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Ministry Of Health

Medical Practice and Licensing Sector

Licensing Department

Healthcare Facilities

Regulation

General Hospital

2013 Version 2.0

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Table of Contents

I Scope 3

II Purpose 3

1- General Considerations 4

2- General Conditions 7

3- Out Patient Service 9

4- Accident and Emergency Service 10

5- In Patient Service 15

6- Special Patient Care 18

7- Obstetrics and Gynecology Service 21

8- Renal Dialysis Unit 23

9- Physiotherapy Services 24

10- Operation Theatre 25

11- Radiology Services 28

12- Clinical Laboratory Service 33

13- Pharmacy Service 35

14- Catering Services 37

15- Mortuary Unit 38

16- Central Sterile Supply Department 39

17- Linen Services 39

18- Engineering Services 40

19- Administration Area 41

20- Management standards and responsibilities 41

21- Healthcare Professionals Minimum Requirements 42

22- Facility management 46

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Scope

This regulation applies to every general hospital subject to licensure under the

Ministry Of Health established law.

The Ministry Of Health reserves the right to amend this regulation without prior notice.

The latest version of the regulation shall be published on the Ministry Of Health website.

www.moh.gov.ae

Purpose

The Ministry Of Health is the sole responsible authority for licensing, regulating and

monitoring healthcare facilities in the Northern Emirates. We are aiming to achieve the

highest level of patient safety and quality of care through the development and

enforcement of up to date health regulation.

Enquiries concerning these regulations should be directed to;

Dr Hessa Mubarak

Licensing Department

Medical Practice and Licensing Sector

Ministry Of Health

United Arab Emirates

Tel +971-4-2301420

Fax +971-4-2301851

Email hessa.mubarak@moh.gov.ae

Website www.moh.gov.ae

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1- General Considerations

1.1 The regulation governs the basic requirement for all general hospitals operating in

the Northern Emirates.

1.2 The regulation will be applied to all hospitals; existing, in renovation, and in

construction. It is also applied when a new facility, service or procedure is to be

introduced.

1.3 Regulation, standards and requirements of the other concerned Federal and Local

Authorities of the UAE should be strictly followed in conjunction with present MOH

regulations.

1.4 Establishing a new hospital, renovating of existing one or adding a new facility or

procedure requires the submission of an application to the Licensing Department. The

application procedure is described on the MOH website. www.moh.gov.ae.

1.5 Feasibility studies, needs analysis, potential future expansion and researches results

are desirable but not obligatory.

1.6 The hospital shall be designated by a permanent and distinctive name which must

not be changed without prior notification and subsequent confirmation from MOH. The

name of the hospital shall not tend in any way to mislead the public as to the type or

extent of care provided by the facility.

1.7 A clearly display of signage and directions for different services and departments

must be provided in two languages (Arabic and English). Also a clearly displayed

hazardous signs aimed to restrict access for the safety of patients, visitors and staff must

be provided.

1.8 Special attention should be given to the control of environmental elements, Such as;

quality of air, temperature and humidity, lighting (natural and artificial) and noise and

vibration levels.

1.9 The hospital must insure that all clinical and medical equipment are installed and

operated according to the manufacturer specifications. The institute must maintain

effective Preventive Maintenance as recommended by the manufacturers. A safety log

book in Arabic & English languages should be annexed.

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1.10 Security and safety of patients, visitors and staff should be insured at all time and

stages according to the existent rules and regulations of the concerned Federal and Local

Authorities In conjunction with present MOH regulations.

1.11 The hospital must provide security services for; access control systems, video

surveillance systems, door intercommunication systems, intrusion detection systems.

1.12 The hospital must establish a fire safety plan according to the Federal Civil Defense

Department.

1.13 The hospital shall provide safe storage and disposal of hazardous materials and

biomedical waste.

1.14 Facilities handling ionizing radiation for diagnostic and therapeutic purposes and

potentially bio-hazard material must comply with the Federal Authority Nuclear

Regulation (FANR), the National Radiation Protection Center (NRPC) and the existing

Federal and Local Laws. The facility should also provide safe storage and disposal of

hazardous materials and biomedical waste.

1.15 Special attention should be given to implement a comprehensive and up to date

infection control standards.

1.16 Privacy and confidentiality of patients, visitors and staff should be respected and

granted according to the UAE cultural requirements.

1.17 Commissioning is conducted at the completion of the construction phases, and is a

pre-requisite to practical completion and building occupancy. Commissioning must also

include the training of the staff and ongoing monitoring of system performance during a

defined period. At the end of the commissioning phase a pre-prepared check list should

be completed.

1.18The hospital must maintain health records and reports in a manner to ensure

accuracy and easy retrieval. Health records shall be maintained in the custody of the

health facility and shall be available to a patient or his/her designated representative

through the attending healthcare professional at reasonable times and upon reasonable

notice.

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1.19 The hospital shall ensure that each patient is allocated a specific unique identifier,

and where multiple records for the same patient exist they are cross-referenced.

1.20 Malpractice insurance for all licensed healthcare professionals according to article

25 and 26 of the UAE Federal Law number 10/2008 concerning Medical Liability

should be maintained.

1.21 It is the responsibility of the healthcare institutes to insure their compliance with all

documents submitted to and approved by the Ministry Of Health.

1.22 Although this document was compiled according to the latest international

regulations, completeness and accuracy cannot be guaranteed. Upgraded version of this

document will be introduced as needed and could be found on the MOH website

www.moh.gov.ae .

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2- General Conditions

2.1 Hospital buildings should be free standing structure with acceptable distance from

other adjacent buildings with an open access to main road to facilitate traffic movement.

The hospital building should have its independent Heating, Ventilation and Air

Conditioning (HVAC).

2.2 The main hospital entrance should be located at ground level, protected from all-

weather elements, and easily accessible to the public and physically disabled.

2.3 Parking area should be specious enough to accommodate patients, staff and public

needs.

2.4 The following facilities should be provided;

2.4.1 Suitable roadways to loading/unloading areas.

2.4.2 Emergency/fire access.

2.4.3 Helicopter landing area.

2.4.4 Adequate security system.

2.4.5 Pleasant Landscaping and lighting.

2.4.6 Other requirements for Federal Authorities.

2.5 Department’s size and layout shall depend on the functional program requirements

and organization of services within the hospital. Combination or sharing of hospital’s

functions shall be permitted, provided the layout does not compromise safety standards

or medical and nursing practices.

2.6 The ceiling height shall not be less than 2.40 meters

2.7 Slip-resistant flooring products shall be considered for flooring surfaces whenever

required for safety consideration.

2.8 Wall finishes shall be washable, moisture-resistant and smooth. Wall finish

treatments shall not create ledges or crevices that can harbor dust and dirt. Joints for

floor openings for pipes and ducts shall be tightly sealed.

2.9 Wired glass; or plastic, break-resistant material that creates no dangerous cutting

edges when broken shall be used in certain areas such as glass doors and sidelights.

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2.10 Curtains used throughout the hospital shall be washable/cleanable, fireproof and

maintained clean at all times.

2.11 Adequate power back up of essential services are to be insured for critical areas and

medical equipment.

2.12 All hospitals having patient facilities located on other than the ground floor should

have electrical elevators.

2.12.1 At least two elevators should be available in hospital of 1- 200 beds

capacity.

2.12.2 At least three elevators should be available in hospital of 200 – 360 beds

capacity.

2.12.3 Typically vertical transportation system must provide segregation between

functions, such as patients, visitors and materials handling.

2.12.4 One elevator shall accommodate the largest option available for

equipment or patient circumstances requiring transport, e.g. a patient bed with all

attachments, trolleys and attendant staff that are needed for worst case safe

patient movement.

2.12.5 The elevator transportation system shall be able to operate during a power

failure event.

2.13 Construction work for renovations to existing buildings should comply with the

above conditions and all rules and regulations of Federal Authorities.

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3- Out patient Service

Outpatient Department shall be in a distinct area on the hospital premises.

3.1 Reception area

3.1.1 A reception counter shall be located to provide visual control of the entrance to the

outpatient unit

3.1.2 The reception counter should provide access to patient records.

3.1.3 Male and Female waiting area for patients and escorts shall be separated and

under staff visual control.

3.1.4 Waiting area shall be provided with provision of drinking water and public

telephone.

3.1.5 A separate controlled area for pediatric patients shall be provided if pediatrics

service is provided.

3.1.6 Wheelchairs shall be accommodated within the waiting area.

3.1.7 Separate Male and Female toilet(s) for public use shall be conveniently accessible

from the waiting area.

3.2 Consultation, Examination and Treatment Rooms

3.2.1 The space requirements shall depend on the services provided but at least shall

meet the following;

3.2.1.1 Where consultation and examination room(s) is in the same room such as;

medical, surgical, obstetrical, dental or similar shall have a minimum floor area of 12

square meters and be provided with hand washing station.

3.2.1.2 Consultation room(s) where no examination is performed a minimum

floor area of 9 square meters must be provided with hand washing station.

3.2.2 Treatment rooms for minor procedures, specific treatment or casting shall have;

3.2.2.1 A minimum floor area of 11.15 square meters.

3.2.2.2 Treatment room arrangement shall permit a minimum clearance of 91.45

centimeters at each side and at the foot of the bed.

3.2.2.3 Hand-washing station shall be provided in all treatment rooms.

3.2.2.4 Documentation space or counter for writing.

3.2.2.5 A lockable refrigerator for medication use.

3.2.2.6 Locked storage for controlled drugs (if used).

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4- Accident and Emergency Service

4.1 The function of the Emergency Unit is to receive, stabilize, and arrange for

appropriate management or transfer patients who present with a large variety of urgent

and non-urgent conditions whether self or otherwise referred.

4.2 The extent and type of emergency service to be provided depends on community

needs and the availability of other services in the hospital and adjacent area.

4.3 – The Accident and Emergency Department consist of;

4.3.1 Entrance/Reception area.

4.3.2 Resuscitation area.

4.3.3 Acute Treatment and associated Consultation Rooms area.

4.3.4 Workstations area.

4.3.5 Staff Amenities area.

4.3.6 Administration area.

4.3.7 Additional, specifically designed areas to fulfill special roles, such as;

4.3.7.1 Management of pediatric patients.

4.3.7.2 Management of major trauma patients.

4.3.7.3 Management of psychiatric patients.

4.3.7.4 Extended observation and management of patients.

4.3.7.5 Procedure Rooms.

4.4 The entrance to the Emergency Unit must be at ground-level, well-marked,

illuminated, and covered. It shall provide direct access from public roads for ambulance

and vehicle traffic, with the entrance and driveway clearly marked.

Signposting that is illuminated is desirable to allow visibility at night.

Temporary parking should be provided close to the entrance.

It is recommended that the Emergency Unit should be accessible by two separate

entrances: one for ambulance patients and the other for ambulant patients. Each entrance

area contains a separate foyer that can be sealed by remotely activating the security

doors.

4.5 The Waiting Area should provide sufficient space for waiting patients as well as

relatives and escorts. The area should be open and easily observed from the Triage and

Reception areas. Space should be allowed for wheelchairs, prams and walking aids.

There should be an area where children may play.

Reception / Triage Area may perform observations and provide first aid in relative

privacy.

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From the Waiting Area there must be access to;

- Triage and Reception Areas

- Toilets

- Baby Change Room

4.6 The Reception / Triage and Staff Station shall be located where staff can observe and

control access to treatment areas, pedestrian and ambulance entrances, and public

waiting areas. The interface between the Waiting Areas and the Reception / Triage Areas

should be carefully designed so as to permit communication and reassurance to

distressed patients or visitors, yet provide safety and security for staff.

4.7 Consultation Room/s are to be provided according to Unit size and requirements for

examination and treatment of ambulant patients. Consult Rooms are to comply with

Standard Components. Consultation room space area should not be less than 12 square

meters.

4.8 Acute Treatment Areas are used for the management of patients with acute illnesses.

Treatment room may have additional space and provisions for several patients with

partition curtains for privacy. Multiple-bed treatment rooms should provide at least

of 7.45 square meters per patient partition.

4.9 Each treatment room should contain;

4.9.1 Examination bed/beds.

4.9.2 Examination light.

4.9.3 Work counter.

4.9.4 Hand washing station.

4.9.5 Medical equipment and medication storage.

4.9.6 Counter space for writing.

4.9.7 Each treatment area must be at least 9 square meters.

4.10 The Resuscitation area is used for the resuscitation and treatment of critically ill or

injured patients. Maximum possible visual and auditory privacy for the occupants of the

room and other patients and relatives should be provided.

The Resuscitation area requires;

4.10.1 Space to fit a specialized resuscitation bed.

4.10.2 Space to ensure 360 degree access to all parts of the patient for

uninterrupted procedures.

4.10.3 Circulation space to allow movement of staff and equipment around the

work area.

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4.10.4 Space for equipment, monitors, storage, workbenches, storage cupboards,

hand basins, X-ray viewing facilities and disposal facilities.

4.10.5 Appropriate lighting and equipment to hang IV fluids.

4.10.6 Easy access from the ambulance entrance and separate from patient

circulation areas.

4.10.7 Easy access to the Acute Treatment/Observation area from the Staff

Station.

4.10.8 A full range of physiological monitoring and resuscitation equipment.

4.10.9 Solid partitions between it and other areas (movable partitions between

bed spaces are recommended).

4.11 Acute mental health area for patients suffering from an acute psychological or

psychiatric crisis should have adequate facilities for the reception, assessment,

stabilization and initial treatment of patients presenting with acute mental health

problems.

4.12 Decontamination Area should be available for patients who are contaminated with

toxic substances. In addition to the requirements of an Isolation Room, this room must;

4.12.1 Be directly accessible from the ambulance bay without entering any other

parts of the unit.

4.12.2 Have a flexible water hose, floor drain and contaminated water trap.

4.13 Isolation Room if required should be provided at a suitable location of the unit with

maintained negative pressure.

4.14 General X-ray services determined by the size of the services are recommended.

Ultrasound and other imagining modalities will enhance the Emergency Unit’s

effectiveness.

4.15 Medical Laboratory. The size and type of this service will be determined by the size

of the services provided and whether or not shared facilities are available within the

hospital.

4.16 A Pharmacy / Medication area is required for the storage of medications used

within the emergency unit. Entry should be secure with a self-closing door. The area

should be accessible to all clinical areas and have sufficient space to house a refrigerator,

which is essential for the storage of heat sensitive drugs.

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4.17 Patient toilet; a minimum of one male and one female toilet should be provided. At

least one dedicated toilet for handicapped patients/visitors equipped with safety hand

rails and suitable hand washing sink.

4.18 Storage areas should be allocated for general medical/surgical supplies, medications

and equipment.

4.19 Sufficient electrical outlets to meet medical equipment functional requirements

should be provided.

4.20 Electrical outlets must be clearly labeled and connected to an emergency power

supply.

4.21 There should be in each location a reliable source of oxygen. Oxygen piped from a

central source is strongly recommended.

4.22 Adequate ventilation and air exchange, of at least 6 air changes per hour as per

ASHRAE requirements shall be maintained in Emergency Department.

4.23 Emergency Department should be kept at equal pressure relative to the adjacent

areas.

4.24 The area temperature should be maintained around 24 °C and relative humidity

30% to 50%.

4.25 High-efficiency filters should be installed in the air handling system, with adequate

facilities provided for maintenance, without introducing contamination to the delivery

system or the area served.

4.26 Undercover car parking should be available for appropriate number of well-

equipped ambulance vehicle(s) which will be determined by the case load and the

availability of ambulance access to other parts of the hospital for non-emergency

patients.

4.27 Hand basins for hand-washing should be available within each treatment area and

should be accessible without traversing any other clinical area. They should be available

at a ratio of one for every four beds and at the ratio of one to one for every Procedure /

Resuscitation / Consulting Room. All hand basins in clinical areas should be of surgical

type with hands-free activation.

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4.28 The floor finishes in all patient care areas and corridors should have the following

characteristics;

- Non-slip surface.

- Impermeable to water, body fluids.

- Durable.

- Easy to clean.

4.29 Emergency Units are high volume users of telecommunications and information

technology. Telephones should be available in all offices, at all staff stations, in the

clerical area and in all consultation and other clinical rooms. The use of multi-function,

wireless communication devices should be considered. Additional phone jacks should be

available for the use of facsimile machines and computer modems where required.

All patient spaces and clinical areas, including beds, toilets, bathrooms, treatment areas,

patient day areas and lounges should have access to an emergency call facility so staff

can summon urgent assistance. The emergency call facility should alert to a central

module situated adjacent to the Staff Station, as well as to the Staff and Tutorial rooms.

4.30 The Emergency Unit receives a large number of patients and their visitors, many of

whom may be distressed, intoxicated or involved in violence. The hospital has a duty of

care to provide for the safety and security of employees, patients and visitors. Both

policies and structures should be in place to minimize injury, psychological trauma and

damage or loss of property. The precise details of security features should be designed in

conjunction with a security risk assessment for the specific site.

4.32 The emergency unit will require ready access to the following key functional Areas;

- Medical Imaging Unit

- Operating Unit - rapid access is highly desirable for surgical emergencies.

- Coronary Care Unit

- Pathology / Blood Bank Unit

- Clinical Records Unit

- Inpatient Accommodation Unit

- Pharmacy Unit - proximity is required

- Outpatients

- Mortuary

4.33 The number of licensed medical staff assigned to each service area of the unit shall

be determined by senior management and consistent with the functional program of the

unit, but a minimum of five casualty officers is required.

At least one full time consultant/specialist A shall be in charge of the unit.

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4.34 The number of MOH licensed registered nurses and nurse assistance assigned to

each service shall be consistent with the types of nursing care needed. See staffing

matrix decision making guideline at the section of Healthcare Professionals Minimum

Requirements.

5 - Inpatient Service

5.1 All hospitals shall provide inpatient service in distinct areas.

5.2 The number of beds per room depends on the demands and the functional program,

but one bed per room is advisable.

5.3 When reconstruction work is undertaken and the present capacity is more than one

patient, maximum room capacity should be not more than the present capacity, with a

maximum of four patients.

5.4 Adequate ventilation and air exchange, with at least 6 air changes per hour as per

ASHRAE requirement shall be maintained in inpatient care area.

Inpatient care area should be kept at positive pressure relative to the adjacent areas.

The area temperature should be maintained at 24 °C or less and relative humidity 30 %

to 60%.

5.5 High efficiency filters should be installed in the air handling system.

5.6 Patient Room

The following requirements shall be provided:

5.6.1 Walls shall be painted with lead free color with no sharp edges.

5.6.2 Window in patient room is required.

5.6.3 Door opening to inpatient bedrooms shall be wide enough for easy movement of

bed or stretcher, a minimum clear width of 1.15 meters with a frame that is 2.15 meters

high is required.

5.6.4 In multi-story hospital buildings, adequate family visiting areas shall be provided

at each floor.

5.6.5 Patient rooms should be constructed to meet the needs of the functional program

and have a minimum of 9.50 square meters of clear floor area per bed in multiple-bed

rooms and 11.35 square meters of clear floor area in single-bed rooms, exclusive of

toilet rooms, closets, or lockers.

5.6.6 In multiple-bed rooms, a clearance of 1.40 meters should be available at the foot of

each bed to permit the passage of equipment and beds.

5.6.7 Each patient should have within his or her room a separate locker.

5.6.8 One toilet room should serve not more than two patient rooms and not more than

four beds. Toilet room doors should swing outward or be double acting.

5.6.9 A hand-washing station for the exclusive use of the staff shall be provided to serve

each patient room and shall be placed outside the patient toilet room.

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5.6.10 Door opening to inpatient bedrooms shall be wide enough for easy movement of

bed or stretcher, a minimum clear width of 1.15 meters with a frame that is 2.15 meters

high is required.

5.6.11 Calling system shall be next to each bed.

Adequate electrical sockets for each bed are required.

5.7 Nurse Station

This area should have space for counters and storage and should have convenient access

to hand-washing stations.

5.8 Documentation Area;

Charting facilities should have linear surface space adequate to ensure that staff and

physicians can chart and have simultaneous access to information and communication

systems.

5.9 Multipurpose Room

Multipurpose rooms are provided for staff, patients, and patients’ families for patient

conferences, reports, education, training sessions, and consultation. These rooms may be

on other floors if convenient for regular use.

5.10 Medication Station;

The following should be provided;

5.10.1 Medicine preparation room.

5.10.2 Should be under visual control of the nursing staff.

5.10.3 Should contain a work counter, a hand- washing station, a lockable

refrigerator, and locked storage for controlled drugs.

5.11 Self-contained medicine dispensing unit;

This should be at the nurse station, in the clean workroom, provided the unit has

adequate security for controlled drugs and adequate lighting to easily identify drugs.

5.12 Clean Supply Room

5.12.1 If the room is used for preparing patient care items, it shall contain a work

counter, a hand-washing station, and storage facilities for clean and sterile supplies.

5.12.2 If the room is used only for storage and distribution of clean and sterile materials,

exclusion of the work counter and hand-washing station can be acceptable.

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5.13 Housekeeping Room

Housekeeping rooms should be directly accessible from the unit or floor they serve and

may serve more than one ward on a floor.

5.14 Areas related to Staff

5.14.1 Staff Lounge Facilities, conveniently located private room for staff to use during

their break.

5.14.2 Staff toilet rooms.

5.14.3 Staff storage facilities.

5.14.4 There should be closets or cabinet compartments for the nursing personnel usage.

5.15 Examination or Treatment Rooms

5.15.1 Centrally located examination and treatment rooms could serve more than one

nursing unit on the same floor.

5.15.2 Such rooms should have a minimum floor area of 11.25 square meters.

5.15.3 The room should contain;

5.15.3.1 Examination bed.

5.15.3.2 Examination lamp.

5.15.3.3 Hand-washing station.

5.15.3.4 Storage facilities.

5.15.3.5 Desk, counter, or shelf space for writing.

5.15.3.6 X-ray viewer that accommodates at least four films simultaneously

should be provided.

5.16 Areas for Patients and Visitors

This area should be designed to minimize the impact of noise and activity on patient

rooms and staff functions.

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6 - Special Patient Care

6.1 Airborne Infection Isolation Rooms

6.1.1 The hospital should specify airborne infection isolation room(s) for treatment of

infectious diseases based on the needs of specific community and patient populations

served by the hospital.

6.1.2 At least one airborne infection isolation room shall be provided in all general

hospitals.

6.1.3 Airborne infection isolation rooms may be located within individual nursing units

and used for normal acute care when not required for patients with airborne infectious

diseases, or they may be grouped as a separate isolation unit.

6.1.4 Isolation rooms design requirements shall include but not limited to the following;

6.1.4.1 Each patient room shall contain only one bed.

6.1.4.2 A separate toilet with shower shall be provided for each patient room.

6.1.4.3 A hand-washing station shall also be provided for each patient room.

6.1.4.4 Perimeter walls, ceilings, and floors, including penetrations, shall be

sealed tightly so that air does not infiltrate the environment from the outside or

from other spaces

6.1.4.5 An area for gowning and storage of clean and soiled materials shall be

located either directly outside or inside the entry door to the patient room.

6.1.4.6 There should be an oxygen source and first-aid kit available inside the

room.

6.1.4.7 Adequate ventilation and air exchange, with at least 12 air changes per

hour as per ASHRAE requirements shall be maintained in the Isolation Room.

The room should be kept at negative pressure relative to the adjacent areas.

6.1.4.8 The area temperature should be maintained at 24 °C plus or minus 1 °C.

6.1.4.9 High-efficiency filters should be installed in the air handling system, with

adequate facilities provided for maintenance, without introducing contamination

to the delivery system or the area served.

6.2 Protective Environment Rooms

6.2.1 Generally, protective environments rooms are not needed in community hospitals,

unless these facilities take care of these types of patients.

6.2.2 The differences between protective environment rooms and other patient rooms is

the requirement for positive air pressure relative to adjacent spaces, with all air passing

through high-efficiency particulate air filters to ensure the protection of patients who are

highly susceptible to infection.

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6.2.3 Protective environment rooms should;

6.2.3.1 Contain only one bed.

6.2.3.2 Have separate toilet directly exist from each protective environment

room.

6.2.4 Have a permanently installed visual mechanism to monitor the pressure

status of the room when it is occupied by patients. The mechanism should

continuously monitor the airflow.

6.2.5Have walls sealed tightly so that the air does not infiltrate the environment

from the outside or from other spaces.

6.3 Isolation Rooms for noninfectious patient

The hospital should provide one or more single-bed rooms for patients that are in need

for close supervision for medical and/or psychiatric care.

These rooms may be part of the psychiatric unit.

6.4 Intermediate Care Units

6.4.1 This unit is for patients who require frequent monitoring of vital signs or nursing

intervention that exceeds the level needed in a regular medical or surgical unit but is less

than that provided in a critical care unit.

6.4.2 Maximum room capacity should not exceed four patients.

6.4.3 A minimum of 1.15 meters should be available at the foot of each bed to permit the

passage of equipment and beds.

6.4.4 Monitoring equipment should be available for each bed.

6.4.5 There should be an emergency alarm to call for assistance from outside the

intermediate care unit.

6.4.6 A hand-washing station should be provided in the patient room in addition to that

in the toilet room.

6.5 Critical/Intensive Care Units

6.5.1 All general hospital shall provide Critical Care services. Type of units and number

of beds needed is based on many factors. In general the hospital should provide one

critical care bed for each operation theater, but it should not be less than one critical care

bed for every 20 general beds.

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6.5.2 The location should offer convenient access for the emergency, respiratory

therapy, laboratory, radiology, surgery, and other essential departments and services.

Transportation of patients to and from the critical care unit should ideally be separated

from public corridors and visitor waiting areas.

6.5.3 Design should apply privacy and quite environment for the care and comfort of

patients.

6.5.4 Each patient space (either separate rooms, or multiple bed space) should have a

minimum of 18.75 square meters of clear floor area with a minimum headwall width of

4.8 meters per bed, exclusive of toilet rooms, closets, and lockers.

6.5.5 The communication system for the unit should include supplies for an emergency

code resuscitation alarm to call assistance from outside the critical care unit.

Hand-washing stations should be suitable to nurse stations and patient bed areas.

There should be at least one hand-washing station for every three beds in open areas and

one in each patient room.

6.5.6 The documentation space should be located within or adjacent to the patient bed

space.

6.5.7 Multipurpose rooms should be provided for staff, patients, and patient’s families

for patient conferences, reports, education, training sessions, and consultation. These

rooms should be accessible to each nursing unit.

6.5.8 The critical care units must be supplied with medical gases outlets, (02 Air

Suction), enough numbers of electrical outlets and examination lights. Supply of medical

gases should be available and centralized medical gas system shall be according to HTM

2022 or its equivalent internationally accepted standard.

6.5.9 Adequate ventilation and air exchange, with at least 6 air changes per hour as per

ASHRAE requirements shall be maintained in Intensive Care Unit area. Intensive

Care Unit should be kept at positive pressure relative to the adjacent areas.

6.5.10 The area temperature should be maintained at 21 °C 24 °C and relative humidity

30 % to 60% and should be adjustable.

6.5.11 High efficiency filters should be installed in the air handling system, with

adequate facilities provided for maintenance, without introducing contamination to the

delivery system or the area served.

6.5.12 Staff areas and toilet can be located in a way that staff may be recalled quickly to

the patient area in emergencies. It should have telephone and emergency code alarm

connections to the critical care unit.

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6.5.13 The visitor waiting room should be designed to accommodate the long stays and

stressful conditions, The locations and size should be appropriate for the number of

patients and units served, with a seating capacity of not less than one family member per

patient bed.

6.5.14 For Pediatric Critical Care Unit;

6.5.14.1 An extra space at each bedside should be provided for the patient's

family.

6.5.14.2 Sleeping space for parents who may be required to spend long hours

with the patient is desirable.

6.5.15 For Newborn Intensive Care Units;

6.5.15.1 All entries to the unit should be controlled.

6.5.15.2 Viewing windows should be made to control viewing of infants.

6.5.15.3 In a multiple bed room, every bed position should be within 6.5 meters

of a hands-free washing station.

6.5.15.4 Where an individual room concept is used, a hands- free washing station

should be provided within each infant care room.

6.5.15.5 Infant bed areas should be designed to produce minimal noise and to

contain and absorb much of the transient noise that arises within the NICU.

6.5.15.6 No direct lighting should be permitted in infant unit.

6.5.15.7 At least one airborne infection isolation room should be available.

6.5.15.8 Space should be provided for lactation support and consultation in or

immediately adjacent to the NICU.

6.5.15.9 A room should be provided within the NICU to allow parents and

infants to spend private time together.

7 - Obstetrics and Gynecology Service

Obstetrical program could essentially be divided into three basic models;

- Traditional Model.

- Labor-Delivery-Recovery (LDR) Model.

- Labor-Delivery-Recovery-Postpartum (LDRP) Model.

The Obstetrics and Gynecology unit shall be located and designed to prohibit nonrelated

traffic through the unit.

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7.1 Labor-Delivery-Recovery Model

Labor, delivery and recovery rooms are designed to accommodate the delivery process

from labor through delivery and recovery of mother and baby.

They are equipped to handle most complications, with the exception of cesarean

sections.

The birthing woman moves only as a postpartum patient to her bedroom or to a cesarean

section delivery room if delivery complications occur.

7.2 Labor-Delivery-Recovery-Postpartum Model

Labor, delivery, recovery, and postpartum occur in separate areas. The functional areas

are separate rooms consisting of the labor room, delivery room, recovery room,

postpartum bedroom, and infant nurseries.

The expectant mother is moved through these functional areas depending on the status of

the birth process.

Labor, delivery, recovery and postpartum model eliminates the move to postpartum

room after delivery. The equipment is moved into different room as needed, rather than

moving the patient to the equipped room.

7.2.1 LDR and LDRP rooms shall have;

7.2.1.1 Controlled access with doors that are arranged for observation from a

nursing station.

7.2.1.2 A minimum clear floor area of 31.60 square meters with a minimum clear

dimension of 3.95 meters.

7.2.1.3 Each LDR or LDRP room should be for single occupancy.

7.2.1.4 Satisfactory equipment and supplies.

7.2.1.5 An emergency communication system.

7.2.1.6 Hand washing sink.

7.2.1.7 Access to a toilet room.

7.2.1.8 Shower for patients use.

7.3 Postpartum Unit

Postpartum rooms have the same requirements as for the inpatient service.

In-services that have only one cesarean/delivery room should have two labor rooms.

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7.4 Cesarean/Delivery Suite

7.4.1 Certain deliveries are handled in a cesarean section delivery room (surgical

operative room) should delivery complications occur.

7.4.2 When cesarean delivery rooms are located within the obstetrical suite, access and

service arrangements shall be such that neither staff nor patients must travel through the

cesarean delivery area to access other services.

7.4.3 There should be a minimum of one such room in every obstetrical unit unless there

is an especially reserved room in the main theatre of the hospital. These should have a

minimum clear floor area of 33.45 square meters with a minimum dimension of 4.90

meters.

7.5 Infant Resuscitation Space

7.5.1 Infant resuscitation should be provided within cesarean/delivery rooms and

delivery rooms or in a separate but immediately accessible room.

7.5.2 A minimum clear floor area of 3.75 square meters shall be provided for the infant

resuscitation space in addition to the required area of each delivery or cesarean/delivery

room.

7.5.3 Infant resuscitation space provided in a separate but immediately accessible room

shall have a minimum clear floor area of 13.95 square meters.

7.6 Gynecology Unit

The Gynecology unit has the same requirements as for the inpatient service.

8 - Renal Dialysis Unit

8.1 Space should be provided to accommodate the hospital procedure program.

8.2 The location should be in access with outpatients.

8.3 The treatment area should be acceptable to be an open area and it should be

considered to provide privacy for each patient.

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8.4 Nurse station should be located within the dialysis treatment area and designed to

provide visual observation of all patient stations.

8.5 Hand-washing stations should be near the nurse station and patient treatment areas

and it should serve not more than four patients.

8.6 Patient toilet should be provided in the unit.

8.7 Airborne infection isolation room should be provided in the unit.

8.8 If a nourishment station is provided, it should contain a hand-washing station, a work

counter, a refrigerator, storage cabinets, a water-dispensing unit separate from the hand-

washing station, and equipment for serving nourishments as required. It should be

located away from the treatment area to prevent the risk of contamination.

8.9 Separate units should be kept for HBV, HCV, HIV patients and other potentially

infective diseases.

8.10 Storage space should be available for wheelchairs and stretchers.

8.11 Laboratory space can be provided to hold the process of blood draws and urine

samples.

8.12 The temperature in the unit should be maintained at 21° to 26°C with a relative

humidity level of 30 to 60 percent.

8.13 A special water treatment unit should be provided.

9 - Physiotherapy Services

9.1 Space should be provided to accommodate the hospital procedures program.

9.2 The control station should provide visual control for waiting and activities areas.

25

9.3 Spaces should be provided to store the wheelchairs and stretchers.

9.4 Patients waiting area should be convenient for the access of wheelchairs and should

have activity center for patients and their company.

9.5 This department should include individualized treatment areas to insure privacy of

the patients.

9.6 The department should have multipurpose areas for different types of treatment such

as; thermotherapy, diathermy, ultrasonics, hydrotherapy and different exercise machines.

9.7 Patient dressing areas, showers, and lockers should be provided and some are

arranged for use by the disabled patients.

9.8 Hand washing stations for staff should be located either within or at each treatment

space.

9.9 Storage area should be available for soiled linen, towels, and supplies.

10 - Operation Theatre

10.1 The number of operating rooms, induction and recovery areas should be based on

the expected surgical workload.

If obstetric services are provided, an extra dedicated OT is recommended.

10.2 The operation theatre should be divided into three areas;

10.2.1 Unrestricted area, for the entrance of patients, staff and materials.

10.2.2 Semi restricted area, it has storage areas for clean and sterile supplies,

storage and processing of instruments and corridors leading to the restricted areas

of the surgical suite.

10.2.3 Restricted area: includes operating, procedure, induction, recovery and

scrub areas.

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10.3 Operating room shall have a minimum clear floor area of 37.15 square meters.

10.4 There should be sufficient space to accommodate all necessary equipment and

personnel to allow for free and swift access to patient and all monitoring equipment.

10.5 The OT entrance door must be wide (about 2.15 meters width) and consisting of

two parts, which can be opened in either sides.

10.6 Independent dirty exit is recommended in OT.

10.7 The floors, ceilings, and walls must be created by a continuous connection.

10.8 Surfaces should be constructed of materials that are monolithic and impervious to

moisture.

10.9 The floors and walls should be anti-static, heat resistant, anti-bacterial, anti-fungal

and resistant to disinfectants.

10.10 Adequate ventilation and air exchange (with at least 25 air changes per hour as per

(ASHRAE) requirement) shall be maintained in the operation room which should be at

positive pressure relative to the adjacent areas.

10.11 Minimum of two air supply inlets with proper contamination control filters (High

Efficiency Particulate Air (HEPA) filters) delivered at or near the ceiling in addition to a

minimum of two exhaust outlets located near floor level.

10.12 Differential pressure indicating device, humidity indicator, and thermometers

should be installed and should be located for easy observation.

10.13 Operating room temperature shall be maintained between 18-22 °C with room

humidity between 35-70% and the temperature and relative humidity set points should

be adjustable.

10.14 Anesthesia scavenging systems should be installed in all spaces used for

administering inhalation anesthesia.

10.15 The scrub facility shall be located adjacent to the operation room(s).

10.15.1 Two scrub positions should be provided.

10.15.2 Ceiling surfaces or tiles at this area shall be smooth, washable and free of

particular matter that can be contaminated.

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10.16 Sterilizing area can be located near operating room(s) with adequate machine and

equipment for cleansing, sterilization and packing of surgical instruments and trolleys.

10.16.1 Sterilizing area air pressure should be kept negative pressure with respect

to any adjoining areas and should have minimum 10 air changes per hour.

10.16.2 Relative humidity should be maintained at 30% to 60%.

10.16.3 High efficiency filters should be installed in the air handling system,

with adequate facilities provided for maintenance, without introducing

contamination to the delivery system or the area served.

10.17 Staff changing area shall be separate for males and females. It must contain

special entrance for the staff and suitable place for changing of clothes, lockers, showers,

toilets and hand-washing stations.

10.18 Staff and patients toilets air pressure should be kept negative pressure with respect

to any adjoining areas and should have minimum of 10 air changes per hour.

10.19 Suitable medical store area should be available for adequate storage of all medical

and no medical requirements of the operation theatre.

10.19.1 Store's air pressure should be kept positive pressure with respect to any

adjoining areas and should have minimum 4 air changes per hour.

10.19.2 Relative humidity should be maintained at 30% to 60%. High efficiency

filters should be installed.

10.20 Sufficient supply of different medical gases should be available and adequate for

procedure(s) preformed (centralized medical gas system in accordance to HTM 2022 or

its equivalent internationally accepted standard is preferable).

10.21 Back-up emergency power supply sufficient to ensure patient protection and

safety in the event of an emergency power cut should be available.

11 - Radiology Services

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The Radiology Services include;

A- General Radiology

Radiography: Film Radiography, Computed Radiography (CR).

Digital Radiography (DR)

Mammography

Bone Densitometry

Dental X-rays

B- Fluoroscopy-Based;

Diagnostic Fluoroscopy (Diagnostic Imaging)

Interventional Cardiology (Cath Lab)

C- Interventional Radiology

D- Lithotripsy

E- Computed Tomography (CT) Scanning.

F- Magnetic Resonance Images (MRI).

G- Ultrasound imaging.

11.1 All General Hospitals must provide conventional Radiography, Computer

Tomography and Ultrasound services on the premises.

11.2 Patients convenience and accessibility should be considered at the planning and

designing of the Radiology Department.

11.3 Radiation protection requirements shall be incorporated into the specifications and

the building plan as required by the National Radiation Protection Center (NRPC) at the

Ministry of Health and the Federal and Local Authorities.

11.4 Consultation area or office for radiologist(s) must be provided. Office shall include

provisions for patient consultation, viewing and charting of radiological films.

11.5 Sharing support areas for diagnostic imaging services (e.g. reception area, and

Consultation area) is permitted.

11.6 Male and Female waiting area for patients and escorts shall be separated and under

staff visual control. If the suite is routinely used for outpatients and inpatients at the

same time, separate waiting areas shall be provided with screening for visual privacy

between them.

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11.7 Waiting area shall be provided with provision of drinking water and public

telephone. Toilet(s) for public use shall be conveniently accessible from the waiting

area.

11.8 Staff lounge with lockers shall be permitted to be outside the suite but shall be

convenient for staff use.

11.9 Staff toilets shall be permitted to be outside the suite but shall be convenient for

staff use.

11.10 Radiology Services;

11.10.1 Conventional radiography room size shall be at least 15 square meters

depending on the type of machine in use and the functional program.

11.10.2 Tomography and radiography/fluoroscopy (R&F) rooms should be a

minimum of (25 square meters).

11.10.3 Room entrance shall not be less than 2 meters height with shielded door.

11.10.4 At least one designated patient gowning area for patient changing shall

be provided within the conventional radiography room.

11.10.5 Shielded viewing window (Lead glass) from the Control Area to the

conventional radiography room should be provided.

11.10.6 Minimum X-ray room surfaces and shielding thicknesses shall comply

with the Requirements of the NRCP and the Federal and Local Authorities Laws.

11.10.7 If film systems are used, a darkroom shall be provided for processing

films (at least 2 meters square) with water basin, table, benches, film holder and

Safe light.

11.10.8 Film storage (active). A room with cabinet or shelves for filing

patient film for immediate retrieval shall be provided.

11.10.9 Film storage (inactive). A room or area for inactive film storage shall be

provided. It shall be permitted to be outside the imaging suite, but must be

under imaging's administrative control and properly secured to protect films

against loss or damage.

11.10.10 Storage facilities for unexposed film shall include protection of film

against exposure or damage and shall not be warmer than the air of adjacent

occupied spaces.

11.10.11 The Ministry of Health strongly advises all new facilities not to

consider using films in their practice due to the environmental hazardous caused.

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11.11 CT room;

11.11.1 Shall be at least 24 square meters depending on the type of machine in

use and the functional program.

11.11.2 Patient gowning area for patient changing shall be provided.

11.11.3 At least one space should be large enough for staff-assisted dressing.

11.11.4 A control room shall be provided that is designed to accommodate the

computer and other controls for the equipment.

11.11.5 A view window (Lead glass) shall be provided to permit full view of the

patient.

11.11.6 The angle between the control and equipment shall permit the control

operator to see the patient’s head all the time.

11.11.7 A patient toilet shall be provided.

11.11.8 If contrast media are used, this area shall include provision for

appropriate emergency equipment and medications must be immediately

available and central oxygen or oxygen cylinder to treat adverse reactions

associated with administered medication. Also the area shall include; crash cart,

sink, counter, and storage area.

11.11.9 One preparation room, if conveniently located, shall be permitted to

serve any number of rooms.

11.12 Mammography room;

11.12.1 The space requirement is at least 9 square meters.

11.12.2 Patient gowning area shall be inside to the room.

11.13 Magnetic Resonance Imaging (MRI);

11.13.1 The MRI room shall be permitted to range from 30.20 square meters to

57.60 square meters, depending on the machine type.

11.13.2 Patient gowning area shall be provided.

11.13.3 There should be a control room with full view of the MRI room.

11.13.4 At least one space should be large enough for staff-assisted dressing shall

be provided.

11.13.5 A patient holding area according to work load shall be provided.

11.13.6 Hand-washing stations convenient to the MRI room, but need not be

within the room should be provided.

11.13.7 A computer room is required.

11.13.8 Cryogen storage is required.

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11.13.9 Equipment installation requirements;

11.13.9.1 Power conditioning.

11.13.9.2Magnetic shielding.

11.13.9.3 For super-conducting MRI, cryogen venting and emergency

exhaust in accordance with the original equipment manufacturer’s

specifications.

11.13.9.4 Adequate space for Coils storage based on the on these

anatomic applications.

11.13.10 Magnetic door interlock should be provided.

11.13.11MRI Warning light and signs should be provided.

11.13.12 Compatible MRI medical equipment including Anesthesia machine

should be provided.

11.13.13 Magnetic shielding may be required to restrict the magnetic field

plot.

11.13.14 Radio frequency shielding may be required to attenuate stray radio

frequencies.

11.13.15 The area around, above and below the MRI suite shall be reviewed and

evaluated for the following;

11.13.15.1 Possible occupancy by person(s) who could have pacemakers

or other metal implants.

11.13.15.2 Equipment that can be disrupted by a magnetic field.

Examples include but are not limited to personal computers, monitors, CT

scanners, and nuclear cameras.

11.14 Ultrasound imaging;

11.14.1 Room size shall not be less than 7 square meters.

11.14.2 Patient toilet shall be accessible within the ultrasound room.

11.15 Interventional Imaging Facilities;

11.15.1 The IR and /or cardiac catheterization laboratory is normally located in a

separate suite, but location in the diagnostic imaging area can be permitted

provided the appropriate sterile environment is provided.

11.15.2 The number of procedure rooms shall be based on expected utilization.

11.15.3 The procedure room shall be a minimum of 37.15 square meters

exclusive of fixed cabinets and shelves.

11.15.4 Electrophysiology labs. If electrophysiology labs are also provided in

accordance with the approved functional program, these labs may be located in a

separate functional area proximate to the cardiac care unit.

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11.15.5 Support areas for the IR suite/ cardiac catheterization lab should have;

11.15.5.1 Scrub facilities with hands-free operable controls shall be

provided adjacent to the entrance of procedure rooms, and shall be

arranged to minimize incidental splatter on nearby personnel, medical

equipment, or supplies.

11.15.5.2 Patient prep, holding, and recovery area or room.

11.15.5.3 A patient preparation, holding, and recovery area or room shall

be provided and arranged to provide visual observation before and after

the procedure.

11.15.5.4 A control room shall be provided and shall be large enough to

contain and provide for the efficient functioning of the x-ray and image

recording equipment.

11.15.5.5 A large view window (Lead glass) permitting full view of the

patient from the control console shall be provided.

11.15.6 Electrical equipment room. An equipment room or enclosure large

enough to contain x-ray transformers, power modules, and associated electronics

and electrical gear shall be provided.

11.15.7 Viewing room. A viewing room shall be available for use by the cardiac

catheterization suite.

11.15.8 A clean workroom or clean supply room shall be provided.

11.15.9 A soiled workroom shall be provided.

11.15.10 Film file room shall be available for use by the cardiac catheterization

suite.

11.15.11 Housekeeping closet shall be provided.

11.15.12 Support areas for staff clothing and change area(s) shall be provided

and arranged to ensure a traffic pattern so that personnel can enter from outside

the suite, change their clothing, and move directly into the cardiac catheterization

suite.

11.16 General considerations;

11.16.1 Each x-ray room shall include a shielded control alcove. This area shall be

provided with a view window (Lead glass) designed to provide full view of the

examination table and the patient at all times, including full view of the patient when

the table is in the tilt position or the chest x-ray is in use.

11.16.2 Each X-ray room shall include a Warning light over the entrance door with

wording “X-RAY IN USE, DO NOT ENTER”.

11.16.3 Adequate ventilation and air exchange, with at least 6 air changes per hour as

per ASHRAE requirements shall be maintained in all Diagnostic Imaging service area.

The area should be kept at positive pressure relative to the adjacent areas.

33

11.16.4The area temperature should be maintained at 21 °C to 24 °C and relative

humidity 30% to 60% and should be adjustable.

11.16.5 High-efficiency filters should be installed in the air handling system, with

adequate facilities provided for maintenance, without introducing contamination to the

delivery system or the area served.

11.16.6 Radiology Departments must comply with the requirements of the National

Radiation Protection Center and other related Federal and Local Authorities Laws.

12 - Clinical Laboratory Service

12.1 All general hospital must provide clinical laboratory facilities according to the

expected workload in the hospital.

12.2 Services to cover the following minimum specialties should be available;

12.2.1 Hematology.

12.2.2 Clinical chemistry.

12.2.3 Immunology and serology.

12.2.4 Microbiology.

12.3 Certain procedures may be performed on-site or provided through a contractual

arrangement with external laboratory service.

12.4 Access to laboratory areas should be strictly limited to laboratory personnel. Members

of the general public should get no further than the reception areas or waiting rooms.

12.5 Phlebotomy room/Specimen Collection Area; 12.5.1 Phlebotomy room shall have minimum space of 6 square meters, a seating

space, a work counter, and a hand-washing station in the vicinity.

12.5.2 Phlebotomy room location, design and door swings should be oriented to

provide patient privacy.

12.5.3 Room shall be furnished with reclining chair or gurney for patients who

become unsteady.

12.5.4 The urine and feces collection facility shall be equipped with a water

closet and hand-washing station.

34

12.5.5 A specimen collection facility may be located outside the clinical

laboratory area.

12.6 Laboratory work areas shall include sinks with water and access to vacuum, gases,

tele/data service, and electrical service as needed.

12.7 Chemical safety provisions. These shall include emergency shower, eye-flushing

devices, and appropriate storage for flammable liquids.

12.8 Facilities and equipment shall be provided for terminal sterilization of contaminated

specimens before transport.

12.9 Where pediatrics service provided a separate, controlled area for pediatric patients

shall be provided.

12.10 Laboratory fume hoods shall meet the following general standards;

12.10.1 An average fan velocity of at least 75 feet per minute (0.38 meters per

second).

12.10.2 Connection to an exhaust system to the outside that is separate from the

building exhaust system.

1210.3 Location of an exhaust fan at the discharge end of the system.

12.10.4 Inclusion of an exhaust duct system of noncombustible corrosion-

resistant materials as needed to meet the planned usage of the hood.

12.11 If radioactive materials are employed, facilities for long-term storage and disposal

of these materials shall be provided.

12.12 Storage facilities for reagents, standards, supplies, and stained specimen

microscope slides, etc. shall be provided.

12.13 Refrigerated blood storage facilities should be provided.

12.14 Waiting area shall be provided with provision of; drinking water, toilet(s) for

public use.

12.15 Lounge, locker, and toilet facilities shall be conveniently located for male and

female laboratory staff.

35

12.16 Adequate ventilation and air exchange, with at least 6 air changes per hour as per

ASHRAE requirements shall be maintained in all Clinical Laboratory service area.

12.17 The Laboratory area should be kept at positive pressure relative to the adjacent

areas.

12.18 The area temperature should be maintained at 21 °C to 24 °C and relative

humidity 30% to 60%.

12.19 High-efficiency filters should be installed in the air handling system, with

adequate facilities provided for maintenance, without introducing contamination to the

delivery system or the area served.

12.20 Selected flooring surfaces shall be easy to maintain, readily cleanable, non-pervious

and with covings to the walls and cabinets to ensure that spills cannot penetrate underneath.

12.21 Clinical Laboratory services should comply with the Federal and Local Authorities

regulating laws.

13 - Pharmacy Service

13.1 The size and type of services to be provided in the pharmacy shall depend upon the

type of drug distribution system used and number of patients to be served.

13.2 If the functional program of the hospital requires dispensing of medication to

outpatients, providing an area for consultation and patient education is recommended.

13.3 The pharmacy area shall consist of the following;

13.3.1 A room or area for receiving, breakout, and inventory control of materials

used in the pharmacy.

13.3.2 Work counters and space for automated and manual dispensing activities.

13.3.3 A compounding area. This shall include a sink and sufficient counter

space for drug preparation.

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13.3.4 An area for reviewing and recording.

13.3.5 An area for temporary storage, exchange, and restocking of carts.

13.3.6 Secure storage shall be provided for narcotics and controlled drugs as per

the Ministry of Health laws and regulations.

13.3.7 A hand-washing station shall be provided either in an anteroom or

immediately outside the room where open medication(s) are prepared.

13.3.8 If intravenous (IV) solutions are prepared in the pharmacy, a sterile work

area with a laminar-flow workstation designed for product protection shall be

provided.

13.4 The laminar-flow workstation shall include;

13.4.1 A non-hydroscopic filter rated at 99.97 percent (HEPA).

13.4.2 A visible pressure gauge for detection of filter leaks or defects.

13.5 Separate room shall be provided for preparation of Cytotoxic IV admixtures under a

Class II: Type B1, B2, B3 or Class III biological safety cabinet.

13.6 Cabinets, shelves, and/or separate rooms or closets shall be provided for bulk

storage.

13.7 Refrigerated storage should be provided if required.

13.8 Adequate ventilation and air exchange, with at least 4 air changes per hour as per

ASHRAE requirements shall be maintained in Pharmacy services area.

13.9 Pharmacy services area should be kept at positive pressure relative to the adjacent

areas.

13.10 The area temperature should be maintained at 23 °C plus or minus 1 °C and

relative humidity 30% to 60% and should be adjustable.

13.11 High-efficiency filters should be installed in the air handling system, with

adequate facilities provided for maintenance, without introducing contamination to the

delivery system or the area served.

14 - Catering Services

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14.1 Food service should be provided for patients, staff, and visitors in according to

functional program.

14.2 Strict hygienic conditions should be maintained in the hospital kitchen during

preparing, storing and serving food.

14.3 Patient food preparation areas should be located near the deliver y and storage

facilities.

14.4 Work spaces for food preparation, cooking, and baking should be as close as

possible to the users.

14.5 A cart distribution should be provided with spaces for storage, loading, distribution,

receiving and sanitizing of the food service with temperature control.

14.6 The cart traffic should eliminate any danger of cross circulation between outgoing

food carts and incoming carts. Cart circulation should not be through food processing

areas.

14.7 Dining spaces should be provided for staff and visitors. This unit should be separate

from the food preparation and distribution areas.

14.8 The waste eliminated process should avoid the contamination of the clean products

and the waste products.

14.9 Measures should be taken to protect the food delivery for the patient and to ensure

freshness, retain hot and cold, and avoid contamination. If delivery is from outside

sources, protection against weather should be provided.

14.10 If selling devices are used for unscheduled meals, a separate room should be

provided that can be accessed without having to enter the main dining area. In this room

there should be a hand-washing station, and a sitting area.

14.11 Coolers, refrigerators, and freezers should be thermostatically controlled to

maintain desired temperature settings.

14.12 Interior temperatures shall be indicated digitally so that to be visible externally.

38

14.13 All cooking equipment should be equipped with automatic shut-off devices to

prevent excessive heat buildup.

14.14 Provision should be made for storage of a minimum of four days’ supplies.

14.15 Smoke should vent outside and the smell shouldn’t escape inside the hospital.

14.16 Such services could be outsourced on the hospital premises or by an external

provider with written agreement. The provided services shall be in accordance with the

MOH standards on allied health services.

15 - Mortuary Unit

15.1 Each general hospital with more than 25 beds shall provide a mortuary within the

hospital premises.

15.2 Mortuary equipment shall be operated and maintained in accordance with

manufacturer specifications.

15.3 Mortuary fridge temperature shall be maintained between 2 - 6 °C and provided

with alarm system.

15.4 Mortuary area shall be maintained clean and disinfected on daily basis, infection

control policy shall be available and implemented in the mortuary area.

15.5 The hospital shall maintain also a policy for handling amputated body parts which

assure proper management and disposal.

15.6 The hospital mortuary services shall be responsible for overseeing the

transportation of deceased patients from wards/departments.

15.7 All dead bodies shall be considered infectious, strict infection control measures

shall be considered during cleaning the body. Body should be cleaned and rapped/placed

in mortuary bag.

39

15.8 Transportation of deceased patient infected with communicable disease shall be

conducted according to UAE Federal and Local Law.

16 - Central Sterile Supply Department

16.1 This area should be physically separated from all other areas of the hospital.

16.2 It should be arranged to handle the cleaning, sterilization and disinfection of all

medical and surgical instruments and equipment for all hospital services.

16.3 Work tables, sinks, flush-type devices, washer and sterilizer decontaminators

should be provided as work load requires.

16.4 The clean room should contain hand-washing stations, and equipment for terminal

sterilizing of medical and surgical equipment and supplies.

16.5 Access to the sterilization room should be restricted. This room should contain Hi-

Vacuum steam sterilizers and sterilization equipment to accommodate heat-sensitive

equipment

Storage area for packs, should maintain suitable ventilation, humidity, and temperature.

17 - Linen Services

17.1 The building should include adequate space to accommodate carts for appropriate

waste isolation such as recyclables, infectious waste, sharps and others.

17.2 Corridors and materials handling systems should be designed to achieve an efficient

movement of waste from points of generation to storage or treatment while minimizing

the risk to personnel.

40

17.3 A separate room should be provided for receiving and holding soiled linen until

ready for pickup or processing.

17.4 Clean linen storage room should be available away from dirty area.

17.5 Cart storage area should be provided for clean and soiled-linen carts separately.

17.6 A service entrance should be provided for loading and unloading of linen.

17.7 A control station shall be provided for pickup and receiving of linen.

18 - Engineering Services

Engineering services and maintenance require sufficient space and access to HVAC

Plant, Central Plant, workshop and equipment areas. Typically these include;

* Plant rooms

* Electrical Transformer and Switchboard Rooms

* Standby Generator Rooms

* Cooling Tower Compounds

* Medical Gas Cylinder and Manifold Room

* Bulk medical oxygen compound for tanker access

* Cold Water Storage Tanks

* Administration

* Workshops readily accessible to building lift systems

* Biomedical Engineering Equipment Workshop

* Engineering Supply Store

* Outside Equipment Storage

* Deliveries and service parking area

19 - Administration Area

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19.1 The hospital should specify a separate department for administration.

19.2 It shall have a suitable area for the hospital manager, assistants, administration and

finance employees.

19.3 An admission Office should be located in a convenient area for patient’s admission

procedures if required.

20 – Management standards and responsibilities

20.1 The hospital shall have a governing body responsible for directing the operation of

the hospital in accordance with its mission. If a hospital does not have an organized

governing body, then the person or persons responsible for the conduct of the hospital

shall carry out the functions.

20.2 The hospital governing body shall be legally responsible for the patient safety,

quality of care and for the conduct and obligations of the hospital as an institution.

20.3 The hospital governing body shall be legally responsible for ensuring compliance

with all UAE Federal and Local laws.

20.4 The governing body should appoint a Medical Director who is a MOH licensed

physician or dentist authorized to practice his/her profession.

20.5 The Medical Director responsibilities include, but not limited to the following;

20.5.1 Ensuring that all healthcare professionals should have active and

appropriate licensure by MOH and have necessary training and skills to deliver

medical services provided in the hospital.

20.5.2 Ensuring that all personnel (non-healthcare professional) assisting in the

provision of healthcare services in the hospital must be appropriately trained,

qualified, supervised, and sufficient in number to provide appropriate care.

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20.5.3 Developing clear internal process for gathering and submitting to MOH

healthcare professional's credentials (license, education, training and experience).

20.5.4 Ensuring a defined process for physician's privileges in the hospital, and

maintaining records of credential outcomes and privileges.

20.5.5 Providing response to any inspection report or requirements by the MOH.

20.5.6 Provide a documented policy and procedures for the following:

20.5.6.1 Infection control measures and hazardous waste management

20.5.6.2 Medication management

20.5.6.3 Patient health record

20.5.6.4 Emergency action plan

20.5.6.5 Patient discharge/transfer

20.6 The governing body should appoint a Director of Nursing Services who is a MOH

licensed Registered Nurse authorized to practice her/his profession with at least five

years’ experience in nursing practice where at least two years were in an administrative

or supervisory capacity.

20.7 The Director of Nursing shall supervise nursing care and nursing aid according to a

written staffing plan which provides for adequate coverage of all nursing requirements at

the hospital.

21 - Healthcare Professionals Minimum Requirements

21.1 Human resources practices should be supported by policies and procedures with

systems that influence employee's behaviors, attitudes and performance.

21.2 The recruitment selection and appointment system shall ensure that the skill mix

and competence of staff meet the hospital needs.

21.3 The hospital shall maintain accurate and complete personnel records for all

employees, including training records, such records shall be maintained and kept

confidential.

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21.4 Continuing Professional Development (CPD) activities shall be documented,

evidence of a learning and development system shall ensure the skill and competence of

staff by allocation.

21.5 Sufficient numbers of medical staff are required to be on duty at all times for good

patient management.

21.6 The number of licensed medical staff assigned to each health service in the hospital

shall be determined by senior management and consistent with the functional program of

the hospital.

21.7 All Medical staff in the hospital shall be holding an active MOH license and work

within their scope of practice.

21.8 Each clinical department must have a designated head of department.

21.9 At least one doctor for ten beds in general wards should be available during routine

working hours.

21.10 Enough number of doctors should be available to cover on call duties at off-duties

hours, weekends and public holidays.

21.11 At least one full time consultant shall be available to manage each of the following

specialties; Medical, Surgical, Pediatric, Obstetrics and Gynecology and Anesthesia.

21.12 One specialist (A) or consultant doctor shall be available for other departments in

the hospital.

21.13 At least one MOH licensed pharmacist should be available to cover the service

requirements.

21.14 There should be sufficient number of nurses on duty at all times to plan, supervise

and evaluate nursing care.

21.15 The hospital shall meet the minimum nursing staffing requirements as shown in

(tables 1&2).

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21.16 The number of MOH licensed registered nurses and nurse assistance assigned to

each department/service shall be consistent with the types of nursing care needed. See

staffing matrix decision making guideline in general hospital (table 3).

21.17 Availability of allied healthcare professionals shall be based on hospital activities

and number of patients and to be determined by senior management to ensure the

appropriate coverage of all medical services to all departments and ensuring staff

availability.

Service Registered Nurse to

patient ratio per shift

Charge

nurse

Notes

General and

Surgical Ward

(Ortho, Obs&

Gyne,

Uro, ENT)

One RN / Four beds One / Twenty

five beds

1-2 nurses extra per

shift

Pediatric Ward,

Burn Unit,

Neuro Surgey,

Short stay ward

One RN / Three beds One / Twenty

five beds

1-2 nurses extra per

shift

CCU Unit One RN / Two beds One each shift 1-2 nurses extra per

shift

ICU & S.BC.U,

NICU

One RN / bed One each shift 1-2 nurses extra per

shift

Table (1)

Service Registered Nurse / Room Charge Nurse Notes

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Operating Theater One Registered Nurse +

1 Nurse assistant

One each shift

Recovery Area One Registered Nurse

One each shift

Delivery Room One Registered Midwife +

One Registered Nurse

One each shift

Table (2)

Table (3)

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22 - Facility management

22.1 Hospitals shall ensure that the health care environment is safe, functional,

supportive and effective for patients, family and staff members.

22.2 The hospital shall establish a multidisciplinary Health and Safety committee.

22.3 The safety management systems and hospital policies shall comply with the

relevant Federal and Local Regulations.

22.4 The safety management system shall include fire safety, hazardous waste

management, emergency plans, security, and any other risks.

22.5 Orientation on the safety measures shall be included with the introduction program

for new staff.