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Hospital Planning: changing concepts

Chapter · January 2003

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Changing Concepts in the
Health Facility Planning
In evolving hospital concept, the architects and
planners have to keep pace with the development in
modern medicine, nursing technique and general
community expectations. Medical technology is
developing very fast so much so that often hospitals
become outdated even before they are put to use.
There has been very rapid change in last five decades
in functioning of hospitals due to medical advances
which have direct bearing on patient care.
Medicine is an everchanging subject. Discove-
ries and inventions keep on changing the paradigm of
health care delivery. Recent trends in molecular
biology, pharmaceuticals and surgical interventions
have not only prolonged the life but also improved
the quality of life. Information superhighway has
turned the world into a ‘Global Village’.
These factors have major influence in the
planning of new hospitals. The other factors which
have direct bearing on hospital planning are:
• Costly diagnostic services cannot be provided in
all hospitals. Thus, there should be proper choice
of place and services to be rendered.
• Tertiary care cannot be provided in all places
due to high cost and lack of availability of
trained man power.
• Design should follow function, however, the
proper use of esthetic quality and humanized
surrounding must be kept in mind so that it
looks attractive
• A study of activities in health facilities at
Growth
different levels is a perequisite of planning as it
anweres several important question
• For health centres of different sizes and with
different functions, what is the proportion of
working hours devoted to various broad acti-
vities or definite tasks:
a. Which different types of staff are needed and
in what proportion?
b. What are the space requirements to discharge
these functions?
c. What is the inter-relationship between these
functions and consequently, what layout will
be more convenient?
As conditions vary from place to place, it is
necessary to undertake such a study for each project.
Health Centres
Grouping of closely related activities should be put
together in one area. All areas should be located in
relation to one another to allow direct communication
and easy flow of patients, staff and services. The
design and the structural system should allow
maximum flexibility and expandability.
 Developments in medical sciences and equip-
ment technology have offered many new diagnostic
and therapeutic modalities namely ultrasonography,
computerized axial tomography, nuclear magnetic
resonance imaging, non-invasive cardiac diagnosis,
coronary angiography, invasive cardiophysiology,
hemo-dynamic studies, pulmonary functions,
endoscopic techniques and procedures, lasers, etc.,
which are now reliable, precise, easy to run and
apply. Many of these have special physical
requirements including controlled environment,
energy and other engineering services. Since these
are capital intensive, there has been an increasing
concern to effect economy in their use.
Task before the architects therefore will be to
determine the broad requirement for the hospital
system. The system should be able to provide
reasonably effective services to patients. Further,
workloads and the required activities of any
healthcare institution are never predictable in detail.
Architects therefore, must recongnise the two main
problems, expansion and flexibility to keep pace with
the rapidly developing technology in medical
sciences. Physical planning must allow for future
expansions in all major functional areas of the
hospital and for internal adjustments in the use of
space to desired degree of changes must be feasible.
Functionally a hospital has six major facility
zones:
1. Accident and emergency.
2. Ambulatory care (outpatients department).
3. Diagnostic and therpeutic facility.
4. In-patient (nursing care) units.
5. Administration department and business.
6. Hospital engineering services.
Each of the functional components need to be
suitably placed depending on their inter-relationship
but with shortest possible travel to achieve
efficiency. These facilities do require their indepen-
dent access and related parking lots. However, for
reasons of overall control and security, entries and
exits are to be kept to the minimum.
a. Emergency Department is an independent unit to
function round the clock like a mini hospital.
Entry to this department has to be prominant
and self-guided so that a very minimum time is
lost in giving immediate treatment to casualty
and emergent cases arriving in the hospital.
b. Ambulatory care unit has to perform three main
functions:
• to diagnose and treat patients at an early
stage.
• follow up treatment after discharge from the
hospital and
• to institute health education programme to
educate the public in environmental hygiene.
The outpatient department in a hospital has
very important role in health care delivery. A
well organised and well equipped outpatient
department can play key role in reducing the
load on the inpatient beds and save a lot of time
and expenditure. Emphasis is now more on
outpatient facilities which are likely to increase
substantially thereby reducing the load of
inpatients and the cost the hospital projects as a
whole. Facilities of this unit are termed as:
• Clinics for various medical and surgical
discipline.
• Supporting facilities like laboratory, injection
rooms, etc.
• Pharmacy and Blood Bank.
c. Diagnostic and therapeutic facilities include: the
radio-diagnostic and imaging department,
clinical pathology as diagnostic facilities
whereas radiotherapy, operation theaters,
rehabilitation and physiotherapy as therapeutic
areas are to serve in common to outpatient
department and inpatient nursing care units.
These facilities are to be suitably placed at dif-
ferent levels in consideration of their functional
use and degree of necessity to dependent
departments.
Diagnostic and imaging units generally deals
with radiography and flouroscopy, ultrasound,
nuclear medicine and CAT Scan, etc. This being a
fast developing technique should be designed
keeping in view the future scope of expansion.
Laboratories are concerned with the analysis of
diseased tissue and fluids and other elements in the
body. This department may comprise activities like
Biochemistry, Microbiology, Clinical Pathology,
Hematology, Histology, Cytology and Serology.
Other activities connected with the department are
mortuary and autopsy.
Radiography
Radiography includes treatment of various types of
radiations, ranging from superficial therapy to
megavoltage therapy. Size of department depends
upon the load, scope of work and type of equipment
employed. High degree of radiations, protective
measures and air conditioning for the efficient func-
tioning of the electronic equipments are the essential
design requirements for the department.
Operation Theater
Hospital is technically a therapeutic aid in which a
team of surgeons, anesthetic, nurses and sometime
pathologists and radiologists operate upon or care for
the patients. Location of the department should be
decided on factors like quiet environment, noise- free
atmosphere, conditions free from contamination and
possible cross infection and convenient relationship
to surgical wards, intensive care unit, radiology,
pathology, blood bank and central sterile service
department.
Understanding of medical and surgical needs of
the patient during surgical procedures and the role of
environment, sterilization and aseptic techniques in
the control of nosocomial infections have led to the
development of modern concept of zoning namely
protective, clean, sterile and disposal zones in
operation theratre design. Filtration and recirculation
of conditioned air and scavanging of expired
anesthetic gases have further enhanced safety and
comfort of the patients and surgical team.
Rehabilitation and physiotherapy department
provides treatment facilities to patients suffering
from crippling diseases and disabilities. These
facilities are classified as physical and electrotherapy,
hydrotherapy, occupational therapy and exercises.
In-patient Nursing Care Units (Wards)
In-patient nursing care units (wards) occupy the
maximum share of hospital space. Concept of
providing this facility is fast changing due to policy
of early ambulation and in fact only a few patients
really need to be on bed. Nursing care is broadly
classified into general wards, speciality-wise wards
and intensive care units. Basic consideration in
placing wards is to ensure sufficient nursing care,
segregating patients according to three categories,
locating them according to the needs of the treatment
in respective medical discipline and controlling cross
infection. Speciality-wise wards however, should be
located closer to their respective outpatient clinics to
act as self-contained centres.
In planning a ward, the aim should be to mini-
mize the work of the nursing staff and provide basic
amenities to the patients within the unit. Ward pattern
has undergone a radical change from Nightingale
ward to Rigg’s ward. Many variations and
modifications of the concept are meeting specific
socio-medical requirements while attempting to
enhance the efficiency of nurse-patients interaction,
observability, lighting and other physical require-
ments, replenishment system for supply of diet
medical and surgical supplies, linen and other
materials at the doorstep of nursing activity have
further relieved the nursing staff on non-nursing
functions to attend patient centered activities.
Norms
In-patient Department
In-patient is not only a place for admitting a patient
who cannot be treated outside hospital, but also a
place of training for doctors and paramedical staff.
In-patients are likely to fall into one of five broad
care grouping in the proportions shown.
1. Intensive Medical Care Where continuous
medical and nursing observation and mechanical
assistance is necessary to maintain life one
 percent.
2. Intensive Nursing Care Where patients are unable
to leave their beds, and where their is need to
continuous nursing, observation and physical
assistance. 20-25 percent.
3. Medium Nursing Care Where patients are able to
leave their beds for short periods (upto four
hours) each day with assistance 20-25 percent.
4. Low Nursing Care Where patients are able to
leave their beds for more than four hours per
day, requiring minimal assistance 20-30 percent
5. Self Care Patients leading apparently a normal
life, who are in hospital for observation 5-10
percent.
Using a similar classification, the proportions of
patients in a developing country are likely to be
considerably higher in the intensive and medium care
categories, perhaps upto 75-80 percent of total
patients being within these two areas.
Out-patient Department
“Ambulatory Care” is the medical care provided to
patients who are not confined to bed. It can be
provided at a general practitioner’s or specialist’s
practice premises or at health post, health centre or
hospital. The functions of outpatient services of a
hospital are to provide diagnostic, curative, pre-
ventive, and rehabilitative service on ambulatory
basis to the the community. The extent of these
functions established by the individual hospital will
vary, according to aim of hospital, expectation of
community and political will. The scope and form is
undergoing dramatic change. If it functions well, it
can reduce pressure on inpatient care, which can be
achieved by increasing diagnostic and treatment
service.
Planning is a dynamic process and necessary for
orderly development. It can be carried out at many
levels of detail and in many timeframes. To assure a
smooth, orderly project the first step in the planning
process is to establish a schedule for the entire
project:
• Preplanning schedule.
• Determination of community need for health-
care.
• Evolution of existing conditions.
• Demographic survey of the community.
• Statement of goals and objectives related to
community needs.
• Capital financing plan
• Operational programme to meet goals and
objectives.
• Master development plan as a framework,
including gross departmental area allocation.
• Schematic plans,and construction staging.
• Cost analysis.
• Detailed space programme of first stage for
construction.
• Equipment list.
• Design of first stage
• Construction of first stage.
• Evaluation of operation and feedback.
A hospital brings together the wide spectrum of
knowledge, professional skill, and physical facilities
so that the present and future generation will advance
in health and well-being. If it can be designed in
proper fashion it can combine science and wisdom to
create holistic approach to health care. The architect
has the task of designing a highly complex structure
for a very complex organization, but his design has to
have sufficient clarity of form to be understood by all
who use it. In addition, he has to design individual
territories—the departments for each of the groups
whose successful interaction is the basis of the work
of the hospital. Each separate department needs its
own identity and within it, its own map, its own
private and public space as well as own frontdoor.
The design must allow the identity of many families
which form its work force to be identifiable,
physically, from inside the complex.
 Hospital design must have flexibility, to adopt monsoon time.
change and its concern should be the quality of
medical care and the improvement of its standards.
It is accepted that planning and proper program-
ming is essential to strengthen the health care faci-
lities. Every country should accept it as its responsi-
bility to design and implement changes that enhance
the performance of the total health service delivery
system in a balanced and integrated manner, because
hospital is a complex organization.
The idea of planning is to prevent the haphazard
mushrooming up of structure, to prevent fragmen-
tation of function and to promote logical flow of
patient, staff and equipment and to attain a fair
degree of uniformity and standardization.
The implementation of a health care facility
project could be regarded as a sequence of phases.
Formulation consists in establishing the need for
a facility; in making sure that its erection would be in
accordance with stated policies and priorities, in
ascertaining that the resources (money and man-
power) necessary for its realization and operation are
available, or will be available when needed. At the
end, formation of planning team should be made.

Site Selection

It is important for hospital building. It must have the

following characteristics:
• Easy approach by people
• Enough land availability
• Sub-soil water must be deep
• Sufficient supply of water and electricity. While
selecting the site, one must keep in mind,
any further expansion in future size of land required
is as follows:
Single storey
50 beds 10 acres Single Storey
100 beds 15-20 acres Double storey
200 beds 20-25 acres 3- 5 stories
500 beds 55-70 acres 4- 6
700 beds 80-90 acres stories 6-9
1000 beds 90-100 acres stories.
Basement is
possible if the sub-soil water is below 25 feet in mid
Preparation of architect brief After obtaining
requirement of clinical and nursing departments
supportive service, administrative and business and
utility services, a general outline of requirement be
prepared to provide the client with an appraisal and
recommendation, so that it can be ensured that the
project is functionally, technically and financially
feasible.
The client’s task is to establish a suitable project
management organization which can develop the
project brief by considering and analyzing all
important factors.

Design Plan (Fig. 6.1)

While designing differnet zones, there is a need to

establish relationship between activities and space in
a health centre. Circulation area such as corridors,
entrance halls, staircase, etc. in the hospital building
should not be less than 30 percent of the total area of
the building.
Basic circulation pattern depends upon land
availability, and environmental circumstances,
however, it may be any one of the following:
• radial-linear
• tree-shaped or dendritic-grid.
The other relevant details need to be kept in
mind are as follows:

Water Supply

About 300-500 liters of water per bed per day

(excluding water for gardening) is to be catered for.
Water supply should be preferably from two sources.
Reserve water for 7 days if from a single source and
2 days if from two sources.

Electricity

Electricity supply should be from 2 grid/3 grid

(source). In addition, generator supply for certain
essential areas should be catered for. Even for more
essential equipment there should be provision for
uninterrupted electric supply. Requirement for the
hospital is One kv per bed per day.
 Fig. 6.1 : General process of planning a health facility
Sanitary Requirements 1 water tap with drainage arrange-
ment in the vicinity of water closets Urinals 1 for
Toilet for an individual room (single or two bed) in a
every 12 beds
ward unit shall be 3.5m2 comprising a bath, a wash
Bath 1 bath with shower for every 12
and WC. Toilet common to serve two such rooms
beds
shall be 5.25m to comprise a bath, a WC in a separate
Bed pan washing 1 for each ward in dirty utility and sinks
cubicle and a wash basin. For a multiple beded ward
unit, requirement of fitments is given below: sluice room.
Sinks and dishwasher 1 for each ward in ward pantry.
Items Quantity
Water closets 1 for every 8 beds (male) Biomedical waste (soiled, semi-soiled and liquid)
1 for every 6 beds (female) amounts to 2 kg per bed per day. The hospital
Ablution taps 1 for each water closets plus drainage should be connected to the main town
drainage system. A sewage treatment plant is
desirable for a large teaching general hospital
Certain General Parameters and 0.75 per second for hospitals of two or
more stories are to be provided at the following
Hospital Space Module is taken as 3.5 sqm. This scale:
space is enough to accommodate a toilet comprising
a WC, Wash basin and a shower. 7 Sqm. is enough Two storeyed Stretcher-cum Service
building lift passenger
for the routine hospital bed, and 14 sqm. will be Upto 199 beds One Nil
required for each bed in the Intensive care unit. 200 to 399 beds Two One
a. Hospital Engineering Grid is taken as 1.6 m one
400 to 499 beds Three One
and a half grid i.e. 2.4 m is the desired width of
500 to 599 beds Four One
a corridor. Width of door, window etc. can also
600 to 699 beds Five One
be expressed in the form of a grid. 700 to 799 beds Six Two
b. Plinth area With all constraints the recommended 800 to 1000 beds Seven Two
area per bed is 75 sqm. whereas in developed
countries it is 150 sqm. k. Fire protection In a high-rise building the
c. Floor height The height of all the room in the following systems should be provided:
hospital should not be less than 3 m and not • Fire safety system
more than 3.65m. • Fire detection system
d. Head room The minimum height under the • Fire alarm system
beams, fans,lights and other fixture on the • Fire fighting system
ceiling should not be less than 2.6m. measured
vertically from the floor. Design Competition
e. Dedoing It should be generally upto a height of
1.2 m. In bathroom upto 2 m. and in operating If the hospital is big, tender can be introduced to
and delivery room dedoing should be the invite the architects for design competition and rate.
complete floor height. A group of users and experts can choose best design
f. Door The minimum width of doors should not be and rates, etc.
less than 1.6 m. and height 2.1 m.
g. Ventilation There should be sufficient ventilation Construction by Contractor
in hospital. As far as possible, there should be
cross ventilation thus size of window should be A project like hospital has to be contracted only at
20 percent of the floor area. reasonable price with reputed contractor. A tender
h. Exhaust fans should be provided as per following has to be issued by engineering department with full
scales. and complete specification stating type of work,
• Operation theatres and delivery suites—20 air excepted cost, period of completion,etc. The planning
changes per hour team should take a decision regarding allotment of
• Radiography room, Radiothapy room—08 air work. Management must exercise proper control on
changes per hour. construction.
i Traction—the traction system of the hospital may
be divided into two parts extramural and Control
intramural.
The extramural system is the ambulance Control is an integral part of the project management
process. It aims at regular measurement of
service. The intramural system includes ramps,
achievement and monitoring by comparison with
lifts, conveyor belts, and dumb waiters and
planned progress. When deviations from planned
trolleys etc.
progress occur, plans may have to be changed. Time
j Lifts (automatic control) with speed of 0.36 m.
is very important and the control process should aim
at early discovery of any departure from the planned
course so that adjustment can be in time to be
effective
Control information provides a basis for
management decisions, and the following require-
ment should be satisfied by an effective control
system.
It should draw immediate attention to significant
deviations from what is expected. It should focus on
the exception rather than the rule.
True and meaningful comparisons can be made
possible.
The information should indicate in due time what
corrective action is necessary and by whom, the
action should be taken. It should also, as far as
possible, indicate what consequences any deviation
from the plan is likely to have on any other planned
activities, especially the time-schedule, in order to
help the project manager to modify his plans
accordingly.
Control information should be expressed in a
simple form so that it is readily understood by those
who have to make use of it.
Key areas of control must be chosen with care so
that the results of control are worth the time and
effect expended.
Figure 6.2 outlines a generic schedule of the
facility development process with an appropriate
timeframe for each activity. The sequence and
duration of each of these activities vary somewhat
depending on project scope and implementation
strategy.
Working with a qualified external planning team
and following the guidelines of reasonable schedule,
the institutions role in the process is to review,
comment, and make timely decisions on the work or
recommendations of the external team that is made
up of health care consultants, architects/engineers,
construction managers, and other consultants and
advisors. This review-and response interaction
among the various parties may require administrative
and board decisions before the next phase of activity
can begin.
Quality Leadership
For a project team to succeed in its task, it needs
technical knowledge, expertise in the subject, know-
how to work as a team, plan, conduct good meetings,
manage logistics and details, gather useful data,
analyse the data, communicate the results and
implement changes.
With quality leadership, use of scientific
approach becomes standard procedure. The focus is
on improving products and services by improving
how work gets done (the methods) instead of simply
what is done (the results). Quality leadership
emphasizes results by working on methods.
Principles of quality leadership include: custo-
mer focus, obsession with quality, recognising the
structure in work, freedom through control, looking
for faults in systems, teamwork, and continued edu-
ction and training. Project teams are a crucial tool for
quality improvement. The success or failure of
projects will have great impact on the health facility.
Project team members learn how to work as a
team and how to improve processes using scientific
tools and techniques.
The basic statistical tools used most frequently in
a scientific approach to quality improvement include:
Flowcharts, Pareto chart, Cause-and-effect diagram,
Operational definitions (what something is and how
it is measured), Stratifications (to pinpoint a problem
by exposing where it does and does not occur. It lets
teams avoid wasteful effort, directing their energies
to the most potentially fruitful areas), time plots
(used to examine data for trends or patterns that
occur. Overtime; the data points plotted in time
order), Control chart (used to monitor a process to
see whether it is in statistical contrtol. It also
indicates the range of variations built into the
system), Check sheets (used to record data), Scatter
Diagrams (display the relationship between two
process characteristics), etc.
Fig. 6.2: Stages in Facility Development
 The success of a project depends largely on get- • Clarity in team goals
ting everything set up correctly: choosing an appro- • An improvement plan
priate process, selecting appropriate team members, • Clearly defined roles
and doing the ground work, so a team will know • Clear communication
what the project is all about. • Beneficial team behaviours
The following activities must be incorporated • Well-defined decision procedures
into every step of project: • Balanced participation
• Maintain communication • Established ground rules
• Fix obvious problems • Awareness of the group process
• Look upstream • Use of the scientific approach.
• Document progress and problems When quality is increased by improving pro-
• Minitor changes. cesses, productivity improves. Better productivity
Teams must spend time in the early stages of lowers unit costs, which in turn lowers prices.
their project planning how the project will unfold. FURTHER READING
Planning is the heart of using a scientific approach to
quality improvement. Ten ingredients for a suc- 1. Amin Tabish Future Trends in Healthcare. Jr. of
cessful team include: Intl Med Sci Acad. 2005
 2. Amin Tabish. Knowledge Based Health Care: Delivery: Strategies that will Reshape the
Need for Global Health Policy. JK Practitioner Healthcare Industry Landscape. International
2006;13 (3):119 Journal of Science and Research (IJSR). Volume
3. Amin Tabish. Human Health in Changing 4 Issue 2, February 2015:727-758
World. PMJ 2006
4. Amin Tabish. Building a Healthy World for
Tomorrow. Editorial. IHSJ. Vol 1 No. 1; January
2007
5. Amin Tabish. Standards for Better Health.
International Journal of Health Sciences, Qassim
University, Vol. 3, No.1, (January
2009/Muharram 1430H)
6. Amin Tabish. Health Policy Challenges. Jr of
Nursing Research & Practice. 2009;5(1,2):54-60
7. Amin Tabish. Healthcare Industry Needs A
Change Model. JIMSA, 2012;25(3):137-138
8. Putsep E: The Modern Hospital: international
planning practice, Lloyd-Luke, 1979, London,
1979
9. Tabish SA & Nabil Syed. Future of Healthcare

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