Session

2
PLANNING ENVIRONMENT
OF CARE MANAGEMENT
INTRODUCTION
The picture regarding medical care services in developing countries
can be described as chaotic. Why?
- Hospital beds are inadequate,
- Hospitals are located far away from the communities when need
them.
- Mostly crowded in towns and cities and heavily biased in favor of
urban population.
- Specialist services are concentrated in urban centers, and there is
duplication of services in many others.
There are many reasons for current state of affairs.
- An absence of a realistic national health policy,
- Haphazard medical care planning
- Inadequate / unavailability of funds for the health sector are
amongst the main reasons.

Experience of many countries having advanced medical care systems

has shown that hospitals are very expensive to build.
DECISION MAKING FOR HOSPITAL PLANNING
Decision making-the selection from among alternatives of a
course of action-is seen as the central job of
administrators.
Effective decision making results in rational selection of a
course of action.
Decision making is often thought of as problem solving, the
problem may be a state of confusion, uncertainty or
chaos.
For effective decision making, the administrator must have:
 A clear understanding of the alternative courses
of action under existing circumstances and
limitations.
 Must have the information to recognize available
alternative,
 Be able to analyze and evaluate such alternatives
(also realizing that not all alternative can be
analyzed) to make rational decision.
In choosing from among alternatives, the more an
administrator recognizes factors which are limiting or
EMERGING ISSUES, CHALLENGES &
TRENDS
Emerging Issues are mainly due to the changing role of
hospitals. The main changes that have occurred in
healthcare delivery system are as follows:
1. Enhanced expectation of patients
- Patients have become quality conscious & price sensitive
- They expect clinical, administrative & supportive services
as well as design of facility to be conducive to their
requirement.
2. Epidemiological & demographic changes
- Cascading incidence of lifestyle diseases & geriatric
related healthcare problems
3. Emphasis on Ambulatory & Day Care Services:
- Shorter stay in hospital.patients want to get treatment
without staying overnight in hospitals.ambulatory service
means outpatient basis treatmemtss, small
surgery,consultations and leave the same day.
Enhanced Standards
Changing functions of hospitals
The focus in healthcare is gradually shifting
from treating illness to creating wellness.
Apart from curing the sick, they have the
added functions of maintenance &
prevention of health, biomedical research
and providing community outreach services.
Health Insurance
plays a crucial role in making healthcare accessible and
affordable. For both insurance providers and healthcare
recipients, hospitals serve as central hubs where insured
patients receive essential medical services. Hospitals
provide a range of services covered under various
insurance plans, from emergency care and surgeries to
routine treatments and specialized therapies
Outsourcing:
Advancement in Medical Sciences:
Advancements in medical sciences
dictate/change the paradigm of HC
delivery.
The advent of futuristic dimensions in
molecular biology, pharmaceutical &
surgical interventions have changed
management modalities of diseases.
New diagnostic and therapeutic
modalities require special controlled
environment, energy requirements &
other engineering services.
STRATEGIC ESSENTIALS
• Hospitals are a combination of technologies,
processes & human resources.
• Medical Architecture MUST facilitate the
adoption of new technologies besides
contributing to the efficiency and transparency
of processes.
• It MUST provide a seamless integration of
clinical requirements with building planning and
designing issues.
• Strategies MUST be formulated to cope with
varying health needs, cultures, climates &
budgets.
• Design responses MUST also embrace all parts
& aspects of the hospital.
STRATEGIC AND OPERATIONAL
PLANNING
Strategic Planning:
It is concerned with developing the main mission of the institution,
developing broad objectives, followed by determining the services
required, and determining the means of fulfilling the same.

Operational Planning:
Operational planning is at the lower level of the organization and
generally focuses on program formulation and implementation. It
is concerned with the implementation of strategic plan in all its
components at the operational level.
CRITERIA FOR EFFECTIVE PLANNING
Planning should be:
• Based on a thorough study of the end result desired.
• Involve participation of the medical staff and other concerned
service representatives.
• Comprehensive

Plans should be:

• Flexible
• Continually updated
• Realistic
• Time-phased.
STEP-BY-STEP APPROACH TO
PLANNING A HOSPITAL FACILITY
Planning involves the following steps:
1. Analysis of the situation
2. Identifying the priority problems
3. Formulating objectives
4. Setting goals
5. Reviewing limitations/constraints
6. Laying down operational policy and
systems
7. Writing down plans
GUIDING PRINCIPLES IN PLANNING A
HOSPITALS
The purpose of planning is to assure the most efficient utilization
of resources and economy of performance.
Given the scarcity of resources, the hospital managers require to
establish short and long range plans in order to avoid
haphazard utilization of resources.
Hospital planning should be guided by universally acknowledged
principles.
The following principles were developed in the
context of the American system of hospitals:
 Patient care of a high quality
 Effective Community Orientation
 Economic Viability
 Orderly Planning
 Sound Architectural Plan
1. PATIENT CARE OF A HIGH QUALITY

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

through adopting following measures:

 Provision of appropriate technical equipment and facilities

necessary to support the hospital's objectives.
 An organizational structure that assigns responsibility
appropriately and requires accountability for the various functions
within the institution.
 A continuous review of the adequacy of the care provided by
physicians, nursing staff and paramedical personnel and of the
adequacy with which it is supported by other hospital activities.
2. EFFECTIVE COMMUNITY ORIENTATION

Effective community orientation should be

achieved by the hospital through adopting
following measures:
 A governing board made of persons who
have demonstrated concern for the
community and leadership ability.
 Policies that assure availability of services
to all the people in the hospital’s service
area.
 Participation of the hospital in the
community programs to provide preventive
care.
 A public information program that keeps the
community identified with the hospital’s
goals, objectives and plans.
3. ECONOMIC VIABILITY
Economic viability should be achieved by the hospital through taking
these measures:
 A corporate organization that accepts responsibility for sound
financial management in keeping with desirable quality of care.

 Patient care objectives that are consistent with projected service

demands, availability of operating finances and adequate
personnel and equipment.

 A planned program of expansion based solely on demonstrated

community need.

 A specific program of funding that will assure replacement,

improvement and expansion of facilities and equipment without
imposing too much cost burden on patient charges.

 An annual budget plan that will permit the hospital to keep pace
with times.
4. ORDERLY PLANNING
Orderly planning should be achieved by the hospital through the
following:
 Acceptance by the hospital administrator of primary
responsibility for short and long-range planning, with support
and assistance from competent financial, organizational,
functional and architectural advisors.

 Establishment of short and long-range planning objectives with

a list of priorities and target dates on which such objectives
may be achieved.

 Preparation of a functional program that describes the short-

range objectives and the facilities, equipment and staffing,
necessary to achieve them.
 5. SOUND ARCHITECTURAL PLAN
A sound architectural plan should be achieved by the hospital
through the following:

 Engaging in architect experienced in hospital design and

construction.

 Selection of a site large enough to provide for future expansion

and accessibility of population.

 Recognition of the need of uncluttered traffic patterns within and

without the hospital for movement of hospital staff, patients and
visitors and for efficient transportation of supplies.

 An architectural design that will permit efficient use of personnel,

interchangeability of rooms and provide for flexibility.

 Adequate attention to important concepts such as infection

control and disaster planning.
 PRINCIPLES OF HOSPITAL
PLANNING
Protection from unwanted and
unnecessary disturbances in
order to help speedy
recovery.
Separation of dissimilar
activities.
Control- the nurses station
should be positioned
strategically to enable
monitoring of visitors
entering & leaving the ward,
infants and children should
be protected from theft and
infection etc.
Circulation: All departments of
hospital
(“Separate must be properly
all departments, yet keep them all together, separate
typesintegrated.
of traffic, yet save steps for everybody, that is all there is to
hospital planning”)
Emerson Globe
 THE ISSUES TO BE ADDRESSED
Designing space for improved patient outcomes:
• Architecture and equipment that emphasize safe design and materials
• Deliberate attention to a visually welcoming atmosphere
• Investment in preventive maintenance
Carefully planning the best use of existing space:
• Space allocation assigned to one central office
• Formal, open process for review of requests for expansion
• Periodic review of space use to determine continuing need
Maintaining excellent security, sanitation, maintenance, and materials
management services:
• Measurement of benchmarks and goals for service and internal
customer satisfaction
• Standards for availability; cost; and quality of plant, plant services, and
supplies
• Maintenance of supplier relationships
• Training, support, and rewards for service employees and supervisors
CONT’D
Using contract services to improve performance:
• Specification of service requirements in cost, quality,
and satisfaction dimensions
• Benchmarking and comparison of service
• Contracting with outside suppliers to ensure near-
benchmark performance
Developing evacuation and emergency plans
capable of handling natural disasters, large
scale accidents, and the possibility of
terrorism:
• Internal plans for response
• Drills and testing
• Coordination with other community agencies
 STRATEGIC ISSUES TO BE
CONSIDERED
Design for Flexibility & Expandability:
 The golden architectural principle of
indeterminacy should be followed which
enables a “ Building to grow with order and
change with calm”.
 Due to the complexity of hospital
organization & diversity in various factors
such as operations, functions and
development, alteration & expansion of
buildings are varied & frequent.
 The hospital building should thus be
adaptable to changing requirements.
CONT’D

Fulfill the Demand Functions

Because of shift of illness to wellness, treatment to
prevention & in-patient to day care; the hospital
facility must also be planned for the following:
1. Day Care facilities
2. Home care facilities
3. Hospice facilities
4. Trans-mural care: Patient tailored care provided
on the basis of a close collaboration & joint
responsibilities between the hospitals & home
care centers.
5. Assisted living: The setting should be designed in
a way that maximizes the quality of life,
independence, autonomy, safety, dignity, choice &
privacy of residents
6. Healthcare hotels: Places meant for convalescence
CONT’D
Emphasis on Patient Focused Hospitals
 Objective should be to create a patient focused,
patient centered architecture by offering an
atmosphere od safety, security cleanliness & Physical
comfort.
 The patient’s family & friends should be made to feel
welcome.
Focus on Energy Conservation
 Use of high efficiency light sources
 Utilization of natural light
 Effective ventilation
 Easy maintainability
 Energy recycling
 Regular energy audit which will help in energy
conservation.
CONT’D
Create a Healing Architecture
 It should do No Harm.
 It should facilitate the healing process.
Aesthetic- An Essential Requisite
 This should be planned for the following
dimensions:
 Psychological Aesthetics: which includes
happiness, joy and pleasure.
 Spiritual Aesthetics: which suggests hope,
contentment and peace.
 Physical aesthetics: implies well-being, ease
& convenience.
 Intellectual aesthetics: inspires interest and
contemplative delight.
Hospital Architecture: Amalgam of Art &
Science
 Medical architecture fulfills a criteria for a science
organization.
 It is also a creative, innovative practice & is an art,
since it can bring about a desired result through
application of skills.
Go Green
 The emphasis on healthcare architecture must be on
improving the quality of the environment for patients
& healthcare providers.
Some of the parameters to be considered:
 Utilization of renewable sources of energy such as
solar, wind & bio-gas
 Scientific waste disposal
 Materials utilized in hospitals building should be non-
toxic & non-allergic.
 Effective use of natural light
CONT’D

Design for Infection Control in Hospitals

 The design should support concept of zoning &
ventilation in healthcare areas.
 Air changes including fresh air allowance should
be ensured as per recommended norms.
 Critical areas such as OT, ICU should be separated
from general traffic.
 Isolation rooms should be planned to prevent
spread of infection.
 Adequate hand washing stations in wards & out-
patient departments.
 Air curtains should be installed at entry of
patient care areas such as ICU, Acute Care wards,
OT sterile area & delivery suites.
CONT
Plan for Holistic & Comprehensive
Healthcare
 Plan for both Macro & Micro level.
 For continuum of healthcare from “Cradle to
Grave”
 For all levels of healthcare: Primary, secondary &
tertiary.
 Design & planning should focus all types of
patients; sick, early sick, very sick & the worried.
 The HC facility should be a place for treatment,
comfort & safety for patients.
 The requirements for staff, visitors & families of
patients should also receive due consideration.
CONT
Environment
- Heating
- Ventilation
- Air-conditioning
Hospital Administration Area
- Offices
- Medical Record
Hospital Information System Department
Hospital Stores
Central Supply Department
Material Management (Procurement, Hospital
supplies
 BED PLANNING IN A HOSPITAL
The bed: population ratio never reaches to a
satisfactory level any where.
Even in cities where it has achieved such figures, more
beds are required because of increasing urbanization
and high density of population.
Hospital facilities in an area are not only utilized by the
population in the vicinity of the hospital-that is-the
direct population, but also by people who will
constitute the indirect population in the larger
catchment area.
When these population factors are worked out, the
calculation for total bed requirements can proceed
as per guidelines of WHO.
About 85% of the bed occupancy in a hospital
is considered optimum.
SELECTION OF SITE
Need for community
- Ease of Accessibility
- Range of services
offered
- Availability of
specialist
- Availability of
technology
 Study of existing
hospital (If any)
 Requirements of
staff & services
PLANNING OF FINANCE
Funds required for
constructing,
furnishing and
equipping the
hospital.
Operating Funds:
Salaries, loans &
interest, Other
maintenance expenses
Arranging financial
assistance, patient
fees, bed charges, and
other modes of
revenue generating
process.
 EQUIPMENT PLANNING
Built-in Equipment This includes counters &
Cabinets in Laboratory,
Pharmacy and other parts of
the hospital, Elevators,
incinerators, coolers, fixed
sterilizing equipment etc.
These are usually included in
construction contract &
planning of these equipment is
the Architect’s responsibility.
Depreciable Equipment Equipment that has a life of five
years or more and have relatively
fixed location e.g. Diagnostic &
therapeutic equipment, laboratory
instruments and office furniture
etc.
Non-Depreciable Equipment Equipment with low unit cost & life
span of less than 5 years. They are
usually under the control of store
room. They include kitchen
utensils, waste baskets etc.
 OPERATION
Admission PROGRAMS
Human Resource

Administration Stores

General Engineering Purchasing

Laundry Maintenance

Clinical Services Waste disposal Plants

Pharmacy Fire & Safety

Nursing Services Disaster Plan

House Keeping Information System

Records Dietary Services

Public Relations Clinical Engineering

Employee Facilities Sanitation

HOSPITAL DEPARTMENTS
Patient Service Departments

- Accidents & Emergency Department

- Outpatient Department (OPD)
- Specialists’ Clinics
- Day Care Services
- In-Patient Department (IPD)
- Operating Unit (Operation Theaters)
- Intensive Care Unit
- Diagnostic Service Departments (Laboratory & Medical Imaging
Services)
- Pharmacy

Hospital House keeping Services

- Catering Units
- Laundry
- Waste management
PLANNING OF DEPARTMENTS
In Patient Department:
Private Room: There may be a private or
semi-private room or multi-bed general
wards. They should be designed to be
safe and aesthetically pleasing so as to
assist in quick recovery of patient. They
must contain space for equipment, staffs
and various need of the patient.
Nurses Control Station: should be located
and designed in such a way that the
nurses can observe the patient room.
The Work Area: related to handling
materials necessary for patient care,
maintaining communication and records
etc.
FACILITIES & SPACE REQUIRED

• Examination and treatment room with wash

basin etc.
• Cupboard for clean linen.
• Basket for soiled linen with sink, waste
receptacles.
• Equipment storage room for walkers, IV stands
etc.
• Space for storage stretchers and wheel chairs
• Lockers for staff personal belongings.
• Staff toilet
• Small Laboratory
OUT-PATIENT DEPARTMENT
Preferably on the ground level with a
separate entrance and adequate parking
facilities.
It should be close to admitting area, MRD,
Emergency, radiology/ Laboratory &
Pharmacy.
Attention should be paid to circulation,
which results in the smooth flow of
various traffic lines traversing the
Department.
Properly signed.
 EMERGENCY DEPARTMENT

Should be located on the ground

floor with easy access for
patients and ambulances
Separate entrance for the
department
Well marked with proper lighting
and signs should be easily visible
and accessible from the street.
Should be close to the admitting
department, medical records and
cashier’s booth, radiology
department, lab services, blood
bank, elevators and wards.
 INTENSIVE CARE UNIT
Should preferably be located on the ground floor
with convenient access from the operation
theater suit & emergency department and easily
accessibility for wards.
It consists patient area, staff area, support area.
Four Basic Requirements:
 Direct observation of the patient by nursing and
medical staff.
 Surveillance of physiological monitoring
 Provision and efficient use of routine and
emergency diagnostic procedures and
interventions.
 Recording and maintenance of patient
information
OBSTETRICAL UNITS
The obstetrical unit should ideally be located
close to the labor and delivery room as also to
the nursery to avoid the exposing the bodies
to infection.
A room for patient education and group
discussions is essential with cheerful
decoration is desirable.

NEWBORN UNIT
 An area of 30sq.ft/ infant with a space of at
least three feet around is recommended.
 All partition should be made of clear glass to
permit observation.
 Furnishing in the full term nursery include a
bed side cabinet, incubator, utility table, wash
basin, waste receptacles, outlets for oxygen
and suction, facilities for examination etc.
 PEDIATRIC UNIT
Equal space should be provided for beds
If patients are allowed to stay with parents,
provision must be made for toilets, sleeping
and storage of personal belongings.
Separate provision for examination and treatment
of infants.
Each pediatric units have isolation room with other
necessities like washing facilities and sterile
gowns & masks.
Single room for critically ill and uncontrollable
patients.
Recreation or pray room
Storage space for toys, linen, recreational
materials.
Walls between patient room and the corridor
should have glass panels for viewing.
Lighting decoration and equipment must create a
cheerful atmosphere.
 PSYCHIATRIC UNIT
Consultation area containing staff offices for
individual and family care sessions.
Conference therapy area for group therapy
session
In-patient area for hospitalizing patients
Activities area for occupational recreational
therapy.
The number of beds should be between 20-24 in
order to permit proper observation and
treatment and private rooms are preferred.
One room for the management of violent
patients are desirable.
There should be no object which can be used to
hurt one self.
 RADIOLOGY AND
LABORATORY SERVICES
Should be easily accessible to OPD, casualty and
in-patient wards
Preferably be sited on the ground floor.
Adequate reception and registration area
Convenient patient flow with minimization of criss
cross traffic.
Adequate waiting area
Separate entrance for accidents and emergency
cases in busy hospital.
Provision of room for technical functioning.
Flexibility, expandability and upgradability need
to be kept in mind while siting the department.
 PHARMACY
Out-patient should have ready access to the hospital
pharmacy to collect prescription.
Staff of wards and departments can access it without having
to travel a long distance through other crowded areas.
Collection of indents and dispensing area which is accessible
to hospital staff when they come to consult the
pharmacist or to obtain stocks for ward use.
Supplies have an access to it from outside.
Space required for:
 Dispensing counter
 Cash Counter
 Drugs storage including dressings
 Cool & cold storage
 Administrative office
 Circulation space
 Space for compounding and bulk preparation
Hospital Store • It should be located centrally to the
hospital.
• Approachable by supply vehicles and
should have separate entrance.
• Risk of fire and explosion in a medical
supplies storehouse, storage of acids,
inflammable materials and oxygen &
other gas cylinders will require special
attention.
CSSD ( Central • CSSD mostly serves the operation theatre,
Sterile Supply emergency, casualty department, wards,
Department) maternity suit and should be so cited as to
be central to all this.

Hospital Dietary • Should be located taking into consideration

Services the prevailing wind direction so that smoke
and kitchen odors are not constantly wafted
to the patient care area.
• Should be sited at ground level and
connected to store with lift.
Hospital workshop/ • A large quantum of various types of mechanical
BME Department and electrical equipment is installed in a hospital
and requires repair and preventive maintenance.

Laundry • Used linen from wards, operation theaters and

delivery suites may be infected and therefore
needs careful handling at an area remote from
all other clinical and supportive services areas.
• Space for washing, storing, dying shades and
ironing rooms have to be catered for at an
appropriate area with plentiful supply of water.

MRD • Should be located immediate to the admission

and registration area.
• Enough space for keeping/storing of patient files.
• Adequate safety
 PROJECT COSTING
The most common method of estimating hospital
construction costs has been the “per bed” method, i.e. if
total cost of a 100 bedded hospital has been Rs. 400
lacks, the cost per bed is Rs. 400,000.
Breakup of Project Cost
Acquisition of site
Site survey, investigation
Landscaping
Construction contact-building with fixed equipment
Supervision & inspection
Equipping the hospital-diagnostic and therapeutic equipment
Movable equipment, furniture etc.
Architect’s fee
Consultant’s fee
Site engineer’s fee
 PHASING
• The necessity to bring facilities
into use quickly as possible for
operational reasons
• The necessity to split a major
project into smaller units as a
contractual consideration
• The necessity of having certain
departments ready before
others.
• Limitation on availability of
capital funds
 COMMISSIONING
Formation of Commissioning Teams
 Hospital Consultants
 Hospital Administrator
 Chief of clinical services
 Senior nurses
 Supply officer
 Others
Activities
 Bring the hospital building, plant and
equipment to a state of the operational
readiness
 Development operational system
 Testing of equipment
 Coordinating training of staff
 Ensure good communication
 HOSPITTAL PROJECT STAGING
Stage A • Project team
Functional Content: • Assessment of functional
Outline Brief: content
• Submission of owners (Govt.
Private organization etc.) for
approval
• Site appraisal, gross floor areas
• Building space . Draft master
plan.
• Estimation of cost and phasing
• Appraisal of work by owners
Stage B • Operational policies
Operational Policies: • Departmental & inter-related
Developmental Plan: activities
• Departmental and hospital
policies
• Development control plan
• Budget cost
• Continuous informal discussion
with owners
Stage C • Schedule of accommodation
Schedules of accommodation, • Sketch drawing
Sketches, Final cost estimate: • Equipment schedules component
estimates
• Cost revenue and staffing estimates
• Final cost approval

Stage D • Working drawings

Detail Design working • Engineering details
drawings, tender action: • Bills of quantities
• Calling tenders

Stage E • Assessment of tenders

Contract & Construction • Award of contract
• Construction
• Engineering commissioning

Stage F • Staff assembly and training

Commissioning • Equipment & supplies assembly
• Testing of installation
Thank you!