Text Book: 1. Principles of Hospital Administration & Planning by B M

Sakharkhar2. Hospital Planning and Management by G D Kunders

Hospital Administration – the conceptAny institution, which has to achieve a goal

has to deliver services within a time using certain infrastructure resources, Through people Specific qualityAt minimal cost

needs administration or management.

Management

• “ It is a set of interactive processes through which the utilization of resources results in the accomplishment of organization objectives.”

Elements of Administration:

PlanningOrganizationStaffingDirectingCoordinatingReporting

BudgetingSupervising EvaluationNewer modern techniques

such as operation research and behavioral sciences

There are several elements for administration. In practice all these elements are interrelated to one another.

Optimum utilization of resourcesInstill efficiency and effectiveness into the system.

New concept

Fast catching up

Phenomenal growth prospects

How do you differentiate hospitals from any other industrial organization

The responsibility- Distinction between a hospital and an industrial organization Hospitals are havens of hope for people suffering from pain and illness.

Management of a hospital entails a lot of responsibilities and is a round-the clock job.

It is not merely the treatment meted out to the patient but the overall atmosphere of a hospital that a patient remembers after discharge.

Inefficiency or inadequacy either the quality of doctors, medical facilities or its administration area can mar the image of an institution.

From ensuring that the corridors are sparkling clean to keeping life-saving machines in working order to attending to patients' complaints and catering needs--the hospital administrators perform multifarious tasks.

An awesome infrastructure and gleaming machine doesn't help out in making a hospital successful.

A hospital deals daily with life, suffering, recovery and death of human beings.

For direction and running of such an institution , its administrative personnel need a particular combination of knowledge, understanding, traits, abilities and skills.

Functions of a Hospitals1. 2. 3.

Functions of a hospitalIntramural functions: confined to inside walls of

the hospital1.Restorative : include diagnostic, curative,

rehabilitative, care of emergencies. 2.Preventive : control of communication diseases,

vaccination, health education, occupational health, supervision of normal pregnancies, child birth and growth of children.

3. Education : medical undergraduates, specialists, nurses, technicians, paramedical staff

4. Research : Clinical medicine, hospital practices and administration.

Extramural functions: which radiate outside the hospital and to home environment and community.

1.Outpatient services2.Home care services3.Outreach services4.Mobile clinics5.Medical care camps

Essentials for running a Hospital1. 2. 3. 4.

Business of running a HospitalFacility management - Water , ElectricityMarketing of HospitalsBusiness DevelopmentQuality and patient safety practices – AccreditationBest Operations Practices for maximum utilization of resources And smooth functioning

Economics– Costing of services - least cost and maximum efficiency and effectiveness

BudgetingFinance Human Resource managementPatient Satisfaction – Customer SatisfactionMaterial Management – to ensure availability of medicines

and consumables and prevent stock outs.Laws & legal requirement for running a Hospital

Hospital Acquired Infection Control Communication skills – handling sensitive issues in hospitalPublic RelationsHealth Insurance & Third Party Administrators ( TPA)Legal Aspects – Medico legal cases, Consumer Protection Act

Professional managementPast vs present.

Run by Senior doctorsRetired personnel from Army or medical services or religious

sisters of mission hospitalsCorporate Sector emergence – application of management skills,

operational strategies and sense of ethicsNeed to conform to international standards Professional management – qualified and trained personnel at

every level ----- deep impact on quality of care to patients.

Quality of care provided by its personnel…be it CEO, Medical superintendent, receptionist or just a sweeper.

Work needs to properly planned and designed only then a hospital is administered professionally.

What it really means is Doing everything at every level of the hospital in a professional manner.

Hospital EthicsCode of Ethics of hospitals go hand in hand with code of

ethics of physicians- Hippocratic oath. Ethics deals with righteousness and wrongness of the actions. Medical Ethics would include: Physician will serve the patient by virtue of his medical

knowledge he possesses. Physicians' primary commitment must be patients welfare

regardless of the financial arrangements. A physician should not discriminate between a private and a

general ward patient.

Confidentiality is important. The physician must honor the confidentiality of the patient and the personal information given by the patient and observations made during examination except for academic discussions and court of law.

No one including the treating physician and the nurse has the right to expose the patient unnecessarily.

Physician cannot give advertisement to solicit patients, to become sexually involved with their patients, enter into business agreement with them etc.

Role of the Hospital AdministratorThe role of a Hospital Administrator is critical in saving lives although the administrator does not himself provide medical services.

Hospital administrators oversee operations in a variety of clinical settings; hospitals, outpatient clinics (including ambulatory care centers, surgery centers, imaging centers, and cancer centers), hospices, and drug treatment centers.

Administrators have many responsibilities including acting as a liaison between the governing board of trustees, the administration team, the medical staff, and department heads.

They also organize and oversee the services of all departments so that they operate as a cohesive unit.

Hospital administrators plan budgets, set the rates for health services that are provided and ensure that federal and local regulatory reporting and reimbursement requirements are met.

Other important tasks involve planning departmental activities, evaluating doctors and other hospital employees, and creating and maintaining policies.

In addition, they set measures for quality assurance, patient services, and public relations.

While a physician’s goal is to optimize the health and well-being of his patient, the administrator’s goal is to support that excellent medical care at a broader level by coordinating all physical, human and financial aspects of the hospital towards achieving quality care.

AptitudePersonal commitmentAstute business judgement, Excellent communication skills and superior administrative capabilities. Leadership initiative & decision makingSoft skill assetsSense of empathy and self disciplineClarity of thoughtTime management skills,Optimistic & proactive an approach

Challenges for a Hospital Administrator

Challenges of hospital administratorWithin the health fieldFrom PublicFor eg:a.Business and professional leaders -trustees of voluntary hospitals. b.Large Number of Physicians -medical staff -concerned about the

facilities and services.c.Accreditation Body/Certification Bodies .d.Professor – teaching faculty in teaching hospitals e.Labor – standards of employment and working conditionsf. Members of registered society, shareholders of corporate hospitals

Conditions peculiar to administrative work in HospitalsConsumers are physically /mentally ill. Needs of consumers have individual needs and require highly

personalized and custom made services. Hospital/institution has to provide wide range of scientific and

technical services such as nursing, anesthesia, radiology etc. And that too round the clock every day of the year.

All the services involve many individuals – ill customer, his emotionally charged relatives, friends, physicians, nurses, technicians.

Apprehension of exposure to diseases, hospital personnel are expected to maintain a very high level of efficiency as it effects lives of people.

Problems of the hospital are very delicate and volatile. Efficiency and quality of health care is dependent on use of

sophisticated technology like medical equipments for diagnosis., treatment etc.

Consumer Protection Act 1986 Disposal of Hospital Waste Management is a peculiar

condition and is a burning issue.

The past An individual afflicted by a wound or disease was condemned to suffer and fend for

himself – the healthy never assisted or looked after the afflicted; an afflicted person considered ‘a spent-force’ no longer useful to society.

Belief – illness was caused either by evil spirits or was a punishment for one’s misdeeds

Treated by the ‘tribe’ with magic spell to appease/scare away the evil spirits with a counter-curse

As civilization advanced from Individual – family – tribe – organized community, society acknowledged common responsibility towards the sick.

The middle of nineteenth century saw the arrival of Florence Nightingale to revolutionize nursing by supplementing good intentions and humane concern with scientific approach to nursing through training.

The institution that we know today as the hospital is a phenomenon of the twentieth century. The early institutions from which it developed bore little resemblance to that important part of community life, which we call the hospital.

In its earliest form the hospital was aimed at care of the poor and lodging was the primary function of the early hospital. The record shows the earliest hospital

in Paris to have been founded about 600 A.D., and St. Bartholomew’s in London dates from the year 1123.

The first hospitals in the New World were built by the Spanish in Mexico City (1524)

and the French in Canada. There was a general tendency to lump together the Physically handicapped, the sick, the socially unwanted and the poor. Special inoculation hospitals were built during the smallpox epidemics to care for persons being so treated, but these died out when this form of treatment was superseded by vaccination.

Indian Scenario: The history of Indian medicine and surgery dates back to the earliest of ages. In

India, hospitals have existed from ancient times.Even in the 6th century B.C. during the time of Buddha, there were a number of

hospitals to look after the crippled and the poor. The outstanding hospitals in India at that time were those built by King Ashoka. Charaka and Sushrutha of ancient India were famous physicians.

The Mohammedans brought with them their hakims who followed the Greek system of medicine “Yunani”.

The use of allopathic system of medicine commenced in the 16th century with the arrival of European missionaries in South India. It was during the British rule- East India company that there was once again progress in the building of hospitals.

Organized medical training was started in the 19th century. The first medical school was started in Calcutta, followed by one in Madras. In the beginning both the modern system and the Ayurvedic system were taught.

Health committee appointed by the Government After Independence, rapid industrialization in country and

continuous growth of population; increasing no. of medical and health problems

Committees therefore set –up from time to time

Reports of the Bhore Committee, Mudaliar Committee, jain Committee, Kartar Singh Committee, Jaisukhlal Hathi Committee, Srivastava Committee, Sidhu Committee and Bajaj Committee continue to guide the makers of health policies in India

Definition of a Hospital ‘hospital’ derived from latin word hospitalis which comes from

hospes, meaning a host.

Hospital comes from French word hospitale (like hostel & hotel) – an establishment for temporary occupation by the sick and the injured

“A hospital is an institution which is operated for the medical, surgical and/or obstetrical care of in-patients and which is treated as a hospital by the Central/state government/local body/private and licensed by the appropriate authority”

- Directory of Hospitals in India, 1988

A hospital is an integral part of a social and medical organization, the function of which is to provide for the population complete health care, both curative and preventive, and whose outpatient services reach out to the family and its home environment, the hospital is also a centre for the training of health workers and bio-social research.

-WHO definition of Hospital

Changing Role of Hospitals in the Health systems Shift in emphasis in : Acute to chronic illnessCurative to preventive medicineRestorative to comprehensive medicineInpatient care to outpatient and home careIndividual orientation to community orientationIsolated function to area wise or regional function.Tertiary and secondary to primary health careEpisodic care to total care.

Hospital as a systemWhat is a system??

1. 2. 3.

Management science defines a system as

“ a collection of component subsystem which, operating together, perform a set of operations in accomplishment of defined objectives”

Hospital as a system

Process( Transformation) Input Output

Feedback

Input

PeopleA. Staff

• Physician• Nurses• Paramedics• Supportive

B. Patient, their attendants and relatives

Material• Drug and

chemicals• Equipment• Diet

Money•To maintain staff, facilities and procure materials

Process- TransformationCommunication : Between

•Physicians and patients•Physicians and nurses•Physicians/nurses and paramedical staff•Physicians and administrator•Administrator and community•Administrator and nursing/paramedical staff•Nursing/paramedical staff and patients

Decision making: For •Cure: Diagnosis, treatment•Care: Creature comforts of patients, diet•Procurement of materials in right place at the right time.

Action•Putting decisions into practice•Balanced mix of communication, decision making and action.

Output:

Efficient Patient care

Peculiarities of a Hospital systemOpen system- interacts with its environment. Boundaries separating hospital system from other social system are

not clear. Output of a hospital system are not clearly measurable. Hospital system has to be in a dynamic equilibrium with its wider

social system. A hospital system is not an end in itself. It must function as a part of

larger health care system. A hospital like other open social systems tends towards elaboration

and differentiation- specialized departments, newer technology, expansion of scope of services…

Hospital as a social systemDual lines of authority1.Administrative /management2.Professional/doctors

Importance of free communication and integration for better patient care.

Classification of hospitalsCan be classified in many ways

According to their objectives : 1. Teaching Hospital2. Charitable Hospital

According to the age group which get treated: 1.Children's Hospital, 2.Women Hospital , 3.Geriatric Hospital

According to ownership and Control: 1. Central Govt : Under Ministry of Health – RML, Safdarjung Hospital

- Railways, CGHS, Ministry of Defence – Army- Under Act of Legislation : Central Act – AIIMS ,

- State Act : PGI, NIMSState Govt or Public Hospitals : run by State govt like LNJP, Gandhi

Hospital. : Corporation Hospitals, Cantonment Hospitals. Local Bodies 2. Non Government Hospitals – Profit Oriented, non profit oriented/voluntary

hospitals. Profit oriented : a. Private nursing Homes/maternity Homes : Corporate

Hospitals: Global Hospital, Yashoda b. Public service : offering services to others on payment

basis- some CGHS/Railway/Army Hospitals.

Private Nursing homes Generally owned by an individual doctor or a group of doctors

No uniform definition for nursing homes – ‘out-of-home’ care facilities offering a range of services similar to many found in a hospital

Run on a commercial basis

Becoming more popular due to shortage of govt. and voluntary hospitals; long queues & man power shortage

Corporate hospitals◦ Latest concept run on commercial lines

◦ Are public limited companies formed under the Companies Act

◦ Can be either General or Specialized or both

Non Profit Oriented /Voluntary hospitals

◦ Those established and incorporated under the Societies Registration Act, 1860 or Public Trust Act, 1882 or any other appropriate Act of the Central or State government.

◦ They are run with public or private funds on a non-commercial basis; by a board of trustees incl. prominent members of community & retd high officials of govt. and appoint Administrator(s) and Medical director(s) to run such voluntary hospitals.

◦ No part of the profit goes to the benefit of any member, trust or any other individual, nor is any such individual entitled to a share in the distribution of any of the corporate assets on dissolution of the registered society

◦ These hospitals spend more on patient care than what they receive from the patients - what is earned from rich patients of private wards are spent on the patients of general wards

◦ The main sources of their revenue are public and private donations, and grants-in-aid from the Central Government, State government and both national and international philanthropic organizations

◦ These run on a ‘no profit, no loss’ basis

According to the system of medicine Allopathy, Homeopathy, Ayurveda, Naturopathy, Yoga

According to the number of beds – Large, Medium, Small

More than 300 beds – Large Between 100-300 beds – Medium Less than 100 beds – Small

According to Clinical Basis : General Hospital, Specialized Hospital

According to length of Stay of Patients : Long Term Stay Hospitals, Short Term Stay Hospitals.

Classification according to the Directory of Hospitals in India, 1988

Types of Hospitals:

1.General hospital – all establishments permanently staffed by atleast two or more medical officers, which can offer in-patient accommodation and provide active medical and nursing care for more than one category of medical discipline (eg., general medicine, general surgery etc.)

2.Rural hospital – hospitals located in the rural areas (classified by the Registrar General of India) permanently staffed by atleast one or more physicians, offering in-patient accommodation and provide active medical and nursing care for more than one category of medical discipline (eg., general medicine, general surgery etc.)

3. Specialized hospital – hospitals providing medical and nursing care primarily for only one discipline or specific diseases (eg., TB, ENT, Paediatrics, Orthopaedics etc.)

4. Teaching hospital – hospital to which a college is attached for medical/dental education

5. Isolation hospital – hospital for the care of persons suffering from infectious diseases requiring isolation of the patients

6. Tertiary hospital – hospitals set up by the Central/State governments in their capitals, for treating referred patients (eg., AIIMS, New Delhi; PGI, Chandigarh etc.)

Classification according to the Directory of Hospitals in India, 1988

Types of Management:

1.Central Government/Govt. of India – all hospitals administered by the GOI viz., hospitals run by railways, military/defence, mining/ESI, Post & Telegraph or public sector undertakings of the Central Govt.

2.State Government – all hospitals administered by the state/UT governments authorities and public sector undertakings operated by states/Uts including the police, jail, etc.

3.Local bodies – all hospitals administered by the local bodies, viz., the municipal corporation, zila parishad, panchayat

4. Private – all private hospitals owned by an individual or a private organization

5. Autonomous body – all hospitals established under a special Act of Parliament/state legislation and funded by the central/state/UT government eg., AIIMS, New Delhi; PGI, Chandigarh

6. Voluntary organization – all hospitals operated by a voluntary body/a trust/charitable society registered by the appropriate authority under Central/state government laws; includes hospitals run by missionary bodies and co-operatives

7. Corporate body – hospital run by a public limited company. Its shares can be purchased by the public and dividend distributed among its shareholders

Clinical/Non clinical services in the hospital:CLINICAL NON CLINICAL

Individual departmentsClinical Service Clinical Support

Services OPD Emergency ICU or Intensive Care Medicine & Medicine Dept Surgery and Surgical Departments Pediatrics OBG Anesthesia Dental Physical Medicine and

rehabilitation

Radiology & Imaging Services,

Laboratory Services, Pharmacy & Medical

Stores CSSD Blood Bank Operation Theatre

Administrative Departments Top Management Hosp Administrator Accounts Department HR Finance & Accounts Dept PR Security Housekeeping Communications- paging,

intercom, LAN Purchase Dept Engineering Services

Clinico Administrative Services Nursing Department Admission office Medical Records Mortuary Infection Control Ambulance

Planning of a HospitalThe successful hospital is based upon a triad

good community planning, good design and construction, and good administration.

A well-planned hospital requires a great deal of preliminary study and planning.

It must be designed to meet all the needs of the people it is to serve. It must be a size, which the people can afford to build and operate. It must be well staffed with a sufficient number of physicians, nurses and other

trained personnel to give adequate and efficient service.A progressive hospital will build its services on certain knowledge of the

community it is to serve. and upon many groups, professional and non-professional;

Essentials for good Hospital planningHigh Quality Patient Care

Patient care of a high quality should be achieved by the hospital through:

Provision of appropriate technical equipment and facilities and competent professional and technical staff to support the hospital’s patient care objectives.

An organizational structure that assigns responsibility and requires accountability for the various functions within the institution.

A continuous review of Adequacy of care provided by physicians, nursing staff, and paramedical technicians and the adequacy with which patient care is supported by other hospital activities.

Effective Community Orientation

A governing board made up primarily of persons who have demonstratedconcern for the community and leadership quality.

Policies that assure availability of services as needed to all the people in the hospital service area.

Participation of the hospital in community programs to provide preventive, emergency, and casualty care.

A public information system that keeps the community informed about and identified with the hospital’s goals, objectives, and plans.

Financial Viability

A corporate organization that accepts responsibility for sound financial management with a view on optimum quality of care.

Patient care care objectives that are consistent with projected service demands, availability of operating finances and adequate personnel and equipment.

A planned programme of expansion based solely in demonstrated community need. A specific, planned program for capital financing that will assure appropriate

replacement, improvement, and expansion of facilities without putting burden on patient charges.

An annual budget plan to keep pace with modern medical and hospital Practices.

Orderly Planning

Acceptance by the hospital’s administrator of primary responsibility for both short and long-range planning, with support and assistance from competent financial, organizational, functional, and architectural advice.

Identification of the hospital’s service area and other healthcare resources. Analysis of the hospital’s medical staff and number of patients admitted in the last three years as the basis

for projecting admission trends of major clinical service. Examination of use of major clinical service departments, and such supportive service departments for

making a future projection for each of these departments. Establishment of short and long-range planning objectives with a table of priorities and target dates on

which such objectives may be achieved. Preparation of a financial program that describes the short range objectives to be achieved and the facilities,

equipment and staffing necessary to achieve them.

A Sound Architectural Plan

Retention of an architect experienced in hospital design and construction Selection of a site large enough to provide for parking and future expansion and

accessibility to people. Determination of facility size appropriate to the projected service demands of the

hospital’s service area and of departmental areas large enough to provide the diagnostic and treatment services.

Importance of establishing convenient traffic patterns both in and out of the hospital for movements of physicians, hospital staff, patients, and visitors and for efficient transportation of food, laundry, drugs and other supplies.

An architectural design that will permit efficient use of hospital personnel, interchange ability and flexibility in work areas.

Adequate attention to important hospital concepts such as infection control and disaster planning.

Regionalization of Hospital ServiceDecentralization by establishing levels of care.Three tier basis

Regional hospital – hosp of entire geographical region, complete range of service- radiotherapy, neurosurgery, thoracic surgery, oncosurgery etc, associated with a medical college/post graduate teaching centre.

Intermediate or District Hospital –several hundred beds, general hospital providing medical, surgical obstetrical and specialized treatment.

Local or Rural Hospital – 30 -100 beds, undifferentiated care- general, medical, surgical and maternity care

Two way flow of referral system & sharing of senior medical staff by consultant sessions and regular visits.

Quality of care & cost.

Levels of medical CareLevels of care Medical facility Levels of decision maker

Primary Dispensary, Primary Health Centre or subcentre

GP, medical assistant, multipurpose worker

Secondary District Hospital( intermediate) or equivalent

GP, partly specialist

Tertiary Provincial or similar hospital( regional)

Specialists

Quaternary Institute of Research and higher training

Super specialists, researcher

Hosp Planning Team1. 2. 3.

Hosp Planning TeamDefining requirements- people involved in direct utilization &

delivery of care- experts in resp clinical fieldsHosp administrator/Medical administratorNursing administratorArchitect & Engineers with exp in hospitalsHosp consultantFinancial expert

Hosp Project StagingStage A: Functional Content, Outline Brief

InceptionProject TeamFeasibility StudiesOutline ProposalSubmissions to Govt/Private Organizations for approvalSite appraisals, Gross floor areas, building space, draft master plan , estimate cost and phasing .Appraisal of work by the owners.

Stage II: Operational Policies & Development Plan

Operational PoliciesDepartment & Interrelated ActivitiesBudget Cost

Stage III: Schedules of accommodation, sketches, final cost estimate

Schedules of accommodationSketch DrawingsEquipment estimatesCost revenue and staffing estimatesFinal cost approval

Stage DDesign detail working drawings, tender action

Working drawingsEngineering detailCalling tenders

Stage EContract & Construction

Assessment of tendersAward of contractConstructionEngineering Commissioning

Stage FCommissioning

Staff assembly and TrainingEquipment & supplies assemblyTesting of installationsOpening

Relationship between Demand and Need

Factors influencing Hospital UtilizationHosp Bed Availability- dev vs develop countriesPopulation coverage and bed distribution Age Profile of populationAvailability of medical services other than hospitalsCustoms & Attitudes of community & doctor- fear admission,

early ambulation.Method of payment for hospital servicesAvailability of qualified medical manpowerHousing & Family Structure : Nuclear vs joint family

Morbidity Patterns: Acute vs ChronicHospital Bottlenecks: Poor admission & Discharge process,

poor lab & radio services. Internal Organization: Tight compartmentalization of beds. Public attitudes: Social & religious attitudes, local customs,

belief.

The Hospital Site- Selection of SiteAccessibility to transportation and communication lines: The accessibility

of the site for ambulant as well as non ambulantpatients, visitors, staff members and personnel, and for the delivery of supplies

should be considered. The location must be within the reach of the community and located in an uncongested area.

Parking Areas. A car parking space per two beds is desirable in metros, lesser in urban areas and less in semi urban areas. Taking into account that for each inpatient there will be at least one visitor per day, for each inpatient admission there will be 3 outpatients. Additional parking space for three wheelers, scooters and motor cycles. Employees and staff parking areas are preferably separated from public parking.

Public Utilities. The hospitals should be situated near adequate sewerage, water, electrical, telephone facilities.

Nuisances. The site chosen for the hospital should be free from undue noise

such as emanating from railway tracks, main traffic areas, schools etc.

Distances : Routes which the patients must take on stretchers, wheelchairs or on foot from their wards to radiology department/lab/physiotherapy dept should be carefully thought to minimise the length of the routes.

Topography. Ideally the building is best located on relatively high ground in order to

take advantage of natural drainage.

Landscaping. The psychological effect of attractive grounds and surroundings on patient welfare, public good will and staff morale cannot be underestimated.

Future ExpansionTotal Cost : emphasis on total cost rather only initial cost of the building.

Site Survey. After selection, provision should be made for a survey and soil investigation. This will help determine the type of foundation, possibility of constructing a basement, and effectiveness of sewage plant.

Map of the plan to be certified by appropriate authorities like City Corporation, Municipality or Panchayat – not disputed land or legal restrictions.

Land Requirements. In rural and semi-urban areas, large areas of land may be available permitting the hospital to grow horizontally. In urban areas, the land area will be available at higher costs and the hospital need to be built on the available land and hence the urban hospitals usually grow vertically in multi-storeyed buildings. The other important points to be kept in mind while determining the land requirements are the local municipal byelaws which change from place to place

Floor Area Ratio ( FAR) It is the ratio of covered area on all its floor of a building to

the total area of its site. Example. FAR of 2:1 is highest esp in cities, high density of buildingsPreferable range 0.5: 1 to 1.5: 1

Hospital Size PlanningBig Vs SmallPros & Cons

There are three kinds of hospital beds:1. “Adult” beds-those of standard length and shape for the

use of adults and older children.2. Cribs-those equipped with sides or guards for the use of

young children and3. Bassinets-for the regular use of infants other than

newborn infants.

Cribs Bassinets

Bed Distribution A hospital bed is one installed for regular 24-hour use by

inpatients during their period of hospitalization.

Total no. of beds : size of the hospitalBed Capacity: max no. of beds that can be established in

the hospital at any given time. Bed Complement: No. of beds normally set up and

available for inpatient use.

Bed Capacity of the hospital: following are included: 1.Observation Beds equipped and staffed for overnight stay2.Pediatric bassinets & incubators in pediatric dept

Beds which are not included are : 1.Bassinets and incubators in maternity suite. 2.Labour room beds3.Outpatient and Casualty /emergency dept4.Beds in diagnostic depts like X ray or in Blood bank5.Recovery room6.Nursing hostel or staff residence. 7.Any other which are not equipped and staffed for overnight stay

Types of Bed AccommodationPrivateSemiprivateGeneral Wards

Grouped together : Departmentalization of services for better utilization of common equipment and facilities.

Bed Distribution by serviceThe distribution of patients in a general hospital is expected in the range from: medical- 30 to 40 per cent, surgical – 20 % ; obstetrical 15-18 per cent; paediatric 10-12 per cent; miscellaneous and others (including eye, ear, nose, and throat) 10-15 per cent.

Factors influence Bed Distribution: 1.New Hospital- phasing by floor by floor , wing by wing2.Fluctuating census- allow interchangeability3.Evaluation of needs, services, hospital policies, staffing

Space Requirements and RelationshipsA master plan takes into consideration the future developments of the hospital, however, a major mistake in forward planning is to attempt to meet

pressure for beds, which is usually dominant, by adding them without giving equal consideration to supporting facilities. The master plan should take into

Account the circulation routes, areas to be allotted to different departments, zones, compactness, and also considering light, wind, hospital engineering, and hospital hygiene aspects.

Min accepted space by 1 bed : 100 sq ft. Total hosp area reqd : 8 to 10 times of min accepted space.

“ Separate all departments yet keep them all close together; separate types of traffic, yet save steps for everybody; that is all there is to hospital planning” .

By Emerson Goble.

4 Following basic rules1. Protection of the patient is the primary rule. – Too much

traffic

2. Plan for shortest traffic route : time is essence in hosp.

3. Separation of dissimilar activities : separation of clean from dirty operations, quite and noisy activities, different types of patients ( seriously ill and ambulatory)

4. Control: placement of nursing station

Distribution of Floor SpaceWards : 37 – 45 % OPD : 12- 18 % Diagnostic : 18 – 22 % Administrative : 8-12 % Service Department : 15 – 20 %

Circulation Routes The utility and success of hospital plans depends on the circulation routes on

hospital site and within buildings.- “ Way finding “ is a major problem. Develop flowcharts depicting movements of patients, personnel and visitors for

predicted movements between departments and within departments.

Internal Circulation: Traffic of patients, staff, employees and visitors, as well as service deliveries, the

emergency entrance. Movt of supplies and materials and removal of garbage should interfere with

movt of people. Corridors, stairways and liftsRamps, steps, stairs: essential handrails and non skid hard level surfaces for

steps and stairs.Avoid undue criss crossing of patients, staff, supplies and visitors.

Separate patient corridors and staff corridors to reduce transit time.

Visitors route should be controlled by visitors pass- colour coded

Outpatients routed from registration to sub waiting areas to lab and radiology dept. They should not routed through inpatient.

Staff should pass from entrance to locker rooms to place of punching time/swipe cards

External circulation4 separate entrancesSeparate Entrance adjacent to kitchen and storage areas

receiving bulk supplies. Main entrance and lobby should be attractive.May create administrative problem, particularly theft

through unsupervised passages.

4 entrances in a hospitalMain Hospital entranceOutpatient entranceEmergency and ambulance entranceService entrance.

Interrelationships of Departments Each major department, clinical area supportive services and administrative

services have to be distributed over the site in appropriate zones to group them in a manner that they are related to each other in context and proximity.

The departments which come in close contact with the public should be isolated from the main inpatient areas and allotted areas closer to the main entrance to the site. Such departments are outpatient and accident and emergency or casualty department. The supportive service department, e.g. the x-ray and laboratory services are extensively used by outpatients and need to be located as near as possible, at the same time integrated with the main inpatient wards.

Beyond this, from the main entrance should be the main inpatient zone, consisting of ICU, wards, operation theaters and delivery suite. This zone is as far away, from the main traffic that takes place in areas close to the main entrance to hospital site.

Central services, especially service departments are better located on the ground floor-they include laundry, CSSD hospital stores, pharmacy, kitchen and cafeteria. These departments should be preferably grouped around a service core area, the entrance of this being independent of the main hospital entrance.

Floors should be constructed of materials by their future use and maintenance. Hard floor, marble vs mosaic.

Corridors of size 8 feet by 8 feet. Walls to be smooth and not attract dust and dirt. Staircase – at least 2 in different areas of hosp- fire exits, broad

enough for handling stretchers in emergency. Elevators- max concentration of traffic. Separate pt and separate

service elevators

Gas Manifold SystemMedical Gases used in a Hospital: Medical Air /Compressed Air: used to operate surgical instruments like

pneumatic drills, saws in operating area etc. CO 2: for laparoscopy, endoscopy, arthroscopy etc. Vacuum for suctionN O – for ventilators in NICU for babies.

When large continuous supply of various gases is needed, two or more cylinders of the gas are connected to each other and their common outlet is connected to a central piping system through a control panel: Manifold

Pumps + compressors + pressure regulators + cylinder manifold + maze of pipes: manifold system

Location should be on ground floor – away from kitchen/open flames, location storing combustible materials, power transformers, areas of critical patient care.

Handling of compressed air and gases – covered under Explosives Act. Sanctions from Dept of Explosives, GOI essential.

Internationally accepted Gas manifold color coded system: Oxygen- YellowNO: Dark BlueCompressed Air – Sky BlueVacuum : Sky Blue.

Residential campusNursing Hostels

Orientation of BuildingsNatural cooling and ventilation by orientation and design. Very large glass- overheating

Air conditioning and air ventilation – “Air Hygiene is imp. Basic principle that contaminated air from one part of the

hospital is not transmitted to another. Energy conversation & solar energy- Green HospitalsBifurcation of areas - Duration of air-conditioning

Building contract and Contract DocumentsBids for construction. Legally scrutinized before advertising and opened in person by the owner.Contract is normally given to the lowest bidder unless strong

justifiable reasons.

Furnishing & Equipping the Hospital3 types of equipment :

1. Built in Equipment : fixed kitchen equipment, elevators, boilers, walk in coolers, deep freezers, surgical lighting etc.

2. Depreciable equipment : Equipment have a life of 5 years or more is not purchased through construction contracts. eg: diagnostic and lab equipment, Pharmacy equipment.

3. Non Depreciable Equipment: less than 5 years span: eg; surgical instruments, linen, kitchen ware, table ware, chinaware, lamps, waste baskets etc.

Actual user involved in laying specifications- Multidisciplinary team.

Protection against weather , theft and damage, should not interfere with construction work.

Role of Engineering ( Biomedical equipment)

Ready to operate StageWritten documents like policies, manual, procedures, rules

and regulations for smooth start.

Before Opening the HospitalTaking Over and afterGo on Stream in a Phased Manner

Skeletal Staff at outset Phasing over a pre determined period of time Synchronize with increasing patient census, occupancy and workload. Time of appointment of staff is crucial. Each staff selection meticulously done. Proper orientation to staff. Training to staff. CEO to work closely with Dept Heads on details and functioning of the hospital. Detailed plan of action. Shake Down Period- Trial Run and appropriate evaluation and corrective measures.

Phasing The necessity to bring facilities into use as quickly as possible

for operational reasons.The necessity to split a major project into smaller units of

building work as a contractual consideration. The necessity of having certain departments ready before

othersLocal priorities for introducing services. Limitation on availability of capital funds.

Commissioning and InaugurationNeed not synchronize. Inauguration to include

Press tour & Press conference Elaborate Programme Elaborate tour to public by expert guides Attractive Brochure Security for VVIP Pooja Ceremony.

Major Challenges• Large scale disasters as Tsunami and Floods like in

Uttarakhand have drawn attention to the need for Prudent hospital planning that must include internal mechanisms for increasing capacity and maintaining capability

• Within a hospital environment there are multiple departments with staff that are capable and competent to provide cross coverage to other areas of the hospital where their expertise may be utilized during a large scale surge incident

• External assistance is unlikely to be available to hospitals in such national catastrophes

Hospitals globally have been tasked by federal funding mandates and accreditation (The Joint Commission to the numbers of patients) to increase their in-house bed surge capacity, identify and establish plans for additional “alternate care” sites and facilities

Floor area ratio (FAR) (also floor space ratio (FSR), floor space index (FSI), site ratio and plot ratio) is the ratio of a building's total floor area (gross floor area) to the size of the piece of land upon which it is built. The terms can also refer to limits imposed on such a ratio.

As a formula:Floor area ratio = (total covered area on all floors of all buildings

on a certain plot, gross floor area) / (area of the plot) Thus, an FSI of 2.0 indicates that the total floor area of a building is two times the gross area of the plot on which it is constructed, as would be found in a multiple-story building.

  

F.A.R= Total floor area on the floors/Plot area

Govt of kerala

Sept 2013: In a bid to boost healthcare sector in the national capital, the Delhi Development Authority decided to enhance floor area ratio of hospitals from 2.00 to 3.75. 

FAR 2.50 is now allowed for plots located on roads less than 24 mt width, FAR 3.00 for plots located on roads having width between 24 mt and 30 mt and FAR 3.75 for plots on 30 mt and above width roads, officials said. 

To meet out parking requirements, additional space would be available in the form of podium parking, they said. 

DDA has now also permitted activities like staff changing room, staff dining facility, kitchen, laundry, radiology labs in the basement without counting into the FAR

HUDA

Area of Plot Maximum permissible Maximum permissible F.A.R coverage on ground floor

upto 10,000Sq. mtrs. 33% of the area of the plot

150%Above 10,000 Sq. mtrs. 25% of such additional plot

150%