1. Hospital ManagementBuilding or extending a hospital department Session III Tuesday, 14 February, 2012 Dr. Ashfaq Ahmed Bhutto MBBS, MBA, MAS, DCPS, MRCGP, (PhD)

2. Feasibility Module 12

3. Promoters Objective The promoter needs to determine the objectives of the project with clarity. These include the type of services to be provided: Secondary care/tertiary care. Sophistication in the building plan and equipments. The investments and returns the promoter is looking for. To rationally determine the above, a feasibility report based on a market survey is essential.3

4. Feasibility report The study should clearly bring out the following: The potential of the planned institution. The medical facilities that are lacking and need to be made available. The migration pattern of patients. Competition from existing hospitals and new entrants. Based on observations and findings from the market survey, a detailed project report should be prepared, with the following objectives: To recommend medical facilities in terms of departments and equipments. To determine manpower requirements. To project financial performance for the first 10 years of operation. To arrive at an implementation schedule for completing the project. To study the scope for future expansion of facilities. The report should realistically discuss operational feasibility, financial viability and the medical departments in heavy demand in thrust areas. It should also analyse the location of the site, the hospital design, manpower4 planning, project cost, financial analysis, sensitivity analysis and implementation.

5. Market Survey The first consideration in the survey is to study the character, needs and possibilities of the community which the hospital is going to serve. The existing medical facilities in the region should be studied in terms of: Quality and number of hospitals. The areas of specialisationdoctors/specialists/paramedical staff. Level of technology, latest medical equipment. Patient flow, disease pattern. Costs of investigation and treatment. Public opinion regarding the existing facilities, the need for more departments, and the response from the medical community are vital to the study. It is on the basis of this information that a decision can be taken about where a hospital should be built and its type and size. Is the community a wealthy one; or is it made up of moderate wage earners; are the industrial workers indigentthese are the deciding factors in determining the kind of hospital should be planned for. For example, if the community largely constitutes wealthy individuals, one can plan to build a luxurious hospital, with deluxe rooms and sophisticated diagnostic and therapeutic equipment; if it is largely meant for indigent patients, a non-profit or charitable hospital is needed. Apart from levels of income, characteristics such as5 occupation, age distribution, and so on must be studied. These determine the amount and kind of hospital.

6. MARKET Survey- Next Phase To study all the existing hospital facilities on an area-wise basis. This study should be comprehensive, covering both short and long-term needs. The most important part of the study is an inventory of the facilities, beds and services of every hospital. It should cover the following areas: Bed capacity of the institution Physical condition of facilities Hospital occupancy Bed ratio Volume and kind of hospital services provided Quality of facilities and services6

7. BASIC QUALITY REQUIREMENTS Module 27

8. Factors considered in location of Hospital 1. It should be within 15-30 min traveling time. In a place with good roads and adequate means of transport, this would mean a service zone with a radius of about 25 km. 2. It should be grouped with other institutional facilities, such as religious, educational, cultural and commercial centers. 3. It should be safe from physical dangers e.g. low lying areas. 4. It should be in an area free of pollution of any kind, including air, noise, water and land pollution. 5. It must be serviced by public utilities: water, sewage, electricity, gas and telephone.8

9. Reachability A general hospital should be easily reachable by public transport, assessed on the basis of transport frequency and the distance to the stop, and also by taxi, car or bicycle. This requirement is complied with if a general hospital is situated at one of the geographic/demographic concentration points in its catchment area. A geographic/demographic concentration point is a municipality where the population level and level of amenities (schools, retail trade, recreation, public services) is such that a substantial proportion of the population in the catchment area of the hospital is more9 or less automatically orientated towards that municipality.

10. Access The site needs to be easily accessible by patients, visitors and staff. This apply to pavements/ footpaths (minimum width, minimum free height, maximum slope, maximum height of kerbs), ramps (minimum width, maximum slope and length, halfway and end platforms), outside stairs (minimum width, maximum rise, installation, height and design of handrails), material properties of paving surfaces (flat, rough and jointless) and lighting. Regulations also apply to the measurements and layout of parking places.10

11. Access There are additional requirements for the less able, such as the size of parking places. Obstacles should be indicated by warning paving, continuous guiding lines must be present. Taxis should be able to come right up to the main entrance and the entrance to the outpatient unit. The entrance to the emergency department and if necessary the main entrance should be accessible by ambulance. Public entrances to a hospital building should comply with minimum dimensions and also be accessible by people with a physical handicap. These entrances should be covered over and provided with good lighting. There are also specifications that apply to the entrance hall (sheltered situation, minimum dimensions, location of the doors, lighting), thresholds (maximum heights) and door handles. In the case of revolving or carrousel doors, there must be an extra11 swing or sliding door provided.

12. Flexibility The flexibility refers to the degree to which a building is adaptable to changing space needs. Flexibility is concerned with a structural process of change, thus spatial adaptation of buildings is inevitable. With a high level of flexibility, these adaptations can be kept to a minimum, as a result of which the financial consequences and the hindrance to management remain within acceptable levels. The main structural design of a hospital should possess a high degree of flexibility. The building structure should be simple to extend at different points and should be able to cope with internal displacement. A characteristic feature of todays hospital architecture is that account was taken of future changes and innovations in science, technology and policy when selecting the building structure.12

13. Flexibility There are four types of flexibility. 1. Usage flexibility: Usage flexibility concerns the possibility of changing the use made of a room/space without the need to renovate that room/space. 2. Disposal flexibility: Disposal flexibility concerns the possibility of removing building elements without a detrimental effect on the cohesion of the building elements to be retained and with a minimum of hindrance. 3. Internal flexibility: The term refers to the possibility of interchanging hospital functions independent of the supporting structure. A supporting structure with concrete columns makes this possible because the internal fittings geared to the function can be removed without constructional consequences and be reconstructed once again. 4. External flexibility : The term refers to the possibility of expanding13 the existing building structure. Expansion possibilities are mainly programmed for functions where growth may be expected. In the

14. Finances Module 314

15. Average Costs The cost computed per bed depends on various factors, such as the cost of the land in a particular place, the wage and salary rate, accessibility of materials, and so on. Similarly, sophisticated equipment and expensive construction material will significantly enhance the investment. Average costs for a typical hospital expressed as per bed, can be rise proportionally: Tertiary Secondar y Primar y15

16. How much money do you need? 1. People in the business. Not the competitors, but entrepreneurs outside your geographic area. 2. Sources of supplies. Theyre very forthcoming because theyre looking for business [from you] but "Do some comparison shopping, 3. Trade associations. 4. Business start-up guides. How-to start-up guides are available from several independent publishing companies and some trade associations.16

17. How much money do you need? 5. Franchise organizations. If youre thinking about buying a franchise, the franchisor will give you lots of data about start-up costs. 6. Business start-up articles. Newspaper and magazine articles rarely give item-by-item start-up-cost estimates but these write-ups can offer ballpark estimates of overall start-up costs. 7. Business consultants. A well-qualified business consultant can offer excellent advice about start-up costs--and even do a lot of the research for you. A consultant can also help you organize your own research into useful financial projections and scenarios.17

18. Sources of funds Government grant- Bank loan Local development corporation A relative Government How good is your case Hurdles to cross-hard-headed administrators, planning officers and financial experts Private - a prospective lender will review your creditworthiness.18

19. The "Five Cs" of Credit Analysis Capacity to repay -most critical. Primary source of repayment - cash. The prospective lender will want to know exactly how you intend to repay the loan. Capital-money you personally have invested in the business and is an indication of how much you have at risk should the business fail. Interested lenders and investors will expect you to have contributed from your own assets and to have undertaken personal financial risk. Collateral or guarantees are additional forms of security you can provide the lender e.g. home. Conditions describe the intended purpose of the loan. Will the money be used for working capital, additional equipment or inventory? Character is the general impression you make on the prospective lender or investor. Are you trustworthy to repay the loan?19

20. Hospital size Module 420

21. Physical Scale of Hospital Stage 1: Collect Data Suppose data collected is: Population of serving area 150 000 Average length of stay in hospital 5 days Annual rate of admissions 1 per 20 population21

22. Physical Scale of Hospital Stage 2: Compute number of beds needed (Bed occupancy 100%) (1) Total number of admissions per year: = district population x rate of admission per year = 150000 x 1/20 = 7500 (2) Bed-days per year: = total number of admissions per year x average length of stay in hospital = 7500 x 5 = 37500 (3) Total number of beds required when occupancy is 100%: = bed-days per year 365 days = 37500 365 = 102.74 Rounded to 105 beds.22

23. Physical Scale of Hospital Stage 2: Compute number of beds needed (Bed occupancy 80%) (1) Total number of admissions per year: = district population x rate of admission per year = 150000 x 1/20 = 7500 (2) Bed-days per year: = total number of admissions per year x average length of stay in hospital = 7500 x 5 = 37500 (3) Total number of beds required when occupancy is 100%: = bed-days per year (365 x 80%) days OR (365 x 80/100) days = 37500 365 = 128.42 Rounded to 130 beds.23

24. Physical Scale of Hospital Stage 3: Compute total area needed for hospital Total area of hospital: = total number of beds x 40 square meters per bed = 105 beds x 40 = 4200 square meters (for 100% occupancy) = 130 beds x 40 = 5200 square meters (for 80% occupancy)24

25. Design considerations Module 525

26. Design of the general hospital building guidelines The guidelines were drawn up on the basis of the different activities that take place in a hospital. These are activities that concern the primary process, i.e. the direct interaction between the patient and the care provider (nursing, diagnostics and treatment), these different activities may be subdivided into three blocks: A. patient-related facilities where the patients themselves are/may be present; B. patient-related facilities where patients themselves are not present; C. general & technical support services. This subdivision is not a blueprint for the way in which a hospital should be divided up, but merely forms a plan based on the different activities within a hospital.26

27. A. Patient-related facilities where the patients themselves are present Three main function groups in this block are: 1. Nursing; 2. Diagnostics & treatment; 3. Special functions (if present). The nursing main function group includes the spatial facilities for special care, general nursing, paediatric nursing, maternity nursing (including delivery rooms), geriatrics and day nursing. The diagnostics & treatment main function group includes the following spatial facilities: outpatient appointment department, general organ function investigations, imaging diagnostics, nuclear medicine, outpatient treatment, operation unit, emergency unit and physiotherapy. The special function main function group includes the spatial27 facilities for dialysis, a rehabilitation day treatment unit or a

28. B. Patient-related facilities where patients themselves are not present This block includes the spatial facilities for: Central Sterilising Services (CSSD), The pharmacy and The laboratories clinical chemistry, medical microbiology, clinical pathology28

29. C. General & technical support services This block includes general and staff facilities (such as central kitchen, linen service, restaurant and technical service), as well as facilities for management and training. There is a trend towards outsourcing some of the facilities listed under B and C to third parties. This is particularly the case with the laboratories and pharmacy, administrative tasks, kitchen facilities, linen service and technical service.29

30. Share as percentage of different blocks what the share in percentage of the different blocks of the floor area on the basis of the usual function package of a general hospital. Function group Share as percentage Standard package Block A: patient-related facilities (patient 65% present) Block B: patient-related facilities (patient not 10% present) Block C: general & technical (non-patient- 25% related) services Total 100%30

31. Planning Module 631

32. Methods of planning and design Planning team & process In general, the people involved in this process are: 1. Health planners, functional planners, financial planners and physical planners. 2. Architects 3. Engineers (such as civil, mechanical and sanitary) 4. Quantity surveyors 5. Finance managers 6. Staff responsible for procurement of supplies 7. Staff members such as doctors/nurses, clients/end users32

33. Methods of planning and design Planning team - Need assessment teamAt the earliest stage, a needsassessment team involving theplanners, end users such as thehospital staff and the communityestablishes an overall plan of theneeds, range of services to beprovided, the target population orcatchment area, the financialfeasibility of the project withcostbenefit analysis and the scaleof the hospital, etc.33

34. Methods of planning and design Planning team Briefing teamAfter the needs and the size of thehospital have been determined, thebriefing team involvingarchitects, engineers, the staff andthe community sit together toprepare the key document, i.e. "thedesign brief" which translates therequirements intofunctions, activities, spacedistribution and/or any otherinformation necessary for thedesign.34

35. Methods of planning and design Planning team - Design teamThis team consists of all the peopleinvolved in designing the facility andpools the expertise of its members toproduce the instruments forimplementing construction, startingfrom preliminary investigation to thefinal designs with technicalspecification, tendering documentsand detailed working drawings andestimates of cost. This team mainlyconsists ofengineers, architects, quantity, surveyors, hospital staff, the communityand the approving authority.35

36. Methods of planning and design Planning team - Construction team This team consists of engineers, architects and builders. The construction team implements the design from the approved drawings and technical specifications within the prescribed time and cost and produces tile facility for commissioning cause serious complications when left untreated.36

37. Methods of planning and design Planning team - Commissioning team The commissioning team responsible to staff the hospital, commissions and procures the equipment, furniture and supplies and prepares it for operation.37

38. Methods of planning and design Planning team - Planning team By the end of the project, multitude of people would have made their contribution to the project as part of a whole working team including the community.38

39. Planning process-contd. Project Team End users Staff Planners Architects Engineers Contractors Suppliers39

40. Stages in planning & designing a hospitalStag Task Input output Working Teame Active Consultativ eOne Establish Information Decisions to User/Client demand for new Indicators construct, Planner hospital or for Projections renovate, hospital expand expansionTwo Prepare design Services to be Design Brief User/Client Architect/ brief delivered Engineers Function requirementThre Design Design Brief Design of Architect/ User/Cliente Additional Data Hospital Engineers from consultants Working documentsFour Construct Design of Hospital Hospital in Architect User/Client Working drawings physical form Builder EngineersFive Commissioning List of Staff Appointment User/Client40 and training of List of furniture Procurement staff staff

41. Size of project Small Medium Large A formal Project Team will be set up. Everything will have to be in writing. To keep a record of decisions.41

42. Planning process Capricode In NHS UK: When planning and building, the Regional and District Health Authorities and their officers are compelled to follow Capricode (Capital Projects Procedures) and operate systems of approval, monitoring and control which are compatible with it. It is a logical sequence of events. It is only a framework, the results depending on how the Appraisal Project Teams use that framework.42

43. Planning process-contd. The Capricode sequence of stages is: 1. Approval in principle (AIP). 2. Budget cost. 3. Design - a long process when sketch plans are developed into working/production drawings ready to go out to tender. 4. Tender and contract - normally the tender documents go to a chosen group of contractors of proven ability: 5. Commissioning . 6. Evaluation -this should be a continuous process. At each stage, what has been done should be assessed and consideration given to possible effects on future progress of the scheme. Overall effectiveness can only be assessed when the project is complete and working.43

44. Planning process-contd. CONCODE: A guidance document on the procurement of building and engineering work and the commissioning of consultant architects and engineers.44

45. Planning process-contd. CONCISE: In NHS UK: A computer-based integrated health building information system to help in the planning and management of projects. It may be used for any scheme, but it must be used for those over 1 million.45

46. Critical path chart46

47. Planning process-contd. Approval in principle (AIP) Once it has been decided that a project has sufficient merit to start an appraisal, a Project Manager will be appointed and an Appraisal Team set up, with membership limited to those making an essential contribution to the relevant stage, changes in membership being considered at the end of each stage. The members will be drawn from those managing and operating the services (doctors, radiographers, nurses, etc.) and those administering assets and resources. Three early steps will heavily involve the doctors and paramedical: 1. Inception; 2. Defining objectives and criteria for development; and 3. Option appraisal.47

48. Planning process-contd. Budget cost Once the decision has been taken that the solution involves building, either new (considered during AIP) or the extension of old, a Project Team will be set up. The job of this team is to develop the scheme, drawing up a brief which includes site, size and scope of the development, subsequently moving to specific layouts of individual rooms and spaces, detailing their contents and arriving at cost implications - both capital and revenue.48

49. Planning process-contd. Design Brief The design brief is a key document: it is the written expression of the clients needs, as expressed in consultation with various professionals, including the architect and engineers. It is important because a good design brief is the sound base for a good design.49

50. Planning process-contd. Information included in design brief 1. Functional content 2. Philosophy of service 3. Workload 4. Planning principles 5. Staffing 6. Functional relationships 7. Environmental factors and engineering 8. Schedule of accommodations 9. Financial aspects 1. Costs 2. Possible sources of funds50

51. Planning process-contd. Departments operational policy Many decisions will require a very complete knowledge of the way in which the department is intended to work; one department will not be exactly the same as any other. This detailed picture will be formalized into the Departmental Operational Policy. Not only will a carefully thought out policy be needed for planning but also for commissioning. The Operational Policy and the layout reciprocate. The layout will dictate the patient and staff flow sequences and hence the Operational Policy, but the needs shown by the Operational Policy will be the major factor in deciding layout-so which comes first? If there is no well worked out Operational Policy, a layout is likely to be imposed because there is nothing to support or deny alternatives. It is not only patient/ staff flows: for example, it may be policy that all equipment maintenance will be carried out by outside contractors.51

52. Planning process-contd. Work flow list A workflow comprises a series of tasks that are assigned to users based on their roles. When the work containing the workflow is instantiated, a user is assigned a task based on his or her role. After the user completes a task the workflow progresses to the next task in the predefined flow until the workflow is complete. The workflow definition integrates all tasks in the flow by supporting rule-based condition handlers for task sequence, routing, and branching at specified decision points. The Work Flow list is an internal departmental document, exploring the viability of the policy.52

53. Planning process-contd. Work flow list-example53

54. Planning process-contd. Using the policies and WF lists For example in a radiology department: Operational policy : Reporting time-Immediate reporting will be available. Therefore: Procedure worked out in detail planning needs determined from work flow lists. This results in layout plans and required drawings.54

55. Planning process-contd. Individual rooms and areas After decision-how many rooms are needed, where and in what layout, planning comes to the individual rooms and spaces. Each Project Team should determine an area for any room or space on the basis of activities that will be needed to meet local circumstances and allocate enough space for those activities to take place. Illustrations of the critical dimensions necessary for general functions can be found in HBN Documents.55

56. Planning process-contd. Activity data sheets This is an information system designed to help both sides of a project and design team by defining the users needs more precisely. There are two principal types: 1. Activity Space Data Sheets (commonly known as A Sheets) and 2. Activity Unit Data Sheets (B Sheets). These are meant to be used by design teams to ensure that the necessary space, equipment and environment are provided to enable the functions of the area to be carried out efficiently.56

57. Sample A sheet57

58. Planning process-contd. The A Sheets are in sections which cover: 1. Functional design requirements: a list of activities that will be undertaken in the space. 2. Activity unit selection: items of equipment that will be needed to enable the activities to be carried out. 3. Personnel: how many people will be occupying the space both continuously and intermittently, staff and patients. 4. Additional equipment and engineering terminals: items not associated with the equipment listed in (2), e.g. clock, curtain track. 5. Planning relationships: for example a barium enema WC will need to be adjacent to the fluoroscopy room. On the reverse side of the sheet are environmental parameters, design character data, door and window details, etc.58

59. Planning process-contd. The B Sheets: The B Sheets can describe a single item such as a chair, or a cluster of associated items such as wash basin, paper towel dispenser, soap dispenser and paper sack stand. Each B Sheet includes a scale graphic illustration together with a list of associated items in Groups 1, 2, 3 and 4.59

60. Sample B Sheet60

61. Planning process-contd. Equipment groups The equipment for any project is divided into groups which depend on the type of contract under which the items will be provided: Group 1: Items (including engineering terminal outlets) supplied and fixed within the terms of the building contract. Group 2: Items which have space and/or building construction and/or engineering service requirements and are fixed within the terms of the building contract but are supplied under arrangements separate from the building contract. Group 3: As in Group 2, but supplied and fixed (or placed in position) under arrangements separate from the building contract. Group 4: Items supplied under arrangements separate from the building contract, possibly with storage implications but otherwise having no effect on space, building construction or engineering service requirements.61

62. Planning process-contd. Equipment groups-examples Group 1: Telephones, clocks, fixed cupboards, drug cupboards, wash hand basins and taps, nurse/ staff call switches, departmental intercom, protective screens, fire extinguishers. Group 2: Soap & tissue dispensers, bench-mounted film markers (less important with daylight systems), viewing boxes. Group 3: All X-ray and imaging apparatus, processing apparatus, filing cabinets, bookcases, movable cupboards, chairs, desks, typewriters, dictating machines. Group 4: Blankets and pillows, cups and saucers, curtains, protective aprons and gloves, a wide range of desk-top accessories.62

63. Planning process-contd. Budgeting for equipment The cost of all equipment, has to be assessed and money allowed for it in the project budget. Equipment is always purchased a long time after the overall budget is decided in the Agreement to Proceed (stage 1 in Capricode) and worked out in more detail in Budget Cost (stage 2). Prices will inevitably rise; there is updating of the predicted cost every 6 months. The process of updating the budget will see that money is available at the right moment for the agreed equipment. There will not be the money for a change of mind. e.g. CT to MRI machine.63

64. Planning process-contd. Consultation over equipment For most items, the hospital standard will be acceptable (e.g. clocks and soap dispensers) but several items require special consideration. Particularly in specialized services. Unless details are specified in the building contract, supply of the these items will be put out to tender by the builder and he will take the cheapest, which may not be suitable. Adequate consultation to ensure that the correct apparatus was specified and supplied is necessary.64

65. Planning process-contd. Instruction to architects The important principle at this stage of planning is that a suitable A Sheet or group of A Sheets is chosen for the activity under consideration and the listed B Sheets are checked for suitability, notes being made of any points requiring special attention. As necessary, amendments are made in the A and B Sheets until the desired result is achieved. The groups of A and B Sheets for all the activities and spaces will be collected together and will constitute the foundation of the design of the department and its contents. These, together with the final layout drawings, are the basis on which the architect will proceed with the detailed design of a department or an extension, and will thereby constitute his instructions.65

66. Planning process-contd. Architectural drawings Block drawings: Once the selection of A and B Sheets, including any necessary amendments or modifications, has been completed, preliminary drawings are prepared and submitted to the Project Team for comment. They will show room shapes but little else.66

67. Planning process-contd. Agreement of layout With the many conflicting requirements to be resolved by the architect, it will be rare for this first block drawing to be completely satisfactory. If previous briefing was accurate and complete, the work done earlier is repaid at this stage. As the block drawing stage proceeds, requests for substantial changes will taken with smile; but if the basic concept is acceptable, minor alterations are taken willingly. It may be possible to propose suitable solutions, but take care not to tell the other professionals how to do their job. If the architect does not get it right, it is probably because your briefing and explanations are inadequate or not understood. The more accurate and the more comprehensive the briefing, the more likely it is that your needs will be translated into satisfactory plans. Finally there will be agreed outline drawings: any future change of layout will be67 resisted.

68. Planning process-contd. Sketch plans When the final layout has been agreed, the process of refining the outline starts; the loaded drawings will start to appear - in other words the fixtures and fittings will be drawn in. As with all the other drawings, these need to be looked at with care; look not only at the location of obvious things, but also the smaller but no less significant items. Now is the chance to ensure that the niggles over the positioning of socket outlets in your office or the sitting of a clock are not repeated; go through every room and space positively, checking all the details.68

69. Planning process-contd. Freezing drawings By the end of this stage of the planning process, the final layout and the functional requirements will have been agreed. The drawings are then frozen. It is from these that the detailed design work starts, with structure, ventilation, electrical and water supply, etc., to be added - a tremendous amount of work with numerous drawings for every part of the building, each devoted to one aspect of the structure or services. These are the Working/Production Drawings. Any change from now on is not just a line on a piece of paper, but will have wide-ranging significance, and it will only be allowed if there is very strong representation backed up by cast- iron reasons. Changes may delay the whole project, which can have implications for costs as well as time.69

70. Planning process-contd. The fallow period From the time of freezing the drawings, there is a long period during which working/production drawings are prepared, tenders invited, contract awarded and building starts. It may appear fallow (empty) for the staff, but there is work to do and it is not nearly as fallow as it looked at first sight. There should be detailed review of the Departmental Operational Policy, deriving from it things like staffing levels and job descriptions for various members of staff.70

71. Planning process-contd. Ordering equipment The specialized Engineer will be involved in the selection and ordering of equipment and a Supplies Officer in the others. Their brief will be to help in the selection process, but they will inevitably be conditioned by what is available on contract, by Policy and by other constraints. We may study equipment care later on.71

72. Commissioning Ready for service. Before being awarded this title, however, a hospital must pass several milestones. Equipment is installed and tested, problems are identified and corrected, and the prospective crew is extensively trained. A commissioned hospital is one whose materials, systems, and staff have successfully completed a thorough quality assurance process.72

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