Hospital Planning and Project Management

Study MaterialOn

PGDHHM Correspondence Course

HOSPITAL PLANNING ANDPROJECT MANAGEMENT

COMPILED BYDr. Vivek Desai

POST GRADUATE DIPLOMA INHOSPITAL 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 byDr. Rajiv Yeravdekar, Hon. Director, SCHC.Printed at Gayatri Graphics, Pune - 411 037.

2 SCHC HOSPITAL PLANNING AND PROJECT MANAGEMENT

DrVivek DesaiM.B.B.S, DHA, DBM, M.PhilVisiting Faculty SIMS

All rights reserved. No part of this work may be reproduced in any form, bymimeograph or any other means, without permission in writing from theSymbiosis Centre of Health Care.

PREFACE

The future of healthcare industry in India will see a continued strong demand forconstruction of health care facilities, including completely new or replacementfacilities and projects involving major additions and modernization. The annual valueof healthcare construction projects will see a upward trend in the immediate yearsahead owing to various factors like opening up of the insurance sector, privatizationinitiatives etc. Therefore planning and design will continue to merit prime emphasisamong several responsibilities of hospital officials. Because of the changing characterof facilities and continuing increase in their complexity, planning and design willassume greater importance than ever before. Thus planners, architects, builders,hospital executives, board members, medical staff representatives, and others whopossess responsibility for undertaking hospital construction projects should havebasic understanding of planning process and of appropriate concepts of hospital andrelated healthcare facility design objectives.

There are very few areas where human factors and human requirements play such acritical role as they do in hospital design. The need for collaboration between thosewho care for the sick and those who plan healthcare facilities is of the most criticalimportance. A close look at almost any hospital department today demonstrates howfar short we fall in meeting the human factor goals of well being and general efficiencyin 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." Shewas referring not only to the clinical care of the sick, but also to the generalpsychological well being of the patient. There have been numerous instances inmodern day hospital care whereby hospital acquired infections owing to faulty air-conditioning, inadequate water supply/drainage etc. have resulted in patientmorbidity and even mortality.

One should define planning as the specification of the means necessary foraccomplishment of goals and objectives before action toward those goals has begun.Planning involves a particular kind of decision making in which one has to specifyalternatives and choose among them. Once the goals are set, alternative plans can beexamined in the context of the opportunities and constraints facing the promoters. Inundertaking any complex project, it is advisable to examine the experience of others insimilar situations and hence such information should be elicited and properlyinterpreted. The basic design of a hospital usually is carried out by one or twoindividuals, 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 trafficflows, technological requirements, and operational procedures to the extent that afacility of beauty, reasonable cost, and optimal utility will result. No other activity is in

HOSPITAL PLANNING AND PROJECT MANAGEMENT SCHC 3

the planning continuum is more important than that occurring in the design phase.

Like any other industrial venture, proper planning of hospitals is vital for success ofthe venture. It is beyond doubt that if hospitals are properly planned andprofessionally, there can be substantial surplus/profit that could be made. The firststep is proper project conceptualization with the right mix of beds and facilities togenerate sufficient income and to attract maximum clientel e. For this acomprehensive market research may be required to assess the need, demand, andsupply for health care services apart from evaluating competition. A detailed financialfeasibility report would then show the promoters the viability of the project subject tovarious 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 avoidingfinancial mishaps, which have taken heavy toll in many a project.

Once the decision is taken to build a hospital, the next step is its architectural design. Adetailed architects brief has to be first prepared to enable the architect in drawing uphis plans. The landscape, facility mix, bed mix, availability of utilities in the vicinitywill have to be considered. Considerable inputs from the other agencies like air-conditioning, electrical, plumbing, etc. will be required to finalize the working planfor the building. Inputs from the equipment vendors especially in specialty areas likecardiac catheterization laboratories, CT-scanners, MRIs, linear accelerators,operation theatres etc will be essential. One thing very common in India is the lack ofemphasis given to support services like kitchen, laundry, CSSD, back up electricityand so forth. Not only are these services vital, but these also have high capital cost andrecurrent expense and hence should be properly planned.

This module is divided into three parts in order to stress the concept of an integratedand coordinated hospital planning.

(1) The first section is devoted to conceptualizing a hospital project in terms of thefacilities to be planned in the center. This will deal with understanding theregional demographics and requirements of health care delivery systems in thedefined geographic service area. It entails undertaking secondary data collectionand conducting market research surveys. This will enable the student tounderstand the nuances of technical and financial feasibility of a hospital project.

(2) The second section deals with the planning and design aspects of hospitalbuildings and will also trace historical and future development in the field ofhospital infrastructure. There will be descriptive narration to assist the student inunderstanding the important planning criteria for hospital departments.

HOSPITAL PLANNING AND PROJECT MANAGEMENT4 SCHC

HOSPITAL PLANNING AND PROJECT MANAGEMENT

CONTENTS

No. Chapter Page No.

1. Planning Process and Market Research ...............................................7

2. Feasibility Study ...................................................................................11

3. Hospital Planning Historical Growth ..............................................15

4. Essentials of Hospital Design .............................................................22

5. Steps Involved in Hospital Design ....................................................35

6. The Design Process...............................................................................54

7. Planning of Inpatient Wards ...............................................................62

8. Planning of Clinical Departments ......................................................68

9. Planning Support Services in a Hospital..........................................126

10. Disaster Management .......................................................................144

11. The Hospital Project Team ...............................................................165


About the Author :

M.B.B.S, DHA, DBM, M.PhilDr Vivek Desai


CHAPTER 1

Healthcare in India

Stakeholders

PLANNING PROCESS AND MARKETRESEARCH

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

community to face the problem pf spiraling health care costs.

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 will benefit many in the population.

The hospital ownership pattern can be basically three types:


i) Government owned - central / state / district / autonomous like army, railways etc

ii) Not For Profit Managed by 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

ones followed until the recent past.

Project Conceptualization

The first step in hospital planning is to freeze the project concept in terms of :

Identification of the market needs

Finalization of the facility mix

Deriving the appropriate size of the project

Determining the possibility of getting skilled manpower

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

surveys required:

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 should be collected and analyzed is as follows:

- Demographic details of the family- Education & Income details- Disease profile in last three years- Choice of health care provider for minor & major ailments with reasons- Method of payment for availing healthcare- Their feel on deficiency in health care market- Critical success factor for the proposed project

b) Doctors 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

sample of 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

information to be collected and analyzed from them would be :

- Personal details on specialty, qualification, experience etc- Area of practice and hospital attachments- Patients seen and their drainage area- Referrals to other hospitals/diagnostic centers with reasons for referring- Views on deficiency in health care market and solutions for same- Patients capability to pay- Critical success factors for a hospital project in the service area

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 important information to be collected would be as under:

- Ownership with historical growth pattern


- Service Mix (diagnostic, therapeutic, medical, surgical, support services)- Bed mix- Productivity of major services- Tariffs of major services- Bed to manpower ratio- Technology level- Annual revenue/expense in last 2-3 years to understand growth 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) Specialties to be practiced in the proposed projectii) Number of OPD rooms

iii) Bed mix with break up

iv) No of operation theatres

v) Diagnostic services

vi) Blood bank

vii) Support services

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

will have to be carefully planned.



CHAPTER 2

FEASIBILITY STUDY

After finalizing the Project Concept in terms of its facilities and size, the next importantstep is to analyze its financial viability. This will also help the promoter in planning themeans of financing the project based on its profitability and capability of servicing thedebt proportion.

The first step of the feasibility process is to identify the cost of the project in a realisticmanner. Many projects have failed midway through construction process wherein itwas identified that the cost overrun would be in more than 50% of the estimatedbudget. Hospital buildings are very complex in terms of its engineering needs andhence specialized agencies are required to plan these and identify the cost. The cost ofthe project should be broken down under the following heads:

I) Civil Works including RCC, masonry, doors, windows, interior, andfaade treatment

ii) Electrical Works

iii) Plumbing and fire fighting

iv) Air Conditioning

v) Landscape and site development

vi) Elevators

vii) Medical equipment broken down under departmental heads

viii) Non medical equipment like kitchen, laundry, computer hardware & software etc

ix) Hospital furniture and fixtures

x) Professional fees

xi) Pre Operative Expenses

xii) Municipal Taxes & deposits

xiii) Interest during construction

xiv) Contingency

The estimates for all the above should be compiled meticulously after detailed

discussions with experts and undertaking adequate research. Financial institutionsalso required sufficient back up data to accept the costs before accepting the project forfunding.

After compiling the project cost, the next important step is to ascertain the income fromthe project from various heads. Whilst doing this, one would rely heavily on theinstitutional market research to understand the industry benchmarks for makingassumptions. Income assumptions will need to be made for the following incomeheads:

i) Room rents for all categories of beds like general ward, twin/single rooms,ICU, NICU etc.

ii) Departmental income for diagnostic services (lab, radiology, EEG, EMG,non-invasive cardiology, audiology, cath lab, refraction etc)

iii) Income from OPD & IPD consultations

iv) Income from surgical operations (major and day care surgeries)

v) Health check schemes

vi) Pharmacy

vii) Emergency

viii) Dialysis

ix) Deliveries

x) Blood Bank

xi) Emergency

xii) Any specialty service like LINAEC, IVF, Angioplasty, Minimal Invasive surgery,organ transplant etc. will need to be separately assessed

For calculating the income some important assumptions will need to be made withregards to the number of OPD/IPD days in a year, bed days available depending onthe bed capacity, average length of stay (ALOS), number of admissions, number ofoperation theatres, number of OPD rooms etc. These assumptions form the importantbasis for assuming a realistic productivity for various departments which whenmultiplied with an average tariff rate will give the income on an annual basis. Anexample for assumption is given below:

Income Assumptions:



Number of beds - 100

Number OPD days - 300

Number of IPD days - 365

Bed Days available - 100 x 365 = 36,500

ALOS - 5 days therefore no of admissions

= 36500/5 = 7300/annum

Number of theatres - 4 , No of surgeries / OT / day

= 4, therefore surgeries/annum = 4 x 4 x 300

Number of OPD - 10, no of patients / OPD / hr = 4,

No of OPD/annum = 10 x 4 x 10 hrs = 400

Number of X-ray - 1 per admission for IPD and 10% of all OPD cases

One has to assume such productivity for all departments by using sound logic andkeep cross checking it with some industry benchmark. All income is calculated on100% capacity utilization and then adjusted for year wise utilization as % in year 1, year2, year 3, till year 10. It is important to include all heads of income as may be possible.

The next important step is to compute all the important expenditure heads for theproject operations. These heads would include the following:

I) Salaries and wages these should be computed on a cost to company basis andshould take into a staffing pattern inclusive of those for leaves, contract labors etc.

ii) Departmental expenses in terms of consumables. This could be arrived aspercentage expense to the departmental income by taking industry benchmarks

iii) Professional fee payable to doctors for rendering clinical services. This woulddiffer from assuming a flat salary to incentive based remuneration. Againindustry benchmarks will have to be followed for same. Some hospitals have amix of both the options

iv) Energy costs in terms of electricity, water, medical gases, generator

v) Food expenses for patients and staff

vi) Laundry & linen expenses for patients and staff

Expense Assumptions:

vii) Housekeeping expenses can be calculated on a per sq ft basis for the building

viii) Stationery expenses

ix) Telecommunication

x) Conveyance and car maintenance

xi) Marketing expenses

xii) Repairs and maintenance

xiii) Insurance, Legal and Audit charges

xiv) Miscellaneous expenses

xv) Depreciation

xvi) Interest cost for loans taken

xvii)Taxes for corporate hospital

After computing the income and expense statements as mentioned above, one arrivesat the various financials such as Profit & Loss statement, Balance Sheet, Cash Flow,break even analysis. After computing these statements once can undertake sensitivityanalysis by subjecting the project assumptions certain changes and evaluating theimpact on profitability like:

- Change in debt to equity ratio

- Change in interest rates on the loan taken

- Change in capacity utilization over the five year period

- Effect of cost escalation

Such meticulous financial analysis will give the promoter confidence to decide onwhether to undertake the project or not. This also helps them to arrive at a proper debtto equity ratio for the project.

Financial Statements:



CHAPTER 3

HOSPITAL PLANNING - HISTORICALGROWTH

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 forthe words hotel, hospice, and hospitality. The earliest examples approximating theinstitutions we call hospitals, however, were the Egyptian temples of 4000 years ago.The association of religion and medicine was a natural one in many ancient cultures.

Originating in the time of the matriarchal goddess religions, when the cyclical processof nature and womens ability to give birth were revered, the relationship between themidwife and the woman giving birth was the first healer-patient relationship. Inprimitive societies those seen as holding mystical powers came to acquire more formalones. Thus healing and believing brought forth the faith healer.

Early knowledge was gained both from intuition, as well as from watching animalsand then passing on the accumulated knowledge down through the generations.Apart from primitive tools there was no technology and medicine was based upontouch, comfort and belief.

The early Egyptians identified over 250 diseases and combined medicine with magicand religion. As they developed the science of medicine, treatment and drugs, therewas parallel development in improvements to public hygiene and sanitation. TheBabylonians further developed medicine and records show that fees were charged fora healers 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 Greekshowever viewed healthcare in a natural and totally holistic framework. The Greeksassumed, as only natural, that healthcare treatment should include music, poetry, artsand good cuisine. Temples dedicated to Asclepius were noted for their cures.

The idea of an institution created specifically to care for the sick appeared in Hindustanin the third century B.C., and in first century Rome. In Hindustan, the king Ashoka iscredited with establishing some 18 centers for treating the ill. There were physiciansand 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 supportedcare system, while in Rome there were special institutions for slaves, gladiators, andsoldiers.

From about 500 BC to 475 AD the Romans assimilated medical cultures from theterritories that they inhabited. Generally, the Romans, as the Greeks, providedhealthcare in the community. The Roman hospital was built upon a military regimewithin a rigid institutional setting. Thus the early example of what has become knownas the medical model was indeed based upon the military model, that is, the provisionof care within an ordered and military setting.

The early Christian era, between 1 and 500 AD brought the return of women in the roleof healers through the Church and convents. It was the Christian commitment to carefor the sick, to comfort the lonely, and to feed the hungry which motivated theprodigious growth of hospices, orphanages, old age retreats and hospitals properthroughout the medieval world. The first Christian Hospital was completed between368 and 372 AD. During the chaos that followed the collapse of the Roman Empirebetween 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 termhospital was synonymous with offering hospitality, i.e., refuge from the ravages of theoutside world. Clarity of form was lost during the medieval Christian period, andhospitals once again became indistinguishable from medieval architectural forms.

In the medieval west, as in the east, the church bore primary responsibility fordeveloping 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 oldestworking hospital in existence. Hospital facilities expanded radically from the elevenththrough the fourteenth centuries. The Crusades were in part responsible. Thecrusading orders built hospitals in Germany and throughout the Mediterraneanworld. Royal and noble families also contributed to the growth. Englands first hospitalwas built at York in 937 by Athelstan, a grandson of King Alfred the Great. In thetwelfth and thirteenth centuries, when Europe was in the grip of a vast leprosyepidemic, hundreds of leper asylums or leprosaria were built. It has been estimatedthat in 1225 there were 19,000 leprosaria in Europe. As leprosy declined, some of theseleprosaria became hospitals. Thus the Hospital des Petits Maisons outside Paris whichbegan as a leprosaria was alter used for indigent syphilitics and mentally disorderedpilgrims. When the bubonic plague struck Europe in the fourteenth century, theleprosaria were the first plague hospitals.



During the seventh century, the rise of Islam led to the Muslim conquest of manycountries. Islam inherited a rich medical tradition, and by the ninth century it hadestablished a sophisticated medical system. Hospital complexes were constructed atBaghdad in the ninth and tenth centuries which employed up to 25 staff physicians,which maintained separate wards for different conditions, and which gave medicalinstruction. Thirty-four such hospitals have been identified in Muslim cities fromMughal India to Spain. Islam, like Christianity, emphasized the communitysresponsibility for those who needed help.

Byzantiums political resurgence under the powerful Macedonian dynasty in the ninthand 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 ofbuildings which included a sumptuous church, tombs for the ruling dynasty, and amonastery. This hospital was the greatest achievement of the long Byzantiumtradition. 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 womenwith various complaints, and 12 for gynecological cases. The remaining 5 wereavailable for miscellaneous use, including emergencies. Each department had a staff oftwo physicians, five surgeons and two nurses or attendants. There were also an out-patient department for ambulatory cases, a pharmacy, baths, a mill and a bakery.

Later, in classical antiquity, the rational processes of thought were reflected in the planform, which gradually evolved a character of its own. Order and clarity becameevident and clear patterns of circulation were delineated and attention was paid tofunctional groupings. More scientific methods of healing appeared throughout theRenaissance period, 1400 - 1700 Ad. This was also the time of Michelangelo andLeonardo da Vinci who saw the integration of art, invention and medicine.

In England the traditional role of the Catholic Church in healing and medicinedeclined as Henry VIII broke away from Rome. The closure of monasteries by him andthe resulting loss of there medical expertise was a spur to the development of themedical profession, which then developed outside its religious origins. Heencouraged and gave authority to physicians, granting the College of Physicians acharter in 1518. The years 1550 to 1850 were the dark period of nursing. Women wereassigned nursing duty in lieu of a jail sentence. Many hospitals fell into decay, andunsanitary conditions, epidemics and diseases were common. The hospital was seenas a place to warehouse the sick and dying and not necessarily a place for care andtreatment.

By the end of the sixteenth century, monarchs and municipalities had become theprime movers in hospital development. In France, as in most continental Europeanstates, the central government took responsibility. In 1656 the Cardinal Mazarincreated the Hospital General in Paris. These hospitals showed the evolution of themedieval concept of care into the secularized one of the sixteenth and seventeenthcenturies. Though much larger and administratively complex than their medievalpredecessors, these institutions were similar in that social functions werefundamental, while treatment was of minor importance. A further change, however,was coming. Vesalian anatomy, William Harveys circulation theory, and a growinginterest in clinical medicine were giving hospitals a new significance. It was there thatthe actual sick could be observed, that medical applications of scientific discoveriescould be made most conveniently, and that students could be taught. Bedsideobservation and teaching began in 1626 at Leyden and Utrecht, won support fromleading English scientists including Sir Francis Bacon, and through the work ofHermann Boerhaave, the Leyden clinician and one of Europes greatest teachers,gained a European following. Even so, the transformation of the hospital into amedical institution was not complete for another century and a half.Between 1700 and 1850 the foundations of the modern hospital system wereestablished. The number of hospitals increased, the quality of medical practiceimproved, specialization advanced, and the emphasis shifted from care towardstreatment and cure. The process was most rapid in England, whose 18th centurydevelopment was phenomenal, but by the middle of the 19th century most Europeansocieties as well as the United States had established a basic hospital system. In theAmerican colonies the first hospital was founded in Pennsylvania in 1751, withBenjamin Franklin as a Trustee. Throughout the entire period of development, twocontrasting systems for planning and financing hospitals appeared. In England andAmerica, private funds and independent boards were the norm. On the Continent,central governments and public funds led the way. The American hospitals served asocial need, but their staffing with trained physicians as both house physicians andconsultants showed an orientation from the beginning towards treatment and cure.

The brilliance of French medical scientists both before and after the revolution wasunconnected with the state of hospitals or other institutions. At this time, hospitalreformers, activated by a humanitarian concern over the real suffering of thoseunfortunate enough to be hospitalized and convinced that an enlightened age had themeans to relieve it, began to agitate for changes. John Howard, an English prisonreformer who became interested in hospitals, was probably the person who did the



most to popularize reform ideas on the Continent. He was particularly emphatic aboutthe need for cleanliness and fresh air to combat the deadly miasmic vapors which werethought to be responsible for illness, infection, and high mortalities.Probably the most important 18th century Continental hospital was ViennasAllgemeine Krankenhaus (general hospital) built by the order of the emperor Joseph IIin 1784. This hospital epitomized the Enlightenment absolutists approach to medicalcare and public health through administrative centralization and rationalization offunction. It also showed the growing conviction that hospitals were primarilyinstitutions for treating sick people, while its provision to accommodate both the poorand paying patients struck a modern note. Viennas influence was also significantthroughout other parts of Europe, appearing in a series of 100- to 200-bed hospitalsbuilt between 1784 and 1850.The combination of further scientific study and epidemics such as cholera in theUnited States from 1830 to 1850 created a demand for more hospitals. As hospitalsgrew larger, so the incidence of cross-infection became greater. A big turning point forhealth-care was the Crimean War. In Crimea, Florence Nightingale gained fame for hernursing skills. At the end of the war Nightingale became committed to designinghospitals. 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. Thedramatically low mortalities in her temporary barracks at Scutari made her a nearlyirresistible influence on questions of hospital organization and architecture. Sheintroduced a regime of greater cleanliness and order and the now famous Nightingaleward, born out of the need for a stricter regime of care and discipline, left an indeliblemark on the subsequent planning of healthcare buildings.Both in the Crimean War and in the American Civil War, a need was recognized toimprove medical care through cleanliness, discipline and scientific rationality. Bothsides built large temporary military hospitals which were considered models oforganization and further proof for the fresh air thesis. Treatment on the battlefieldbecame the generator for new models of care planning. Surgery until then was alwaysseen as a last resort. The outcome was invariably poor due to cross-infection and painmust have been horrendous without proper anesthetic. Yet towards the end of the 19thcentury, with Louis Pasteurs and Joseph Listers understanding of living organismsand methods of antiseptic, the surgeon came to the fore. As it became understood thatsurgery was best undertaken in antiseptic conditions, the importance of the hospital asthe focus of healthcare treatment became further established. X-ray technology, whichdeveloped first as a diagnostic tool, became a form of therapy requiring specialinstrumentation and facilities; while advances in biochemistry opened a wide variety

of treatments and diagnostic tests which only a fully equipped laboratory couldperform. In much the same way that manufacturing technology shaped the factoriesand shops necessary to its efficient use, medical technology influenced thedevelopment of the modern hospital. The key dates may said to be :y 184The discoveryof anesthetics, which spread throughout the Western world within a few years.

1866-9-Listers use of carbolic sprays for antiseptic surgery, which bycombating infection enormously reduced the number of post-operative fatalities.

1886 - Von Bergmans introduction of aseptic techniques, the sterilizing ofinstruments and the use of autoclaves.

1895 - Roentgen used X-rays as an aid to diagnosis. Instead of relying on theirfive senses, doctors now had the possibility of confirmation in black andwhite. Laboratories similarly added a new dimension to medi cine andenormously extended the use of pharmaceuticals.

Not until the late 18th and early 19th centuries was hospital planning treated on afunctional and scientific basis. Then the pavilion type plan evolved, segregatingpatients into small groups and ensuring natural light and ventilation. Two otherfactors led to this kind of planning. Fear of contagion led to segmentation intoincreasingly isolated pavilions, and differentiation of the medical profession led to theorganization of many pavilions into specialty departments. The period from the turn ofthe century to the present day has seen the architectural forms of hospitals change fromlow horizontal pavilions to a vertical mono-block.

With the discoveries of X-rays and radium, the diagnostic approach to healthcarebecame bound to a building rather than being brought to the people. Technologicaladvances accelerated throughout the 20th century. Each bore the need for newequipment, with technology further centralizing and emphasizing the place of thehospital as the main focus of medical skills.

After World War II, major factors influencing the evolution of hospitals in the US wereprimarily internal in nature. Major design influences related to changes occurringwithin a particular hospitals medical staff or those produced by new treatmentmodalities and equipment. External forces played a relatively minor role ininfluencing design, and the evolution of one hospitals facility was little influenced byany other institution, except during periods of competitive action.

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During the 1960s, architectural firms in the US specializing in hospital design directedtheir efforts to developing new programming techniques, applying systems theory toplanning, and updating departmental planning through functional analysis. The spaceage that flowered in the 1960s was another turning point for hospital design. Electronicdevices developed for NASA included CRTs (cathode ray tubes) for monitors andimaging devices. With the 1970s came several changes in the health care system whichshifted emphasis in hospital design. The most important factors influencing thephysical organization of the hospital were no longer internal changes but externalconstraints. Important forces of change were :

Federal governments participation in the health field.Changing patterns of illness and new modalities of treatment.A new emphasis on the treatment of chronic diseasesExtension of health care benefits to employees through OSHA.

The principal areas in which these changes made their impact on the physical planof the hospital were :Size, type and distribution of inpatient care units.Growth of outpatient services and increased emphasis on ambulatory care.Role and design of emergency departments.Inter-relationships of the various departments within a hospital.Overall relation of the hospital to the community it serves.Regionalization of the health care system.

Scientific medicine administered through hospitals has proved to be very costly.Publicly funded insurance and compensation plans and state-funded free medical carehave helped to ease this problem in Europe. In the United States private healthinsurance has been the favored method. In the course of the 1970s, it became clear thatprivate insurance protection against high hospital costs was inadequate, and thecreation of a further national health insurance program has become a political issue. Itis also widely believed, however, that insurance programs have underwritten therising costs of hospital medicine while promoting unnecessary use of hospital facilities.At the same time, rising costs have produced cutbacks in hospital services as well ashospital closures, raising again the problem of accessibility to care for the poorestgroups in society.Today, the weight of economics, social values, and futurist ideas necessitates areassessment of this series of !gifts" of history. Some of these gifts have becomeliabilities. The reasons for original design are important; if they are understood, it willbe easier to decide whether the reasons apply today. If not, new designs should becreated.

ESSENTIALS OF HOSPITAL PLANNING

CHAPTER 4

Choosing a Site

(1) The first consideration in choosing the site of a hospital is convenience for thepatients. In view of the increasing importance of the outpatient service given by thehospital, convenience of access to patients is absolutely essential, and should takepriority over other factors in the selection of the site.

(2) The next most important consideration is that the site should be large enough toenable the hospital to expand and develop in the future. Central positions, in urbanareas, are in great demand; it is often difficult, to find a site big enough for a hospital ina central area. Sometimes there is a fairly well developed main residential area, andthe hospital can be sited in a central position in relation to this. Sometimes it is knownthat the town is going to expand in a particular direction; and it may be possible to finda large site fairly near the periphery of the present town that will, in due course,become central to the major residential area.

(3) Close collaboration with town-planning authorities is necessary in choosing thehospital site. In determining the area for the hospital, preliminary calculations arenecessary. These will show the approximate total volume of the building, and the sitearea must be related to this. The degree of crowding on a site can be considered interms of !plot ratio". This is the ratio of the total area of the building on all floors to thearea of the site. A !plot ratio" of one represents a building whose total floor area isequal 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 foropen space, access roads, car parking, and so forth. For purpose of reference, it maybe assumed that a plot ratio of two to one is the greatest that should be considered forhospital 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 thathospitals developed at a plot ratio of two to one will g ive a crowded s ite, h ighbuildings close to one another, very little open space, and a certain amount ofovershadowing 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 asite may be built up will depend, to some extent, on whether the hospital is in an



urban or rural area, on the climate, and on the general character of buildings in theneighborhood.

(4) In most cases a site should be accepted only if it provides room for substantialfuture growth.

(5) In principle, the site should be at least double the area required for the hospital asit is originally planned.

(6) As soon as one or more possible sites satisfying the requirements as set out abovehave been found, they should be surveyed by the architect, assisted by anengineer.

(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 aneffective sewage plant will have to be investigated.

(9) It should also be established that the site is free from air pollution from adjoiningindustries or other sources and free from insect vectors of disease.

(10) The proximity of sources of noise should be avoided.

(11) In hot climates, it is important that the site be exposed to breezes, and in harshclimates, it should be reasonably sheltered.

(12) The bearing qualities of the soil will also require investigation; the risk of earthmovements, geological faults, or underground mine workings has to beconsidered.

The first task of the architect is to prepare a master plan for the site as a whole. Thisplan should take into account foreseeable future developments of the hospital as wellas the buildings erected in the first project. An architect who has specialized in hospitalconstruction 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 ofaccommodation or detailed plans of the individual buildings, but an architect withsufficient experience will be able to calculate the approximate volume of each buildingfrom the general data that are available.

The Master Plan

The master plan is the equivalent of an exercise in town planning. It is mainlyconcerned with establishing the circulation routes on the site and the relativedisposition of the various departments and buildings that make up the hospital. Thecirculation routes on the site are of prime importance, and the success of the hospitalplan depends very largely on getting them right. A hospital has two independent setsof circulation routes external and internal.

All the major departments need to be linked by internal traffic routes for the use ofpatients and staff and for the delivery of supplies from the supply areas to their pointsof 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 alsomoved on trolleys. Trolleys cannot be pushed up stairs, and all vertical circulationpoints within the hospital therefore have to be provided with lifts. Much of hospitalplanning stems from the problems of internal circulation and, in particular, the need tolocalize vertical circulation, so far as possible, at certain key points. It is very muchmore economical and efficient to concentrate lifts than to distribute them amongdifferent parts of the building. Four lifts banked together will give the same service aseight individual lifts distributed at separate points.

The external traffic within the site is considerable. Ambulances and delivery vehiclesneed 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 ofdeliveries are made for the hospital as a whole, it is also desirable to have road access toall major sections of the hospital, and certainly to any independent buildings that theremay be. This access will facilitate the bringing of heavy items of equipment close to thepoint where they are to be installed. It is also necessary for the use of fire engines in theevent of fire in the hospital, and will facilitate the maintenance of the fabric of thebuildings.

In developing the master plan, areas have to be allotted within the site for each majordepartment of the hospital. These areas should always be large enough to allow foreach department to expand by additional building while remaining properlyconnected to the circulation networks. Only if this is done will it be possible for thehospital to grow in an orderly manner.

Certain broad principles for establishing the departmental zones may be set forth. Theparts of the hospital that are most closely linked to the community should be allottedpositions closest to the main entrance to the site.



These include the outpatient, casualty services and such offices or other facilities as areneeded to provide a base for domiciliary services. Next in order of distance from theentrance should be a zone allotted to the medical service departments, such as radiodiagnosis and the laboratories. These departments receive a great deal of workdirectly from the outpatient department and need to be close to it. Beyond this is thearea allotted for inpatient care. Apart from the areas of the hospital used by thepatients, there is a substantial area required for the housekeeping and domesticservices stores, laundry, kitchens, and boiler house. These departments are bestgrouped 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 theperimeter, to give the staff easy access to roads and public transport.The considerations set out above will need to be related to the nature of the site. Inmany climates the orientation of buildings in relation to sunlight or to the prevailingbreeze will determine many aspects of the master plan. Many sites are sloping, andthis may provide both difficulties and opportunities in planning

The first requirement in providing for growth and change is room for expansion in themaster plan, but there are other factors that need consideration. The master plan candevelop 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 onthe ground and employing lower buildings.The former approach will lead to a hospital, which is compact and in which thedistance from point to point within the hospital is minimized. There are manyadvantages in a compact hospital,

(1) It saves the time of the staff,

(2) It helps to promote collaboration by making it easy for members of the staff tomeet one another.

(3) But the more the hospital is planned as a single, massive block, the more difficultwill it be to make effective provision for growth and change

(4) The concentration of all departments close to one another means that only a verylittle space is available for each to expand

(5) Further concentration makes it inevitable that the buildings go up to a fair

Planning for Growth and Change

number of storeys; and to add to a department on the fourth or fifth floor of a block isalways difficult, and sometimes impossible. If such a department needs to beextended, it means taking over space from some adjoining department above orbelow it. This will involve massive redistribution and reorganization of manydepartments. It is therefore necessary to weigh very carefully the advantages anddisadvantages of concentrated versus diffuse types of structure.

The principal factor in the decision will be the prediction of the amount of change andgrowth likely to occur. It may be that some sacrifice in concentration during the earlyyears of the hospitals life will be justified in the interests of allowing for future growthand change. The preparation of a master plan at an early stage will being thisconsideration forward and enable the advantages to be weighed and a rationaldecision to be reached.

It is essential to consider which parts of the hospital are most likely to require room forgrowth and which are relatively static.

The increase in cases coming into the hospital results directly from the increase inmotor traffic, and sometimes from mechanization in industry; and there seems noreason to suppose that further development in these directions will not causecontinued increase in casualty rates.

The medical service departments, particularly the radio-diagnostic service and thelaboratories, will generally need to be extended. The demand for these services by theclinical staff is continually increasing as new methods of diagnosis and treatmentbecome available. Therefore, these departments should be planned to allow forsubstantial growth and should, if possible be at ground level, or in two-storeybuildings.

The accommodation for in-patients may, as the services required on each in-patientfloor can be conveniently and economically designed to run up and down in a verticalbuilding, e.g., lifts can be planned to deliver food trolleys to the ward pantries of everyfloor. The lavatories, bathrooms and sanitary rooms can be replaced one above theother, making use of vertical ducts for plumbing services.

It may not be necessary to increase the total amount of in-patient accommodationwithin a hospital. It will almost certainly be necessary to redistribute theaccommodation among the different clinical departments, w hose relativerequirements for beds are likely to change within the life of the building. This can bestbe provided for by having on each floor a single, general- purpose arrangement,



capable of taking any category or patient; then, shifting a user from, say, medicine tosurgery on a particular floor will not involve any structural change. Certain in-patientaccommodation - for children, maternity, infectious diseases, and psychiatry willrequire special planning, As a result, the in-patient accommodation for these servicesmay best be planned as separate wings apart from the main block.

This is important criteria in country like India wherein there is diverse climate as wemove from North to South and East to West. In certain climates, building have to beheated in winter or cooled in summer; and, in some areas, buildings may need bothheating 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 morespread out the hospital, the larger is the surface available for heat loss or heat gain andthe more expensive is the maintenance by artificial means of the desired internalconditions.

The expense of cooling by air- conditioning is very great, far exceeding that of heatingin most climates. Therefore, wherever air- conditioning is deemed to be necessary, thebuilding should be designed in as compact a manner as possible. The cooling costs willbe directly proportional to the volume of the building, so the volume should be keptdown by the use of low ceiling and by restricting the size of rooms to the absoluteminimum. It is of vital importance that the decision should be taken at an early stage asto whether cooling by air- conditioning is required, as the whole design of the buildingwill 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 becarefully 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 recoverywards, labor rooms, X- ray rooms, and other special areas.

There has been considerable research on the design of buildings for various tropicalconditions, and the results are available in the form of recommendations. It is worthnoting that the design of a building for comfort in a hot, humid climate is totallydifferent from that in a hot, dry climate. Broadly speaking, in the former air movementpast the body is the main objective. The buildings should be light and open andplanned so that even the slightest breeze can pass right through the buildings at lowlevel to cool the occupants. It is impossible to plan highly concentrated hospitals foruse 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

Considerations Based on 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 anddissipate it at night. The small windows keep the amount of radiation entering thebuilding to a minimum.

In developing the master plan, attention must be given to the relation of building toeach other with regard to sunlight and shade. In cool climates, where sunlight isdesirable, buildings should not be planned so as to cut off one anothers light. In hotclimates, the buildings can be planned to shade each other to some extent. The shadowscast 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 ofhospitals in tropical climates should take care to familiarize themselves with the greatmass of valuable information now available on design for comfort.

In temperate climates, where the winters are not very long or very severe, it will not benecessary to give great weight to the problem of heating in relation to the general planof the hospital, which can be designed primarily with other considerations in mind. Butin climates of extreme cold and long winters, where the cost of heating is heavy, somethought should be given to making sure that the general plan results in a reasonablycompact building.

The methods used for heating and ventilation of the hospital are important, as baddesign can increase the risks of cross-infection.Massive ventilation is veryadvantageous in reducing this risk. In warm climates, massive natural ventilation iseasily obtained and is desirable, for comfort. It will therefore be wise to rely, in hotclimates, on natural ventilation as much as possible and to have recourse to air-conditioning only under extreme conditions.

In cold climates, the ventilation of hospitals during the winter presents difficulties, assufficient ventilation is apt to cause undue cooling by the introduction of cold air fromthe outside. Any proposal for artificial ventilation or air-conditioning in hospitalbuildings must, therefore, be submitted to expert bacteriological criticism beforeadoption.

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 openwounds are exposed to the air. These areas must be ventilated by special means to givea high degree of air hygiene. The design of a ventilating plant for these purposes ishighly specialized, and must be entrusted to an expert.



Light and Color

Visual Impact of the Hospital

Windows light most hospitals. It is important that patients lying in bed should not beexposed to too large an area of sky in direct view through the windows. Control ofglare from windows requires great care in design, and various special arrangementshave been proposed for this purpose. It is therefore important for the architect toconsider the design of the windows in the light of criteria that are now known to begood for hospital purposes.

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 todifficulty for doctors and nurses who have to assess a patients condition partly byreference to his skin color.

Emergency arrangements for providing artificial lighting by a stand-by plant, in theevent of a failure of electric power from the main source, are always essential.

The color used internally on the walls, ceiling, and floors of a hospital is an integral partof the design of the building and should be determined by the architect. The generallighting of a room is greatly affected by the color scheme, and it is necessary for thecolors to be considered simultaneously with the design of the windows if the best effectis to be achieved. Color can make all the difference between a depressing ordisquieting atmosphere and a restful or a pleasantly stimulating one. There now existsan international color notation, and colors can be specified in relation to this.

Hospital buildings are very large. As the hospital is very often set in a residential areaamong buildings of a domestic scale and character, the contrast between its size andthe small, scattered houses around it may be very violent.

Consideration of planning for growth and change tends to soften the visual impact ofthe hospital. The parts of it that form its front door or shop windows are the buildingsfor outpatient care, reception, and emergency care. These will almost certainly belocated nearest to the entrance to the site, and may very well be planned ascomparatively low buildings, in the interests of future growth and flexibility.

The architectural handling of the design will also affect the visual impact of thehospital. The architect has the opportunity, in planning the hospital, to give visualexpression to the human units of which the hospital is composed, or to suppress thesedivisions in the interests of uniformity. For instance, in designing a ward building, he

could allow each nursing unit individual expression on the faade of the building; or bygiving each unit an identical series of windows, he could carry uniform architecturaltreatment over the whole.

More than a third of the cost of hospital building goes into the mechanical engineeringservices heating and ventilating, electricity, lifts, and communications. These servicesform the circulation and nervous systems without which the hospital cannot function.Therefore, the contribution of engineers to the design is of capital importance. Theirhelp will be needed at an early stage, when the approximate demand for water, electricpower, fuel, gas, and sewerage is being estimated. Their advice will be needed on thechoice of site and on the master plan for the hospital. Later, they will have to designsystems of heating and ventilation, lifts and telephonic and other communications.

Engineers will have to concern themselves with the installation of all the mechanicalequipment also with its subsequent maintenance. They should advise the hospitalauthority on maintenance problems at a very early stage in the design. They shouldadvise against the installation of any machinery or equipment for which maintenancearrangements cannot be guaranteed. Decisions on these matters may affect the masterplan of the hospital, and they should be considered at an early stage.

The engineers must also collaborate with and advise the architect on the space that willbe needed in the building to house the mechanical services. This space must be ofsufficient size to allow not just for present services, but also for any future services thatmay be required. The mechanical services must be planned so that easy access can beobtained to all equipment for repairs and maintenance without disruption of the dailyfunction of the hospital. Provision must be made for stand-by power in the event of ageneral power failure at the main source.

All these considerations point to the fact that a modern hospital can be built andoperated only if the town in which it is located is sufficiently well equipped withelectric power, potable water, sewers, and other technical infrastructures. In addition,competent personnel must be available to maintain the mechanical and electricalequipment; and spare parts and other essentials for repair must be obtainable. Allthese resources must be fully developed and at the disposal of other institutions as wellas the hospital; it would be unrealistic to think that an isolated and self-supportinghospital could bear the cost of such technical services only for itself.

Hospital Engineering



Hospital Hygiene

Another important factor is hospital design is the special attention that must be givento conditions of hygiene. Hospitals exist to treat illness, and often act as reservoirs ofinfections. Surveys have found that a substantial proportion of patients acquireinfections during their stay in hospital. The cost of extra patient-days in hospitals as aresult of cross-infection, bears heavily on the patients, sickness insurance and on thenational health budget. It is therefore essential to take reasonable precaution in thedesign and organization of hospitals to minimize the risk of infection.

In addition to the risk to patients and staff, hospitals can also prove a danger to thecommunity if the arrangements for waste disposal are inadequate. The hospitalssewage may contain dangerous organisms. Outbreaks of typhoid have been tracedback to pollution of the water supply by hospital effluents. The approval of healthauthorities should be sought with regard to hospital sewerage and disposalinstallations.

Introduction of antibiotic drugs substantially reduced the dangers of infection withinthe hospital. As a result, many precautions in the design of the buildings and in themethods of work by the hospital staff were abandoned or neglected. Strains,particularly of Staphylococcus, have developed resistance to nearly all antibioticsknown at the present time. These resistant organisms tend to establish themselves inhospitals, hospitals, whose staff often become carriers. It is therefore, more necessarythan ever to pay the strictest attention to all available methods of control of infections.

The first line of defense must be appropriate training of all staff in correct methods ofwork. Staff must be trained in aseptic techniques for use in all surgical procedures andin !barrier" nursing of infectious patients. It may be extremely useful to secure thepermanent advice of a technician with an engineering background in order to controland 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 agreat deal to facilitate safe working by the staff.

One of the most important matters in planning a hospital is to consider the disposalroutes of all waste and infected material. In every part of the hospital where patientsare treated, there will be infected material to be disposed of. In wards there will be thepatients bedding and infected utensils, and other waste material of various kinds.Operating rooms and surgical treatment areas will have infected dressings, dirtyinstruments, 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 suppliescoming into the unit and with minimum handling by hospital personnel. In thenursing units, soiled linen should preferably be taken immediately from the patientsroom to a disposal room, from which a lift or other special route is available to areception 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 itspoint of origin and remain in that container until it reaches a point at which it issterilized or incinerated.

It has been demonstrated that chutes are to be avoided at any cost, because they cannotbe cleaned and disinfected.Moreover, because of the possible difference inatmospheric pressure between the upper floors and the basement, clouds of dust cancirculate through the chutes. Small lifts or vertical conveyors of the !dumb-waiter"type should replace chutes.

It should noted that under no circumstances should nurses or other persons concernedwith the care of patients be required to sort or count soiled linen. The disposal routefrom the wash-up room serving the operating theatre should be direct to the centralsterilizing department, and should not pass through the operating room or any otherroom in the operating suite.

Blankets used on patients beds are a special problem, as the wool blanketstraditionally used cannot be sterilized or laundered without becoming felted andrapidly destroyed. Therefore, it is preferable to use blankets of cotton or other materialthat can be boiled.

Cleaning methods can help or hinder hygiene. Sweeping and dusting as traditionallyperformed are dangerous. They spread dust in the air and raise the bacterial count.Wet cleaning by approved methods and vacuum cleaning by approved types ofmachine with special filters must be the methods adopted.

Surgical instruments and bowls have, until fairly recently, been sterilized in boiling-water sterilizers at various points in the hospital; and dressings have traditionally beensterilized 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 centraldepartment serving the whole hospital. It is recommended that new hospitals shouldbe planned, from the start, with facilities for central sterilization. Under this system,all objects that require sterilization are supplied in sealed packages from the centraldepartment to the point of use. After use, non-disposable items are returned to the



central sterilizing department for re-sterilization. In recent years many newdisposablearticles 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 toincur the cost of cleaning and re-sterilizing the conventional equipment after each use.

The planning and operation of the central sterile supply service require exper technicaladvice. However, several authoritative reports that give guidance on the subject areavailable. It should be noted that the adoption of a central sterile supply service, whichhas gained favor on grounds of improved safety may have economic advantages aswell. It affects the planning of the hospital radically, inasmuch as it eliminates the needto provide sterilization facilities in the nursing units, outpatient and casualtydepartments, and many other points within the hospital. In addition, this type ofsterilization avoids the damage to paint that sterilization with boiling water causes.

Many surgeons like to have their own individual sets of instruments. It is moreconvenient to arrange for these to be sterilized in a room adjoining the operating room.All other requirements for operations, including dressings, bowls, syringes, and soforth, can be supplied to the operating room from the central sterilizing department.

In planning operating rooms and treatment areas generally, it is of vital importance toseparate clean and dirty areas and to ensure that clean material goes directly to its pointof use without coming into contact with any used material or with personnelconcerned with the handling of used material.

Proper techniques by staff and effective sterilization of instruments, bowls, anddressings 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 themouth and nose may infect patients and staff. Open wounds are particularly subject toinfection from air-borne organisms. Hence, air hygiene must be considered as affectingthe atmosphere in the hospital as a whole, and particular regard must be paid to it inoperating rooms and treatment areas in which open wounds are exposed to the air.

So far as the general areas of the hospital are concerned, it is important to ensure a goodgeneral rate of ventilation, and standards have been established for this purpose. Itshould be noted, in addition, that isolation rooms should be provided with specialventilation arrangements to ensure that contaminated air from them does not reachother parts of the hospital. The ventilation of operating rooms is a highly technicalmatter on which important research has recently been conducted; it is now possible tospecify with considerable exactitude the requirements for the special ventilating

system needed in operating rooms. Such systems need very careful design byengineers, and should be subjected to bacteriological control.

When hospital sewage is not passed into the public sewage disposal system, it requirestreatment 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, whichcan be destroyed.

The next stage in an actual project would be the preparation of the architects brief. Atthis point it is necessary to go into the needs of every service and departmentindividually and in great detail, always bearing in mind the general principlesgoverning the plan as a whole.

It is necessary to consider, first, the function and organization of each section, whether itis the surgical service or the catering department. It is essential to decide on controllingprinciples and to reach decisions on methods of working before attempting to draw upschedules of rooms. At this stage advice should be sought from people with practicalexperience in the running of the various services. It is important, however, to poseproblems in a general form to these advisers and to press them to think afresh toconsider not only how they have organized their work in the past, but also how theywould organize it for better service to patients, or for greater efficiency, if free to thinkthings out from first principles. Unless care is taken at this point, there is a risk that thearchitects brief will reflect, with minor improvements.

It is of the utmost importance in planning a hospital that a large measure of imaginativeforesight should be brought to bear in an endeavor to identify the probable growingpoints and to plan the greatest degree of adaptability in those services that seem mostlikely to expand.

The Architects Brief



STEPS INVOLVED INHOSPITAL DESIGN

CHAPTER 5

Planning the Grid

Grid is defined by Merriam-Websters Collegiate Dictionary as: !a network ofuniformly spaced horizontal and perpendicular lines (as for locating points on a map);also: something resembling such a network."

A planning grid is an architectural design tool which is !something resembling such anetwork."

Healthcare designers can derive their planning grids in one of the two following ways:

1. In urban situations, where the hospital takes the form of a vertical buildingcomprising of a podium containing diagnostic / therapeutic and interventionalservices and a tower housing the inpatient facilities, the planning grid is determined bythe layout of the inpatient tower. The module(s) used to determine the shape and sizeof 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 cansee how the planning grid modules (in red) of 3.90 M x 8.50 M is determined by theaccommodation desired for a single bed patient room, a double bed patient room andtheir toilets.

Expanding on this with the addition of the access corridor and stringing the rooms outin 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 thisplan we can see something important has been added, namely, the positions of thecolumns that will support the building. We can thus see how the structural grid, thenetwork of lines defining the location of columns, has been derived from the planninggrid. The structural grid need not necessarily be the same as the planning grid, but isalways derived from it.



The positions of the structural columns determined by this planning grid, twisted orotherwise, will continue downwards through the rest of the hospital, through thelower floors (the podium mentioned above) till their respective foundations, wherethey 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 SciencesDepartment, the Main Kitchen and the Mechanical Areas in the basement, to name justa few, will all need to be designed within the constraints of these column positions.Extrapolating from here, we can see how the faade of the hospital will need to bedesigned in harmony with the windows of the inpatient rooms above, which will bedesigned with the use of the planning grid. Even if the podium extends beyond thefootprint of the tower above, it is almost certain that the positions of the additionalcolumns required would be derived from the structural grid used for the tower, whichhas been derived from the planning grid determined by inpatient facility design.

2. In semi-urban or rural situations, where the land available is very likely to be largerwith respect to the built-up area desired, determining the planning grid is anotherballgame, one with much greater flexibility in the rules.

In this situation, the planning grid will be determined by what designers call as theirconcept for the hospital. This concept is also an ordering tool, and will have beenused to determine the form of the hospital in even the previous example of the urbansite, but with less freedom. When there is a lot of land available, it gives the architectmore elbowroom, and his hand is likely to move with more (hopefully graceful)abandon. This freedom enables many different types of building layout and form.

The thought process behind design can be described as a process of analysis andsynthesis or divergent and convergent thinking. That is, a parting followed by ameeting of thought within their minds. At the point of separation, the designer throwsup a whole lot of different ways in which he could define an ordering principle that hewould use to design the hospital. Suffice it to say for now that based on his / her chosencriteria the architect will (converge) select one or a combination of concepts to providethe ordering principle.The focus of our discussion here, the planning grid, in this situation gets relegated toan almost incidental design tool, subject to great local variation if the structure is singlestoried, and might vary substantially even if the hospital is partially high rise and

In vertically organized healthcare facilities, we design from the top down.

partially low rise, as the two forms of building could have planning grids independentof each other. Faade design might also vary greatly, there being less discipline to befollowed.

Another important design issue in the planning of a hospital is the layout of the majorcirculation paths.

Hospitals, like the small cities they are likened to, contain main circulation routes oftendescribed as hospital streets. The way in which the different parts of the hospital areassembled, as a coherent whole but with the parts differentiated, make for analogieswith urban design; the way in which traffic moves, and the routes that are taken bymechanical and electrical services are fundamental generators of the plan.

In a vertically stacked hospital, which could also be called a functionally stratifiedhospital, almost always the inpatient areas are placed on the upper floors, to allow for amore 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 inpatientfloors. Another important planning feature, the vertical circulation core, is also to someextent located within the building by the layout of the inpatient floors. We somewhatsimplistically claimed in that earlier lecture that in vertically organized hospitals wedesign !from the top down." What we actually do is during the layout of the inpatientfloors, we provisionally decide on a position for the vertical circulation core and otherstaircases that may be required, many times by the local building codes. This location,however, is to be checked for its design impact on the lower floors containing thediagnostic / therapeutic / interventional departments. This checking process isdescribed by the diagram of the design process presented in the self-same earlierlecture.

The pattern of circulation conceptualized for the hospital under design will beconsiderably impacted by the location(s) of the vertical circulation core(s).

The vertical circulation core is the center, the focus of all the major circulation paths ofthe hospital. An attempt can be made through design to minimize vertical

Different parts of the hospital may have different planning grids derived from thefunctional planning requirements of the hospital departments they house.

Circulation :



transportation by siting (for example) all surgical beds, operating theatres and theintensive care unit on the same floor. This design approach may be used as ajustification to reduce the number of elevators, or the width of the staircases, but in noway does this mean that the core can be located more casually by the designer.

Avoidance of dependence on lifts is particularly important in places wheremaintenance and availability of spare parts is unreliable; long waits for lifts are a majorcause of inefficiency and frustration to hospital users more of a problem the taller thebuilding is.

It is important that patients, visitors and staff be able to orient themselves whilemoving through the hospital by providing windows in corridors to enable them tolook out and to allow natural light in, important in alleviating the tedium of longcorridors. If the site enables them, courtyards are also an excellent means to this end.

As such there is no easily available prescription for the way the circulation pattern for ahealthcare facility should be. The qualities it should possess, however, I will try toenumerate:

1. It should have conceptual clarity. By this I mean it should be designed withpurpose, and should not be leftover space or squeezed into the gaps betweenother areas. Geometry can be a recourse, but it should work wi thother planning imperatives, and junctions should be uniquely treated to avoidconfusion over which corner of the hexagon (for example) you have reached.

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, outside views, courtyards, all these will help.

3. It should enable way finding. In combination with well-designed signage andmaybe super-graphics, people should be able to find their way to their destinationwith ease. Color-coding for floors or departments is sometimes used.

4. They should be wide enough to handle anticipated traffic. Stretcher traffic needs8- 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 toOT staff to the contrary.

5. They should be indirectly lit. Patients on stretchers get to look at the ceilings. Thesign put up by the traffic police at the end of Marine Drive in Mumbai says, !Drivecarefully. Hospital ceilings are boring." While not advocating rash driving, wewould advocate making the ceilings interesting.

Some of the hospitals currently existing in India have been provided with ramps inaddition to the usual elevators and stairs. Power cuts are realities that have to beconsidered. But consider putting some (two) of the elevators on a generator, if thishelps in avoiding the ramp, which is wasteful of space and difficult to use, as thegradient is often excessive. (With an acceptable gradient, the length becomes excessive,considering that the lower floors of hospitals are considerably higher than those of theusual non-hospital building.)When planning for the area occupied by this circulation space (corridors) in thearchitectural 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 andmay also vary if the architect has any special feature in mind for that department whichis 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 OperationTheater Suite (with 8-0" corridors) to 20 25% for the Administration Department.

On the Inpatient floors or even in the Outpatient Department, these corridors can bemodulated by recessing pairs of doors that occur at regular intervals, and using anaccent color in the niche so created. This helps relieve the boredom of walking throughlong, uninteresting corridors.

Very frequently the major circulation paths through the hospital are laid out evenbefore the tentative space allocation for the hospital departments is done. Thus, theimportance of conceptualizing these paths in a way that they contribute to the conceptand functional layout of the hospital is not to be underestimated, the exercise shouldnot be done casually.

Frequently the manner in which the healthcare architect conceptualizes the working(and therefore layout) of certain hospital departments, notably the Operation TheaterSuite and the Radiology & Imaging Sciences Department (as described in a later lecturetitled !The Architecture of Imaging") will determine the circulation pattern throughthat department, and hence affect the layout of circulation paths in contiguous areas ofthe hospital.Defining major circulation paths through the proposed and future buildings is a



design decision that will considerably impact the form, layout and thus the eventualfunctioning of the healthcare facility being designed.

Identifying and understanding the conditions which constitute barriers to those with adisability (this category includes, besides the wheelchair bound, those who for anyreason have difficulty in walking, and also those with a sensory that is, visual orhearing impairment) is a fundamental requirement for the effective provision ofaccommodation and facilities to be used by disabled people.

If the needs of people who have temporary or permanent disabilities are taken intoconsideration, the resulting design can make the design easier and safer to use forthose 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 aconsideration, wheelchairs or other larger wheeled items need to be considered; forvertical 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 thosewho are suffering from shock or stress, as many users of health buildings are. Buildingdesign that gives consideration to all users will also be easier and safer during anemergency evacuation.

The best design philosophy is to consider the journey through the healthcare facilityfrom start to finish, analyzing all the related components of the task (negotiatingentrances, corridors, lifts, reception areas, toilets, e

Hospital Planning and Project Management

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