PLANNING AND ORGANIZATION OF HOSPITAL

Mr. RAKESH PATIDAR JCN, BHANDU

INTRODUCTION
A hospital, in the modern sense, is an institution for health care providing patient treatment by specialized staff and equipment, and often, but not always providing for inpatient care or longer-term patient stays. Its historical meaning, until relatively recent times, was "a place of hospitality". It is a health facility where patients receive treatment . Hospitals are the most complex of building types. Each hospital is comprised of a wide range of services and functional units. These include diagnostic and treatment functions, such as clinical laboratories, imaging, emergency rooms, and surgery; hospitality functions, such as food service and housekeeping; and the fundamental inpatient care or bed-related function.

MEANING OF HOSPITAL
The word hospital is closely related to the word hospitality and is derived from the word hospice which means a place for refuse a house for rest. This is should be the underline factor in planning a hospital.

DEFINITION OF HOSPITAL
ACCORDING TO WHO:Hospital is an integral part of a special and medical organization, the function of which is to provide for the population, the complete health care, both curative and preventive and whose outpatient services reach out to the family and its home environment. The hospital is also a centre for the training of health worker and for bio-social research.

ACCORDING TO STEADMANS MEDICAL DICTIONARY:-

Hospital is an institution for the care, cure, and treatment of the sick and wounded, for the study of the disease and for the training of the doctors and nurses.

IMPORTANCE OR PURPOSE OF THE HOSPITAL :Provide care, cure, and preventive services to all people irrespective of race, color, caste, and economical and social status. Protect the human rights of clients while clients taking care in its jurisdiction/ in all areas of its services. Provide training for professionals, i.e. doctors, nurses, pharmacists, dentist other technical staff. Provide in-service and continuing education. Participate/ conduct research (and investigation in basic and applied biomedical, social sciences) Define the role of leadership in community.

FUNCTIONS OF HOSPITAL:

Client care: - care of the sick and injured the diseased person. Diagnosis and treatment of disease: - there are diagnosis and treatment services to in-patients. Within this broad function there are many division of medical, surgical, OBG, pedia, etc Out-patient services: - there are services to out-patient with an equally wide range of specialties and technical modalities. Medical education and training: - hospital provides professional and technical education for many classes of health personnel. Medical and nursing research: - since accumulation of different types of patient, the hospitals provide the basis for scientific investigation. Prevention and disease and promotion of health: hospitals provide services to surrounding population that may be preventive care and promoting their health.

MANAGEMENT OF THE HOSPITAL

Governing body:The governing body is the highest decision making authority of a hospital. It formulates policies and provides direction to the hospital for effective and efficient function of the hospital. The governing body should review the status of the hospital services at least once a week with a minimum of 7 members present at each meeting. Hospital committee:The governing body appoints a hospital committee to look after the day to day functioning of the hospital or any particular area.

Medical director:In larger hospital the medical director overseas the functioning of the hospital and look after the intake and turnover of staff. Medical superintendent:It ensures that the policies of the governing body are effectively implemented to maintain standards and provide quality patient care. He/she responsible for the overall performance of the medical staff and is helped by the hospital administer, nursing superintendent and department heads.

Hospital administrator:The hospital administrator for all administrative and support services in the hospital. He/she provides leadership and coordinates all support service as finance. Housekeeping, legal matters, human recourses development, marketing. Nursing superintendent:It is responsible for all nursing services. These involve planning patient care, obtaining regular ward/patient reports/data from nurses and reviewing them. Department heads:Heads of various departments are responsible for the smooth and uninterrupted functioning of their areas. They ensure a good working condition of the equipment and project future needs to the hospital administrator.

CLASSIFICATION OF HOSPITALS The most commonly accepted upon different criteria for classification of the hospital are according to: I. Length of stay of patient (long term and short term) II. Clinical basis III. Ownership/ control basis IV. Objectives V. Size VI. Management VII. Systems

LENGTH OF STAY OF PATIENT (LONG TERM AND SHORT TERM)

A patient stays for a short term in a hospital for treatment of disease that is acute in nature, such as pneumonia, peptic ulcer, and gastroenteritis, etc.
A patient may stay for long- term in a hospital for treatment of disease that is chronic in nature such as tuberculosis, leprosy, cancer, psychosis. The hospital according to long-term and short term also known as chronic care hospital.

Clinical bases: These are hospital licensed as general hospital; treat all kinds of disease, but major focus on treating speed disease or condition such as heart disease, or cancer.

OWNERSHIP/ CONTROL BASIS: It is into 4 categories Public hospitals Voluntary hospitals Private/charitable/nursing homes Corporate hospitals

Public hospitals Public hospitals are those run by the central or state governments or local bodies on non-commercial lines. These may be general hospital or specialised hospitals or both. Eg. J.J Hospital, K.E.M Hospital. Voluntary hospitals Voluntary hospitals are those, which are established and incorporated under the societys registration act 1860; or public trust Act 1882 or any other appropriate act of central or state government. They are run with public or private funds on a noncommercial basis.

Private nursing hospitals/ nursing homes An individual doctor or a group of doctors generally owns private nursing hospitals / nursing homes. They run the hospital or nursing home on a commercial basis. They accept patient suffering from infirmity, advanced age, illness, injury, chronic, disability etc. However, do not admit patient suffering from communicable diseases, alcoholism, drug addiction or mental illness. Usually they prefer patient from wealthy families. Corporate- hospitals Corporate hospitals are hospitals which are public limited companies formed under the companies act. They are normally run on commercial lines. They can be either general or specialised or both (Hinduja hospital, Mallay hospital, Apollo hospital, Apollo group off hospitals.)

CLASSIFICATION ACCORDING TO THE OBJECTIVES:

It is classified into 4 types 1. Teaching cum research hospital Teaching cum research hospital is a hospital to which a college is attached for medical/ nursing/ dental/ pharmacy education. The main objectives of these hospitals is teaching bases on research and the provision of health care is secondary,eg AIIMS,New Delhis,PGMERI, Chandigarh,JIPMER, Pondicherry, K R hospital, Mysore, Victoria hospital, Bangalore belong to this type.

2. General hospitals General hospital that provide treatment for common disease and conditions. all establishment permanently staffed by at least two or more doctors, which can offer inpatient accommodation and provide active medical and nursing care for more than one category of medical discipline such as general medicine, general surgery, obstetrics and gynaecology, paediatrics etc. the main objective of these hospitals is to provide medical care to the people. While teaching and research is secondary and incidental, e.g. all district and taluk or PHC rural hospital belongs to this type.

3. Specialised hospitals Specialised hospital are hospital providing medical and nursing care primarily for only one discipline or a specific disease or condition of one system. these hospitals concentrate on a particular aspect or organ of the body and provide medical and nursing care in that field, e.g. tuberculosis, ENT, ophthalmology, oncology, leprosy, orthopaedics , paediatrics, cardiology, mental health/ psychiatric, oncology, STDs, maternal etc. 4.Isolation hospitals Isolation hospital is a hospital in which the person suffering from infections/ communicable diseases required isolation of the patient, e.g. Epidemic diseases hospital, Bangalore.

CLASSIFICATION ACCORDING TO THE SIZE: SR.NO TYPE OF HOSPITAL BEDS

1.

Teaching hospital

500 beds ( beds to be increased according to the number of student )

2.

District hospital

200 beds ( may be raised up to 300 beds depending upon population)

3.

Taluk hospital

50 ( may be raised depending upon population to be served)

4.

Primary health center

6 ( may be increased up to 10 depending upon needs)

CLASSIFICATION ACCORDING TO THE MANAGEMENT:

Union management/ government of India State govt. Local bodies Autonomous Private Voluntary agencies

State government All hospital administration by the state/ union territory. Government authorities and public sector undertaking operated by the state the state union territories, including the police, prison, irrigation department etc. Local bodies All hospitals administered by local bodys i.e. municipal coopration, municipality, zilla parisad, panchayat e.g. coopration maternity homes. Autonomous bodies All hospital established under special act of parliament or state legislation and founded by the central/ state government union territory e.g. AIIMS, New Delhi.

Private All private hospital owned by an individual or by a private organization, e.g manipal hospital, Bangalore. Voluntary agencies all hospitals operated by a voluntary body/ a trust society registration or recognised by the appropriate authority under central/ state government laws. This includes hospitals run by missionary bodies and co-operatives.e.g. CMC, Vellore.

CLASSIFICATION ACCORDING TO THE SYSTEM: Allopathic hospitals Ayurvedic hospitals Homeopathic hospitals Unani hospitals Hospitals of other system of medicine.

REQUIREMENT OF HOSPITAL
A hospital shall have all of the following: (1) An organized governing body. (2) A chief executive officer. (3) An organized medical staff. (4) An organized nursing staff. (5) Medical services, continuous. (6) Nursing services, continuous. (7) Permanent on-site facilities for the care of patients 24 hours a day. (8) A hospital-wide infection control program. (9) Minimum on-site clinical provisions .

PLANNING AND DESIGNING A HOSPITAL

The planning of the hospitals depends on its objectives/ purpose. Once the objective/purpose of the hospitals has been identified, a project coordination team is appointed. This team is responsible for the planning and designing the hospitals. The project coordination team generally consists of: Financers Architect Engineers Medical officers Health planner Finance manager

STAGES IN PLANNING AND DESIGNING

HOSPITALS
There are 9 stages in planning and designing hospitals :1. Identifies available finance and other possible sources of finance. 2. Deciding on the area/ location of the hospitals. 3. Identifying the needs of the area by carrying out a survey. 4. Deciding on the present and proposed services to be offered. 5. Preparing the design. 6. Starting construction. 7. Identifying and hiring the required personnel and working out a schedule for training. 8. Working out a schedule for purchase of required equipment/ materials. 9. Commissioning the hospitals.

PHASES OF PLANNING AND DESIGNING A HOSPITAL

Following are the phases of planning and designing a hospital: FINANCE: LOCATION: PREPARING THE DESIGN: FINANCE:An assessment should be made of available finance and possible sources of arranging finance. Banks such as the industrial development bank of India (IDBI)

LOCATION:The objective/ purposes of the hospital along with the need of the community to determine the demand for hospital services identification and location.

Information gathered from the needs assessment survey of the community Local cultural practices Climate Population- birth rate Economic status Sources of income Disease pattern Major prevalent illness. Morbidity rate. Mortality rate. Available medical facilities. Average charge of medical facilities. Available of manpower Status of supportive service such as water, electricity etc

Factor determining the demands for hospitals services: Morbidity ( include prevalence of disease, accident rates, specific disease) Demographic (include the character of the population such as age group, sex ratio ) Socio economic factor Hospitals statistics
Catchment area: Urban a radius of 10-15 km initially may be considered in areas where good transport is available. Rural a radius of 20-25 km which could be increased depending on future requirement.

PREPARING THE DESIGN:

Once the location of the hospitals has been decided, the following factors should be considered: Site selection Legal requirement Size of the land. Plot ratio. Landscaping. Designing consideration Possibility of future growth Color coding.

ORGANIZATION OF HOSTITAL

ORGANIZING OF OPD

ORGANIZING OF OPD:
Care of the ambulatory patient is the main consideration in the OPD. For maximum efficiency there must be perfect coordination with the inpatient department (IPD) and the r facilities of the hospital. The main considerations are: Within the OPD, the physical facilities should be placed such that smooth flow of operation and easy and quick intercommunication is maintained. Service to common to both the IPD and OPD (radiology, laboratory, blood bank) should be readily and easily accessible. Provision of adequate auxiliary department. Installation and review of an appointment systems based on the doctors hours of working. Detailed review of amenities for patient.

LOCATION AND PHYSICAL FACILITIES

LOCATION

The OPD is the showcase of any hospitals, and reflects its image. It should leave an independent approach at the hospitals and should on the ground floor for easy access. Some treatment facilities like radiology, pathology, physiotherapy and blood bank should be interposed between the OPD and IPD. PHYSICAL FACILITIES AND SPACE REQUIREMENTS The OPD of a general hospital should have five distinct sections: 1. General facilities. 2. Clinics of different medical disciplines. 3. Supporting facilities such as laboratory and injection room. 4. Pharmacy. 5. Blood bank.

PLANNING :The size of the OPD depends upon the volume of attendance, the clinics provided and the extent of other facilities such as laboratory, blood bank, and health education programmed, operating facilities and emergency ward. The size of the OPD also depends on the land available and the location of the hospitals. The physical facilities may be considered under four groups - Public areas. - Clinical areas. - Administrative areas. - Circulation area.

ALLOCATION OF AREA (IN SQ. FT) FOR VARIOUS UTILITIES

Number hospital bed Public areas Clinical areas 1025 5655 2125 7105 3000 11205 3400 14695 4300 17525 4350 20815 of 50 beds 100 beds 200 beds 300 beds 400 beds 500 beds

Administrative

2260

2960

1420

5280

6200

7000

areas
Circulation areas 3060 3810 5175 6625 7965 9835

Total areas

12000

16000 1600

21000 2400

30000 3000

36000 3600

42000 4200

Wall and partition 1200 areas (10%)

Gross areas for 13600

17600

26400

30000

39600

46200

total building.

1. PUBLIC AREAS:

These will include the following Traffic Main Entrance Reception and Information Registration and Records Area Non-clinical Areas Entrance Hall Waiting-Area Public Toilets and Washrooms Snack Bar Consultation Room

Treatment/Dressing Room - The size will vary from120 sq. ft160 sq.

Special Examination Room

Medicine ECG 150 sq. ft

ENT

Audiometry

120 sq. ft

Psychiatry

ECT

100 sq, ft

Eye ,

Refraction room Perimetry room Tonography room Slit lamp room

160 sq. ft 120 sq. ft 120 sq. ft 120 sq. ft

Orthopedics

Plaster room etc

150 sq. ft each room

2. CLINICAL AREAS:
An OPD include surgical, dental, ophthalmic, ENT, maternity, and gynecology, pediatric, medicine, psychiatric, and emergency department. There are ancillary facilities such as treatment section which minor OT, injection and dressing room, dispensary. There is also a growing need to institute health education program in environmental hygiene, family planning.

3. ADMINISTRATIVE AREAS
Administrator's Office Business Office Housekeeping

4. STORAGE FACILITIES General Stores Drugs Stores Linen Storage

PLANNING AND ORGANIZING AN INPATIENT UNIT

PLANNING AND ORGANIZING AN INPATIENT UNIT

While planning a ward, the aim should be to minimize the work of the nursing staff and provide basic amenities to the patients so that his/her stay is made as comfortable as possible. 1. POLICY OF THE HOSPITAL: 2. PHYSICAL FACILITIES 3. STAFF I. POLICY OF THE HOSPITAL: The policy of the hospital will decide whether the hospital will be a general one with all facilities or specific (super specialty hospital) e.g. neuroscience center.

II. PHYSICAL FACILITIES 1. Location and area: The inpatient area should be located away from main and the OPD area. It is relegated to the back to ensure quietness and avoid disturbance and potential sources of cross infection Important measurement to keep in mind while designing the ward. The size of a hospital bed is 66 X 33. The minimum distance between the center of two beds should be 0.25 m, space at the foot-end 0.90m, space at the head-end 0.25m, thus the space required would be 3.15 m, x 2.25 m = 7.09 m2 (75 sq.ft)

The area per in a ward is 79-90 sq. ft. The area per bed in an acute ward is 100-120 sq. ft. The area per bed in the ICU is 120-150 sq.ft. A single bed room with independent toilet should have a minimum space of 125 sq. ft. Space between two rows of beds is 5 ft. The distance between two beds should be is 3 to 4 ft. The width of a dormitory should be 20 ft. The size should of an isolation units should be 14 m. Width of the hospitals corridors should be 3 m wide to accommodate two passing trolleys.

2. SIZE: The size of the ward or nursing unit varies in different hospitals. Various factor have a bearing on the optimum size of the unit. Type of the patient Requirement of staff Position of staff Position of the head nurse and ward clerk 3. SHAPE/DESIGN: The primary objective of the ward design is to enable the nurse to react to emergencies with maximum efficiency and minimum efficiency and minimum physical and emotional stress.

a) Open ward:-

The regular pavilion type of ward was first constructed in 1770 by a man Frenchmen about 80 years later. The Florence nightingale adopted this design and it is still known after her name. This ward consists of patient beds in two rows at right angles to the longitudinal walls the bathrooms and WC. About 30-35 patients were housed in such wards and the length of the ward was not less than 96 feet. This type of ward was in use till 1925.

Advantages

Disadvantages

Nurses

have

ample Visibility and can observe Danger of A critically ill patient, placed closer to the nurse's for maximum attention would lie in the centre of greatest traffic-density.

cross-infection patients directly.

There is cross-ventilation.

Danger of cross-infection. Noise and lack of privacy.

It is economical to construct and maintain thus.

Constant glare which disturbs the patients.

Natural light is available.

Danger of cross-infection.

b) Rig's ward:
the first major development over the above mentioned defects appeared in rigs hospital, Denmark and thus the name rigs ward. In this design the ward unit is divided into small compartment.

Cubicles separated from each other by low partition. Each cubicle having 1, 2, 4 or 6 beds arranged parallel to the longitudinal walls

Disadvantages of rigs ward: Communication between the nurse and patient becomes more difficult. Patients cannot be directly observed by the nurse. Wards are longer; consequently, the nurse has to walk more. More nurses are required. Costly to build and maintain.

TYPES OF WARD DESIGN

Nightingale Ward: - open ward with 2030 beds. L-shaped Ward: - in this, the nursing station is placed at the 90 degree junction. T-shaped Ward: - the nursing station is at the vertical arm and the patient areas are located on the horizontal arm. Serious patient and nurse to the minimum. Circular Ward: - this design occupies the minimum space and reduces the walking distance between patient and nurses to the minimum.

C) ANCILLARY ACCOMMODATION:-

Types of ancillary accommodation: Nursing station Treatment room Clean utility room Ward kitchen/pantry Day room Stores Dirty utility room Bathrooms and toilets Visitors room Duty room for doctors Seminar room Attendant room Side room laboratory Locker room for staff

III. STAFF Medical Nursing Supportive

SPECIALTY WARD UNITS

Postoperative and orthopedic wards Paediatric ward Psychiatry ward Skin ward Infectious diseases ward Obstetrics and gynecology department Operation theater unit Intensive care unit

HOSPITAL ANCILLARY SERVICE:

Those support services other than room, board, and medical and nursing services that are provided to hospital patients in the course of care. They include such services as laboratory, radiology, pharmacy, and physical therapy services. Dietry services Center sterile supply department (CSSD) Laundry services Laboratory services

DIETRY SERVICES
The purpose of dietary services department in every hospital is the preparation of nutritionally adequate , attractive meals. The goals of dietary service on hospital will include :i)Optimum nutrition of the patient. ii)The maintenance of morale. iii)The dietic education of patients , and iv)The achievement of these goals, with maximum effectiveness and resulting economy.

CENTER STERILE SUPPLY DEPARTMENT (CSSD) CSSD is the abbreviation of the Central Sterile Supply Department. The objective of establishing a Central Sterile Supply Department is to make reliably sterilized articles available at the required time and place for any agreed purpose in the Hospital as economically as possible, having regard to the need to conserve the time of users [especially Doctors And Nurses]. The Sterile Supply Department within a hospital receives stores,sterilizes and distributes to all departments including the wards, outpatient department [OPD] and other special units such as operating theatre [OT]. Major responsibilities of CSSD include processing and sterilization of syringes, rubber goods [catheters, tubing], surgical instruments, treatment trays and sets, dressings etc. it is also responsible for economic and effective utilization of equipment resources of the Hospital under controlled supervision.

LAUNDRY SERVICES
All hospital are concerned with the dangers of cross-infections and the need for using only sanitary , germ- free linen. So there is a need of an efficient mechanical laundry to ensure the availability of germs free linen. Surgically linen are autoclaved in the surgical area to ensure sterility and further safeguard the patients. 1. LOCATION AND SPACE: Whether the laundry is the main building of the hospital or in as space one. Or with one or more of the hospitals support services, its location should be convenient to the user units. 2. DESIGN CONSIDERATIONS AND PHYSICAL FACILITIES:the design of the laundry should be that it helps in the following main laundering process: Sorting (counting, weighing), Washing (sluicing, if blood-stained) Hydroextraction, Drying/Flat ironing, Pressing/Hand ironing/folding, Packing.

LABORATORY SERVICES
The primary function of laboratory or pathology services is to give assistance to the attending doctor in the diagnosing and treatment of patients. Investigations made by this service reveals normality or degree of deviation from normal. 1.Location and Space: - it should be centrally for easy access by clinicians. At the same time, it must be so situated that future expansion will not be impeded in designing a regional hospital laboratory, the requirement of space will be based on the services available, number of specialized units, the level of research to be carried out and possible future expansion. 2. Personnel: - the staff will consist of medical and non-medical professional, both technical and non-technical. The number will depend on the size of the department and the workload. The laboratory workload will vary, depending on the population, and the quality and kind of medical practice in the hospital.

DIFFICULTIES IN RUNNING A HOSPITAL

Failure to appreciate legal and professional responsibilities Problems in clinical management Medication errors Administrative errors Failure of communication, including inadequate medical records.

POLICY, RULES AND REGULATION

Definition Policy-plan of action (Fippo 1976) is a man made rule of predetermined course of action that is established to guide the performance of work toward the organization objectives. It is a type of standing plan that serves to guide subordinates in the execution of their task Those that apply to patients Those that apply to personnel Those that apply to environment in which patient receive care and in which personnel work Those that apply to relationship with other department of discipline

HOSPITAL POLICY FIELD

1.

2.

3.
4. 5.

6.
7. 8. 9. 10.

Provide patient care service, standard of care, type and volume of service, emergency services. Purchase of drugs, equipment and supplies Working capital investment Depreciation allowance Hospital personnel Public relations Medical services Nursing services Dietary services Controlling financial input and output