December 12, 2012

MH0052 [Hospital Organisation Operations & Planning] Set1 Q3

Q3. Kunnath enterprises is a construction company would like to open a new hospital at Yelahanka, Bangalore. They have got a team who constitute the hospital planning
a. Who are the team of experts who constitute the hospital planning?


Hospital Planning Team
The hospital planning team should ideally consist of the following members:

1. Hospital Administrator
The Administrator is the chairman of the planning team. He is mainly involved in putting up hospital requirements to his team in terms of, facilities for the hospital, design consideration, orientation of interrelated departments and service facilities. He also oversees and coordinates the various activities involved in planning.

2. Hospital Engineer
The engineer appointed to prepare the plan of the hospital should have previous experience in constructing hospitals. He works in close coordination with the administrator and the architect.

3. Hospital Architect
The hospital architect should have knowledge of the work flow involved in a hospital setup so as to suggest the design considerations of the hospital. The experience and expertise of the architect and the hospital engineer helps in planning a good hospital.

4. Financial Expert
The financial expert helps the administrator to study the feasibility of the project. He can advice on the funds required for the project and the sources available for the same. The estimates given by the finance expert helps in drawing up a smooth plan.

5. Health Statistician
The health statistician also contributes to the study of the feasibility of the project. He helps the team by providing vital information on the demographic picture of the region, disease related statistics, socio-economic condition of the people, all of which helps the administrator in deciding the type of facilities required and charges to be levied.

6. Representatives of government or local bodies
The representatives of the government or local bodies help in the coordination of the project. They form a link between the community and the hospital.

7. Nursing Director/Superintendent
The nursing director can give valuable inputs to the project team, especially in ward planning.

8. Social scientist
The social scientist helps in identifying the felt needs and real need of the community. His suggestions during the planning process helps in fulfilling the community's expectations of the project.

9. Consultant representative from user department
The success of everything planned in the hospital depends on whether it is user friendly. It is therefore necessary for the planning team to take into consideration the suggestions of the consultant representative from the user department. The design and functioning should be user friendly.

b. What are the steps followed in hospital planning?

The steps involved in preparing a project proposal for a hospital can be short listed as follows:

Conceptualization/ inception
This step involves the decision to build a hospital. The type of hospital to be built, location for the building, whether it should be a corporate, nonprofit voluntary or trust hospital should be decided at this stage. The target group which would benefit from this venture should also be considered.

Project Conceptualization :  This is the preliminary stage where one is trying to visualize his / her hospital in terms of its ownership, philosophy, bed-mix, facility-mix, etc.  This requires undertaking at the very least a basic but comprehensive research of the physical, geographic surroundings of the proposed area. Most important, this information can be obtained through the web, current and archived newspaper mentions, municipality reports, and then undertaking a short survey or holding focus group discussions.  The basic idea is to understand the gaps in the medical market in that area and intending to fulfill them, unless of course, the owner is a Doctor entrepreneur, who knows exactly what he wants.

Feasibility study/ Project report:
Extensive data is required while preparing the project report. It is as good as virtually visualizing the entire hospital. In depth technical knowledge is required to prepare this report. It estimates the viability of the project and explores the possibility of raising funds from investors, stake-holders, banks and other sources.

Feasibility Analysis :  When the project concept in understood, agreed on and locked-in, the next stage is to understand the viability of the proposed hospital.  This would mean undertaking a detailed working of at least the following:

  Project Cost:  Comprising of civil work, medical equipments, furniture and fixtures, professional fees, interest during construction, pre-operative expenses and contingency expense appropriations.

  Department wise assumptions of income, expenses, depreciation schedule, loan repayment schedule, etc.

  Profit & Loss, Balance Sheet,  Cash Flow Statements.

  Sensitivity Analysis:  This is the most important document generated for the project and helps the Promoter to undertake a “go or no go” decision. It also identifies the financial limitations of the proposed project and  frequently helps the Promoter to structure the means of financing the project.  It’s important to note here that all assumptions should be made with a realistic view.

Project approval by appropriate authority:
After preparing the feasibility report, the same need to be submitted for sanction to the appropriate authority.

Site selection
The selection of site for the purpose of construction should be decided upon with utmost care. There should be exhaustive information of the selected plot of land. It should take into consideration transport modalities available for quick access to the hospital, environmental factors (wind, rain, sun, smoke, height of neighboring buildings), sources of water supply, electricity etc. There should be a good communication system operating in the locality (phone lines, pagers, mobiles, fax etc).

Preparation of Master Plan
Preparation of master plan is to establish circulation routes (both internal & external) on the site where various departments and buildings that make up the hospital can be established with no inconvenience caused. It can be written, sketched, or a model. It may include future plans, expansion of particular areas and identifying buildings for expansion.

Architects brief/Functional brief
An architects brief is the written expression of the functional need of the client, prepared in consultation with various professionals in the planning team. The contents of the functional brief includes a broad description of the project, schedule of accommodation, functional policies & procedures, staffing and equipment requirements, functional interrelationship among departments.

Preliminary drawings/Working drawings
This is the design stage in which the functional brief is converted into drawings. The hospital administrator has a consultants role to play at this stage, clarifying doubts which the engineers and architects may have.

Hospital Designs :  Hospitals are highly engineered buildings, so this step requires a meticulous attention to micro details.  For this reason alone, its vital that one hires a competent team of designers, which would include a  architect, a structural consultant, a electrical consultant, a plumbing consultant, a interior and designer consultant, a landscape consultant, etc.  The emphasis should be a building which does its job brilliantly, more functional than glamorous.  The focal point of this exercise should be to ensure that energy efficiency, natural light and ventilation and ease of maintenance get all the special attention they need. Always remember that the highly engineered buildings cost more and the per sq.ft. cost  would vary between Rs. 1,500  and  Rs. 3,000 per sq. ft.

Actual construction
This stage involves notifying tenders and calling for quotations. Selection of tender and award of contract are the steps that follow before starting the actual construction.

Equipment planning
This involves short listing the companies, selection of the models after discussion with those who use them, arranging for model demonstrations, negotiations and calling for quotations. Sometimes training sessions are arranged for equipment handling among the staff if required.

This involves recruitment, selection and training for all grades and designations.

Commissioning of the hospital
This involves forming a commissioning team which includes heads of administration, nursing, finance, stores & purchase and human resources. This team begins coordinating, planning, staffing people and installing equipments for commissioning the hospital. The team is also concerned with developing an operational system and framing policies and procedures. The sequence of stages of commissioning the entire hospital is also decided by the commissioning team.

Commissioning the Hospital: The last step of hospital project is to ready it for accepting patients and starting all operations.  This process should begin at least 6 to 9 months prior to inauguration as there are a plethora of activities  to be completed before the patient walks in, issues like developing personal policy, salary structure, standard operating procedure for all department selecting and customizing hospital information system, recruitment, trial runs of equipments, stationary, designs, etc.  It is generally easier to put up the hardware, but the success of the project will depend on how the software bit of commissioning the hospital is handled.

Project Management: The  notion that an architect is automatically a good Project Manager is a myth. Even from a layman’s angle, it should not be very difficult to understand that the architecture should effortlessly accommodate the complexities of engineering services and the installation of very sophisticated, very costly medical equipment — apart from the various financial  and speed of work related issues involved in project execution.  You can see why it is extremely important to have a separate project management entity to ensure that the final designs are executed as per what was envisaged.  All tendering activities, quality of construction, managing change of design midway, site safety and bill certification periodically are some of the vital aspects of project management.

Shake-down period
The shake down period is the time taken from total commissioning of the hospital till satisfactory functioning of the hospital is achieved. This may prolong even to a few years. A well planned project will have a very short shake-down period.

Hospital Planning

While planning on a hospital, the following points may be borne in mind:
Accessibility and Traffic
Building Structure
Town Planning, and last but not least

Newer technology and new trends in medicine, emerging concepts in building structure and requirements have made hospital being flexible all the more important and challenging.

Certain trends in Hospital Planning encompass the following points:
Rapidly changing needs and technologies
Changing regulations (by governments and insurers), with direct impact on hospital design.
Life-cycle costs determining changes in architecture and in construction methods
New standards for admission to inpatient wards: short stay (daycare); inpatient ward, up to 5 days; hotel stays at either moderate or more luxurious hotels (private patients); nursing home; home for the elderly (long stay)
More focus on preventive medicine
Patients with complex diseases and more than one disease (comorbidities) will determine more and more the functions of hospitals in the future
Hospitals have to be able to attract medical tourists
Hospitals must be acceptable to all cultures and religions
Many hospitals have to cope with the implementation of technical information and communication systems, including IT networks like HIS, RIS, PACS (Health Information System, Radiology Information System, Picture Archiring Communication System)
Changed room requirements (e.g. imaging PACS) due to new workflow procedures (filmless / paperless / wireless hospital)
The expectation of the patients / customers are rapidly increasing
Much more focus on OPD services, short patient stays, and daycare
The healing environment plants, water and natural daylight have a proven influence in the patients recovering process is playing a central role and also enhancing the concentration and well-being of the doctors, nurses and staff
Architecture as a company brand architecture must be updated and upgraded
Natural light and natural ventilation for most of the buildings, especially for the inpatient wards and workplaces
More emphasis on easy way-finding for elderly and disabled people
New meaning: the hospital is not a place for sickness and sick people but rather a place for health and recreation!

Consider the following during planning stages:
Primary structure: This includes the main structure with floors, columns and walls, should be built to have a 50-60 year lifespan.

Secondary structure: 
The secondary structure (in terms of the three main structural groups) has a life-span of 15-20 years. Examples of the secondary structure are:
Steam, ventilation, cooling, water of different qualities, gases, waste-water systems
Electrical lines of the most diverse types, and fire-extinguishing systems
IT net with fiber optic cables, pneumatic delivery, gas exit lines, all supply and disposal pipelines, elevators, heating, radio nets, etc. Since the kinds of installation and their capacities vary dramatically, an undefined, chaotic structure of installation routes and their junctions can be found in nearly all hospitals
Examples of increasingly frequent installations in hospitals are: air conditioning systems, electrical lines, and fire protection systems
Examples of reduced systems are: pneumatic delivery, heating systems, steam installations. In general, the installation system as a whole diminishes a hospitals flexibility and, even worse, makes necessary changes of units very expensive. Architects and engineers have to implement increased requirements for nearly all installation system groups, including installation, emergency energy supply, the fire alarm system, electrical and electronic installation, IT systems, etc.

In practice, the flexibility of hospitals should be measured by the organization of its installations. Among several solutions already tested are:
Substantially larger story heights, in order to be able to plan sufficient straight-line installation routes
Systematic junctions for crossing installation of different types (electrical installation, air-condition installations, gases)
All installations located above the main corridors, with short bypasses reaching the rooms
No bypassing of room units to reach other departments
Fire protection provided not directly oft the installation, but oft easily removable panel ceilings
Implementation of smart technologies with less consumption of space and easier maintenance, e.g. fog fire sprinklers, which eliminate water damage and operating problems.

Tertiary structure: 
The tertiary structure (in terms of the three main structural groups) has a lifespan of approximately 10 - 15 years. The elements of this structure include:
All decoration and furnishings, wall panelling, paint colors, lighting, floor mats, etc.

All flooring, dry-wall construction, wood fittings
All furniture, and all sanitary equipment, such as basins
False ceilings, doors, and internal glass constructions
All installation system routes
Considering the primary, secondary and tertiary structure of a hospital:
Diversification of classesof hospital departments
Planning strategies should be respected at all times. Hospital planners have to distinguish among the following categories or classes:
- departments with many installations, like OT, ICU, nuclear medicine, ambulant surgery, emergency department and laboratories
- parts with fewer installations, like wards, which could be named hotel-areas
- departments like administrative offices and OPD consultation rooms with still less in the way of technical installations, medical equipment, training facilities, etc.

Keeping these classes in mind, the hospital might want to focus on the possibility of certain micro-extensions or changes of the interior within the same levelof the above-mentioned classes. Establishing a new high-tech treatment or diagnostic area in a class A high-tech department located in an area with the necessary level of blood and nerve system capacity, is easier than introducing an OR department in an administration area.

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