriately dressed in terms of flooring,
woodwork, false ceiling, painting, soft furnishing, fixed furniture etc. For
this the interior designer needs to have detailed meetings with the users.
• Can be broadly classified as Medical & Public areas
• Finishing material for medical areas needs to be carefully planned as in
operation theatres, laboratories, critical are units, procedure rooms,
patient rooms etc
• The same process of concept – schematic – working drawings will be
followed and co-ordination will need to be done with various other
consultants

• MASTER PLAN
• Long range plans for 10-20 years
• Can be used by existing hospitals also
• Only conceptual in nature
• Most important criteria is to build the expansion whilst
hospital is in operation (horizontal v/s vertical)
• Redundancy of certain engineering will need to be costed
and client to take decisions

• ARCHITECTURAL RE-DESIGNING
• For existing hospitals
• Objectives should be very clear
• Limitations to be identified
• Least disruption of services
• Temprory relocation of services
• Get clearance from structural eng & other agencies to
assess the feasibility
• May or may not blend with old structure

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PROJECT MANAGEMENT

Forming the Team:

• Project Manager – from promoters side or consultants/architects
• Architect and his site engineer
• Contractors – civil, electrical, plumbing, HVAC, medical gases
• Structural eng, Electrical, Air-conditioning and plumbing consultants
• Promoter’s representatives including a site engineer, accountant
• Special invitees – Doctors, bio-medical engineer, administrators
• Hospital Administrator – for expansion projects

Roles for:
Structural Engineer:
- Studies pertaining to soil testing and advises the architect on the type of
structure and foundation needed to support the building
- Prepares schematic structural layout and grid planning to enable the architect
to proceed with detailed planning
- Prepares preliminary and detailed costing for columns and beams
- Prepared detailed construction drawings
- Undertakes inspection and testing, and reviews construction
- Scrutinizes contractor’s bills and certifies payments

Electrical Engineer:
- Study the site layout and availability of electricity in vicinity
- Calculate the load required and advise on location for the transformer as well
as routing of cable from the supply source
- Prepares detailed electrical layout for the architect
- Prepare estimates of costs
- Prepare tender documents and scrutinise same for awarding the contract
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- Undertake inspection during execution and certify bills
Plumbing Engineer:
- Study the requirement and availability of water in vicinity
- Study method of disposal of liquid waste and the adequacy of existing sewage
system in the vicinity
- Advise for ideal location and capacity of treatment plant, septic tank, soak pit,
sump, overhead tank etc.
- Prepare a schematic & detailed plumbing drawing
- Estimate the cost in consultation with architect
- Design and co-ordinate the tendering process
- Undertake inspection and testing and certify bills for payment

Tender Document:
• Notice inviting tenders
• Pre-Qualification process
• Open v/s limited tenders
• General and special conditions of the contract
• Technical specifications
• Bill of quantities
• Important - date of commencement/completion, defects liability period,
certification and payment of interim bills, retention amounts, penalty clauses,
variation clauses, extra items, arbitration, quality checks etc.

Selection of contractors:
1. Verify credentials
2. Do not necessarily go in for lowest tender at cost of quality
3. Call for negotiation
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4. Build good rapport as the agency will be crucial for good construction
and speedy execution

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Characteristics of a project:
• A start and a finish
• A defined time frame for completion
• A unique one timeness
• An involvement of several people of varying skills on an ad-hoc basis
• Limited set of resources
• A sequencing of activities and phases

Remember:
• Project Planning begins with the end in mind i.e. the goal and works backwards.
• Clarify what you are trying to accomplish for the client and keep it uppermost in
mind. Make sure that everybody else on the project team is aimed at the same
direction
• Goals should be SMART :
• Specific
• Measurable (milestones)
• Agreed upon
• Realistic
• Time-framed

For Effective Project Management

• Manage COST – QUALITY – TIME
• Establish Checkpoints
• List the Activities in proper chronology
• Determine Relationships between activities
• Make Time Estimates for each activity
• Create Project Schedule
• Timely Communicate Information to all concerned
!21
• Hold Regular Meetings with Agenda & Minutes
Financial Budgeting

• Deriving a realistic project cost
• Continuously monitoring the project cost for identifying escalation items/reasons
• Look for cost cutting – cement/steel prices, labour cost, staggered delivery, ordering
equipment at correct time
• Ensure liquidity of funds for making payments to various agencies
• Phasing out where ever essential/possible in case of liquidity problem
• In case of debt, timing of taking debt to reduce the start time for payback
• Buying material on credit

Equipment planning

• Prepare detailed list in consultation with doctors and other users
• Seek quotations from all vendors OR give advertisement
• Seek list of clients and cross check
• Look for sound credentials and ownership pattern
• Can we directly import from country of manufacture?
• Keep an eye on currency fluctuation
• Take help from bio-meds for doing a cost-feature analysis
• Call for negotiation and argue for extended maintenance contract
• Draw the contract carefully and insert clauses for downtime, response time, spare
parts availability
• Be sure on post installation trial runs
• Look for schemes on hire-purchase, leasing, consumable deals etc.

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DEPARTMENTAL PLANNING

PATIENT HOUSING SYSTEM:

- Should be dealt with as the residence of patient and hence should be as close to the
patient’s residence. The difference is that the patient would need nursing and other
medical attention. It is thus necessary that the planner should know the type of
nursing required in the wards, because the requirements vary with type of patient.
Broadly the patients in need of care can be divided into five categories.

1. Intensive medical care
2. Intensive nursing care
3. Medium nursing care
4. Low nursing care
5. Self care with minimal nursing care

• In acute care wards 4-5 hours of nursing care may be required
• In normal wards requiring medium nursing care one nurse may be enough for 10 beds
• One sister in charge should look after not more than 30-35 beds
• Maximum distance between the nursing station and the furtherest bed should not be
more than 75 feet (govt hospitals)and in newer hospitals even not more than 30 feet

The decision on patient housing system would thus depend upon the following

• Type of ownership and philosophy
• Type and level of nursing required
• Division by speciality/sub speciality
• Accommodation by sex or social-economic class
• What proportion of beds are to be in single room, double rooms, etc.?
• How many intensive care beds and assumptions on type of nursing care ?
• Is it to be combined ICU/ICCU/SICU or separate?
• Will there be grouping of certain specialities?
• Will there be any psychiatric beds?
• Is there a self care unit to be planned?
• Any special planning requirements besdies the standard nursing unit like doctor’s
cabin, recreation lounge, fathers room, day room, business lounge, dining room
• Home Health Care concept

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Type of wards;

1. Nighting Gale Type :
•Open type with perpendicular arrangement of beds
•Nursing unit at one end and sanitary block at the other end
•Advantage – good supervision, visual access, accommodates more beds
•Disadvantage – noise, lack of privacy, too many patients, problem in cold countries,
danger of cross infections

2. Rigg’s Pattern:
•Improvement on nighting gale type by dividing the ward in cubicles (not full walls)
with 4-6 beds

3. Single Rooms (most common in US after Nuffield Foundation’s recommendation
which stressed on possibility of infection by grouping patients)

4. Double rooms (more to improve productivity and decrease costs)

5. Patient units of 4-6 beds are more popular in Europe where 20-25% beds are single
rooms

Shape of the Wards:

a. Single corridor – Nighting Gale Type but has drawback of long distances but is
suitable for tropical countries where air-conditioning is not commonly used

b. Double corridor – patient rooms on periphery and service areas in middle
- economizes the distances to be travelled
- problem of ventilation and natural light in work areas
- good for fully air-conditioned buildings (common in US)
- best for nursing efficiency
- central service should not be more than 20 feet

c. Circular – not popular because of construction difficulties and again
requires provision of light in the middle
- good for observability and supervision
- distance to be travelled is also less

d. X shape and Y shape

Note: In our country because of the intense heat, the wards should face North-South with
the patient rooms facing South.
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Basic requirements in Wards:

- Nursing station – sitting arrangement, shelves, telephone, computers, drugs,
emergency trolley, wash basin, lockers, change room
- Toilets – for patients, staff
- Dirty utility room/s
- Clean storage
- Pantry/dining
- Strecther/wheel chair bay
- Treatment room
- Other requirements – day care room, meeting, prayer room, business lounge, staff rest
- Corridor width and door widths
- Height
- Plug points
- Toilet dimensions

* Effect of size on Occupancy

Types of Special Wards

- Critical care units – ICU/SICU/ICCU/NICU/PICU/ITCU/Respiratory care units
- Burns units
- Neo-natal units
- Maternity (LDRP concept)
- Psychiatric
- Paediatric
- Geriatric

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OUTPATIENT DEPARTMENT

- Increasing importance of OPD worldwide under ambulatory services concept
- Ambiguity in roles of OPD and casualty should be sorted out and define the OPD/
referral/emergency clearly
- Timings for OPD to be clearly specified
- Should we go in for general/private OPD model
- Would you like the inpatient and OPD services to be integrated?
- Will the OPD be an autonomous department?
- Work out the load projections inlcuding forecasting for growth and peak loads
expected
- Room utilization and clinic scheduling to be defined
- Define the relationship with support departments like billing, pathology, radiology

Location & Space Requirements:

- Not necessarily on the ground floor
- Accessibility as per ambulatory/escorted/vertical transport availaibility
- Separate block for OPD and diagnostics
- Reception area/s – central v/s individual
- Billing area for cash collection
- Nursing station (one for every 3-5 rooms)
- Waiting area (per person 4sft and as per projected peak load for next 10 years)
- Record room (localized/central)
- Examination Area (individual/common/speciality)
- Hand wash facility
- Changing room facility
- Treatment Area (common)
- Internal layout details as per the speciality
- Sample collection room
- Water cooler
- Toilets/DU

Relationship with other departments

- Billing
- Pharmacy
- Medical records
- Social Worker
- Pathology
- Radiology
- Other diagnostics
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- Role of computers

PATHOLOGY (Department of Lab Medicine)

Today pathology covers a variety of sub – specialities like:

- Biochemistry
- Haematology
- Histo-pathology
- Serology
- Microbiology
- Blood Bank

Its importance has increased in recent years due to the over reliance of the medical
fraternity on diagnosis and preventive aspects. Consumer protection act has also lead
doctors to advise for more tests to ensure correct diagnosis. The fast pace of technological
advances has further made this speciality more important in hospitals and due importance
has to be given for its proper planning.

Important points for planning:

• Whether to have a lab or not
• Contracting the lab out
• Projects may have only laboratory (Speciality Ranbaxy)
• Level of sophistication that the promoters want which will give us the range of
investigations to be expected
• Specialised services like Histo-pathology, microbiology, blood bank etc
• Technology that would be installed or is anticipated
• Projections for handling IPD/OPD/referral investigation
• Whether 24 hours or not
• Centralised labs usually are better due to ability for better quality control
• De-centralised laboratories will be essential for medical colleges or bigger hospitals
as all labs can not be accommodated centrally due space constraints
• Availability of skilled manpower
• Number of tests expected to be conducted per technician per annum
• Reception, report delivery systems and Billing counters
• Room for doctors reproting
• Satellite lab requirements
• Satellite collection centres
• Material to be used for floor, walls, and work benches, should be carefully decided to
avoid corrosion due to chemicals
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• Interface of equipment with computers for online printing
• Role of computers in reporting ad dissipating information to other users in hospital

Decision criteria as suggested by Public Health Department USA

1. Determine which services are to be provided
2. Determine space requirments to accommodate equipment and personnel in the
following areas:
a. Administrative
b. Technical
c. Auxiliary ( includes washi ng, sterilizing, storage and locker facilities)
3. Divide the technical area into functional units such as Heamatology, Biochemistry,
Histopathology, Microbiology, Blood Bank etc)
4. Determine where the procedures are to be performed
a. Those to be combined in the same work area
b. those to be done in completely separate work area
5. Estimate the volume of work in each area or unit and allow fo r future increase in
workload
6. Indicate the number of personnel requiring a work station in each unit
7. Describe the major equipment in each unit:
a. Indicate the linear feet of bench space required and how the space may be
arranged
b. Indicate equipment that requires utility lines and indicate the location
c. List equipment such as refrigerators, centrifuges, desks that may be jointly used
by technologists from different work stations

8. Indicate the desirable functional arrangements (example microbiology may be located
at the extreme end to avoid contamination hazard and the washing area should be next
to units, haematology may be next to the waiting area or specimen centre)
9. Indicate which areas may need to expand. (It may be possible to locate these areas in
the end of the department to facilitate efficient, co-ordinated expansion)
10. In the technical area a standard module for work area is suggested (for instance a
module of 10ft X 20 ft). By using such modules the architects can plan the structural
patterns more efficiently.
11. List the utilities to be provide and any special requirements for instruments such as
electronic counters. Separate electrical circuits may be necessary for some electronic
equipment to avoid fluctuations in voltage, which may affect the accuracy of these
equipment.
12. List environmental requirements such as light, ventilation, colour, and isolation of
equipment that may require special environment.
!29

!30
RADIOLOGY (Department of Imaging)

• X-RAY
• NUCLEAR MEDICINE – emission radiology
• ULTRASOUND
• CAT-SCAN
• MRI
• MAMMOGRAPHY
• PET SCAN

One has to be very careful in planning this department as it is probably the most
expensive of all departments in an hospital. It is estimated that the department may
account for 40-50% of the cost of the total medical equipment.

Basic Planning Criteria:

1. Workload projections for all sub-specialities for the next 5-10 years
2. What would be types and numbers of investigations for various patients?
3. What would be the utilization of work space?
4. What is the best way of locating the units to ensure supervision, maximum efficiency
and convenience to patients and staff?
5. Whether to have the department centralized or decentralised? Centralised department
would be the best but may not be feasible due to high investment costs. Centralised
area will require separate wait areas for IPD and OPD patients.
6. Will always have separate facility for casualty department
7. Mobile units and IITV requirements
8. Consultation with BARC or any Atomic Energy authority should be consulted for
specification regarding X-ray protection.

Location & Space Requirements:

- Preferably on the ground floor but not necessary
- Accessibility as per ambulatory/escorted/vertical transport
- Separate block for CT/MRI due to environmental requirements
- Reception area/s – central v/s individual
- Billing area for cash collection (centralized/de-centralized)
- Nursing station
- Waiting area requirements will be more due to patients coming on stretcher
and wheel chairs. Also procedures may take long time.
- Record room (localized/central)
!31
- Reporting Area (individual/common)
- Hand wash facility and toilet facility inside the X-ray/USG rooms
- Contrast media room and patient preparation room
- Storage room for films, reports etc
- Dark room/s – where there are several x-ray rooms, a dark room in between a
set of two proceudre rooms should be adopted for better speed
- Changing room facility in all procedure rooms
- Internal layout details as per the speciality. Seek details from vendors.

Relationship with other departments:

• In-patient work loads and emergency calls system
• OPD (Digital imaging data transfer facility)
• Outside referrals (use of tele-medicine)
• Operation theatre requirements (Mobile/IITV)
• Medical records
• Admission and Billing
• Casualty

!32
OPERATION THEATRES

This is the core area of any hospital as usually 50-60% of patients in any hospital are
surgical. Also it is very expensive to construct and maintain the OTs. In the current trend,
many surgeries have been replaced by more simpler laser, keyhole, microsurgeries, and
endoscopic surgeries. In western countries it is now even possible to operate by using
tele-medicine ROBOTs from far off places.

There are various types of sub-specialities which have unique requirements which
planners will have to bear in mind. The commoner specialities are:

• Cardio-thoracic
• Neuro-suergery
• Ophtalmic and ENT surgery
• Orthopaedics
• Plastic surgery
• Paediatric surgery

Factors influencing Operation Theatre Complex Planning:

a. The number of surgeons and their specialities
b. Projection on patient load
c. The case mix and type of operations. For planning purposes it is advisable to
categorize the operations as emergency ad elective.
d. Number of existing/proposed surgical beds
e. ALOS of surgical patients
f. Number of beds available or needed
g. Average time taken for surgery including cleaning up time
h. Emergency surgery workload and the time to be kept reserved
i. Socio-economic trends in the service area
j. Is the institution going to be a teaching hospital?

• For Indian Theatres conducting general surgeries it should be estimated that
average daily number of surgeries will be 5 @ 75 minutes per operation
• Separate emergency OT is justified when 50 or more cases are reported in the
casualty

Projection of OT Facilities:

Number of operations per day = Number of surgical beds
ALOS of surgical patients
!33

Number of OT rooms = Total number of operations in hospital
Capacity of one OT
Distribution of OTs;

Centralized De-centralized

- greater economy of staff & equipment - quantum of work should justify
- better professional supervision - Ophtalmology, ENT, gynaecology
- greater efficiency - Teaching institution requirement
- Separate units/depts
- Speciality requirements

Location:

• Top floor may be good by architectural viewpoint but medically lower floors are
more preferred. There would be problem of solar heating, and “stack effect” infection
from the lower floors due to upward air-movement.
• It permit easy accessibility and communication from the surgical wards
• Should be close to vertical transport with preferable dumb waiters for CSSD

Basic Requirements in design:

• Clean and dirty should be segregated
• The department should be independent of the general traffic and movements of the
rest of the hospital
• The roms should be arranged in a manner that allows continuous progression from
entrance through the various zones that become increasingly clean.
• Staff within the department should be able to move from one clean area to another
without having to pass through unprotected areas
• Dirty material should be removed from the department without passing through the
clean areas
• The heating and ventilation systems should be safe and comfortable to both staff and
patients
• Entrance should be so located as to discourage unauthorized entry

Circulation within the department:

Patients:

!34
Wards ------------! Reception ---------! Pre-op waiting --------! anaesthesia ------!

Operation theatre --------! Post op area -------! ICU/Ward

Staff:

Entrance -----! Chagning rooms ------! Working area ------! Rest room/changing –

room ------! Exit

Equipment & Supplies:

a) Clean : Entrance ----! Supply area ---! Thetare area ----! Point of use

b) Sterile: CSSD ----! Thetare -----! Preparatio area -----! Point of use

c) Dirty : Theatre ----! Disposal Room ----! CSSD ----!----> Laundry

Space Requirements:

1. Entrance and receiving station
2. Patient receiving and transfer area (1.5 beds per theatre)
3. Changing rooms (12 sft per person) and toilets
4. Rest rooms
5. Office for OT incharge/sister
6. Office for staff (if required)
7. Operating room suite (for each OR)
a. Scrub up and gowning area (100 sft)
b. General preparation area
c. Aneasthetic room for induction (not common now, if used then 150 sft)
d. Operation theatre
e. Exit lobby
f. Disposal and cleaning area
8. Disposal corridor
9. Stores
10. Mobile X-ray room
11. Dark room (if required)
12. Pantry
13. Recovery area (1.5 beds per theatre)
!35
14. Clean and dirty utility (80-100 sft)
15. Circulation space for the above areas
16. Plant room for OT utilities like A/c, electrical etc. (800-1000 sft)

Planning Approaches:

The guiding principle for planning an efficient theatre system is to ensure easy circulation
of staff and materials. It should be insisted upon that theatre corridors should never be
less than 2.85 meters wide and preferably 3.2 meters.

Layout Zones:

Zone I : consists of OR, anaesthetic room, scrub up, and preparation space
Zone II: stores, processing, TSSU, and sterile store
Zone III: reception area, transfer spaces, post-op recovery, staff changing, admins

Classification of Layouts:

There are six basic layouts which have been used in modern theatre plans in western
countries.

1. Single bank – single corridor : ORs are arranged in a line on one side of corridor and
the stores, processing sections, and change rooms etc on other side
2. Single bank – double corridor : OR banks are surrounded by corridors around it with
stores ad supllies on one side and patient and staff traffic on the other with separate
entrances for staff and patients
3. Double bank – double corridor (Type A) : In big OT complexes to decrease travelling
length, the theatres are designed in two banks with double corridors on the same basis
as single bank double corridor design
4. Double bank – double corridor (Type B) : Here the stores and supplies arrive directly
from their issue areas into the section for them which is placed between the two
banks. The transport is by lifts
5. Multi bank – single corridor
6. Multi bank – double corridor

Other considerations:

!36
• Air – conditioning systems – temperature 21 + 2 degrees, three stage filteration with
laminar air flow, progressive positive pressure concept, 50-100% fresh air, return air
concept, AHU locations,
• Electrical wiring and sockets
• OT lights (60,000 to 1,00,000 Lux Halothane lights temp is only 14 degrees), ease in
handling the lights during operation
• Telephone and communication
• Computers for billing and inventory
• Piped suction, oxygen, and nitrous oxide (pendents)
!37

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STRATEGIC OVERVIEW OF INDIAN HEALTH CARE SETTING

• WHAT CONSTITUTES HEALTH CARE INSTITUTION?

! ENGINEERS (consulting as well as contracting)

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