THE HANDBOOK FOR HOSPITAL PLANNING AND

DESIGNING
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INTRODUCTION

Planning and designing hospital is a complex and multifaceted process that requires
careful consideration of various factors to ensure the delivery of high-quality patient care
while optimizing operational efficiency. Hospitals and other healthcare facilities are
designed with the help of healthcare architects, who have a crucial and varied role to play.
Due to the special and complex requirements of healthcare facilities, their participation is
essential. Task of the architects before construction of a hospital are 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
recognize 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.

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 2. Ambulatory Care (outpatients department).
3. Diagnostic and Therapeutic Facility
4. In-Patient (Nursing Care) Units.
5. Administration Department and Business.
6. Hospital Engineering Services.

Each of the functional components needs to be placed appropriately based on their

interdependence but with the shortest possible travel to achieve efficiency. These facilities
do require their independent access and related parking lots.

However, for reasons of overall control and security, entries and exits are to be kept to a
minimum.

1. Emergency Department is an independent unit to function round the clock like a

mini hospital. Entry to this department has to be prominent and self-guided so that a
very minimum time is lost in giving immediate treatment to casualty and emergent
cases arriving in the hospital.
2. 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 a very important role in health care delivery.
A well-organized and well-equipped outpatient department can play a key role in reducing
the load on the inpatient beds and saving a lot of time and expenditure. The emphasis is
now more on outpatient facilities, which are likely to increase substantially, thereby
reducing the load of inpatients and the cost of hospital projects as a whole.

Facilities of this unit are termed as:

Clinics for various medical and surgical disciplines.

Supporting facilities like laboratory, injection rooms, etc.
Pharmacy and Blood Bank.

Diagnostic and therapeutic facilities include:

1. The radio-diagnostic and imaging department,

2. Clinical pathology as diagnostic facilities
3. Radiotherapy, operation theatres, rehabilitation and physiotherapy as therapeutic
areas are to serve in common to outpatient department and inpatient nursing care
units.

These facilities should be placed at different levels accordingly, taking into account their
functional use and the degree of necessity for dependent departments. Diagnostic and
imaging units generally deal with radiography and fluoroscopy, ultrasound, nuclear

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medicine, CAT scans, etc.

This technique is rapidly developing and should be designed with the future scope of
expansion in mind. Laboratories are concerned with the analysis of diseased tissue,
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
involves the treatment of different types of radiation, from superficial therapy to
megavoltage therapy.

The size of the department depends on the load, scope of work, and type of equipment
employed. High levels of radiation, protective measures, and air conditioning for the
efficient functioning of the electronic equipment are the essential design requirements for
the department.

Operation theatre is technically a therapeutic aid in which a team of surgeons,

anesthesiologists, nurses, and sometimes pathologists and radiologists operate on or
care for 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 theatre
design.
Filtration and recirculation of conditioned air and scavenging of expired anesthetic
gases have further enhanced the safety and comfort of the patients and surgical
team.

The 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.

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 Nursing care is broadly classified into general wards, specialty-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.
Specialty-wise wards, however, should be located closer to their respective
outpatient clinics to act as self-contained centers. In planning a ward, the aim
should be to minimize 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 Riggs 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 requirements, 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 care is not only for admitting patients who cannot be treated outside the
hospital, but also for training doctors and paramedical staff.

In-patients are likely to fall into one of five broad cares grouping in the proportions shown.

Intensive Medical Care Where continuous medical and nursing observation and
mechanical assistance is necessary to maintain life one percent.

1. Intensive nursing care is where patients are unable to leave their beds and where
continuous nursing, observation, and physical assistance are needed, with a 20-25
percent increase in the number of patients.
2. Medium Nursing Care allows patients to leave their beds for short periods (up to
four hours) each day with assistance from 20-25 percent.
3. Low nursing care where patients are able to leave their beds for more than four
hours per day, requiring minimal assistance of 20-30 percent.
4. Self-care patients leading an apparently normal life while in hospital for observation
represent 5-10 percent.

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 a

health post, health center, or hospital. The functions of outpatient services of a hospital
are to provide diagnostic, curative, preventive, and rehabilitative service on an ambulatory
basis to the community.

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The extent of these functions established by the individual hospital will vary depending on
the hospital’s aim, expectations of the community, and political will. The scope and form
are undergoing dramatic change.

If it functions well, it can reduce pressure on inpatient care, which can be achieved by
increasing diagnostic and treatment services.

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 healthcare.
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.

The departments responsible for each group’s successful interaction are the foundation of
the hospital’s work.

Each separate department needs its own identity and within it, its own map, its own
private and public space as well as own front door.
The design must allow the identity of many families which form its work force to be
identifiable, physically, from inside the complex.
0 beds -10 acres, 100 beds 15-20 acres, 200 beds 20-25 acres, 500 beds 55-
70acres, 700 beds 80-90 acres, 1000 beds 90-100 acres. Hospital design must
have flexibility, to adopt change and its concern should be the quality of medical
care and the improvement of its standards.
It is accepted that planning and proper programming is essential to strengthen the
health care facilities.
Every country should accept it as its responsibility 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.

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 The idea of planning is to prevent the haphazard mushrooming up of structure, to
prevent fragmentation 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 manpower) 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.

When selecting the site, one must keep in mind that any further expansion in the size of
land required will be as follows:

Single storey
Double storey
3-5 stories
4-6 stories
6-9 stories.
Basement is possible if the sub-soil water is below 25 feet in mid monsoon time

The need for a good hospital design not only indicates impeccable infrastructure, but also
a step towards healing and wellbeing. Hence, hospital design is an extremely crucial
aspect. Here are the things to be taken into consideration while designing a hospital:

Preparation of architect brief

After obtaining requirements of clinical and nursing departments supportive service,

administrative and business and utility services, a general outline of requirements is
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 project management organization that can develop the project brief
by taking into account and analyzing all important factors.

Design Plan

While designing different zones, there is a need to establish relationship between

activities and space in a health centre.

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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 1
kWh per bed per day.

Sanitary Requirements

Toilet for an individual room (single or two beds) in a ward unit shall be 3.5m2 comprising
a bath, a wash and WC.

Toilet common to serve two such rooms shall be 5.25m to comprise a bath, a WC in a
separate cubicle and a wash basin.

For a multiple bedded ward unit, requirement of fitments is given below:

Biomedical waste (soiled, semi-soiled and liquid) amounts to 2 kg per bed per day.

The hospital 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

The Hospital Space Module is taken as 3.5 sq.m. This space is enough to accommodate
a toilet comprising a WC, wash basin and a shower. 7 sq.m is enough for the routine
hospital bed, and 14 sq.m will be required for each bed in the Intensive care unit.

1. Hospital Engineering Grid is taken as 1.6 m one and a half grid i.e. 2.4 m is the
desired width of a corridor. Width of door, window etc. can also be expressed in the
form of a grid.

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 2. Plinth area

With all constraints the recommended area per bed is 75 sq.m. Whereas in developed
countries it is 150 sq.m.

Floor height

The height of all the room in the hospital should not be less than 3 m and not more than
3.65m.

1. Head room

The minimum height under the beams, fans, lights and other fixture on the ceiling should
not be less than 2.6m. measured vertically from the floor.

2. Dado

It should be generally up to a height of 1.2 m. In bathroom up to 2 m. and in operating

and delivery room dado should be the complete floor height.

3. Door

The minimum width of doors should not be less than 1.6 m. and height 2.1 m.

Ventilation – There should be sufficient ventilation in hospital. As far as possible, there

should be cross ventilation thus size of window should be 20 percent of the floor area.

Exhaust fans should be provided as per following scales.

Operation theatres and delivery suites – 20 air changes per hour.

Radiography room, Radiotherapy room – 08 air changes per hour.

1. The traction system of the hospital may be divided into two parts extramural and
intramural. The extramural system is the ambulance service. The intramural system
includes ramps, lifts, conveyor belts, and dumb waiters and trolleys etc.
2. Lifts (automatic control) with speed of 0.36 m and 0.75 per second for hospitals of
two or more stories.

Fire protection – In a high-rise building the following systems should be provided:

Fire safety system

Fire detection system
Fire alarm system
Firefighting system

Design Competition

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If the hospital is big, a tender can be introduced to invite the architects for a design
competition and a rate. A group of users and experts can choose the best design and
rates, etc. Construction by Contractor A project like a hospital has to be contracted only at
a reasonable price with a reputed contractor.

A tender has to be issued by the engineering department with full and complete
specifications stating type of work, the accepting cost, period of completion, etc. The
planning team should take a decision regarding allotment of work. Proper control of
construction must be exercised by management.

Control

Control is an integral part of the project management process. It aims at regular

measurement of achievement and monitoring by comparison with planned
progress. When deviations from planned progress occur, plans may have to be
changed.
Time 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
requirement 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.
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.

The success of a project depends largely on getting everything set up correctly: choosing
an appropriate process, selecting appropriate team members, and doing the groundwork,
so a team will know what the project is all about.

The following activities must be incorporated into every step of project:

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 Maintain communication
Fix obvious problems
Look upstream
Document progress and problems
Monitor changes. Teams must spend time in the early stages of their project
planning how the project will unfold. Planning is the heart of using a scientific
approach to quality improvement.

MARKET SURVEY – HEALTHCARE IN INDIA

Healthcare in India is in a developing stage and requires a radical policy shift at the
government level to implement changes and address the challenges of the future. Under
the umbrella of health care providers are outpatient set-ups, nursing homes, hospitals,
medical colleges, health spas, diagnostic centers, ayurvedic and naturopathy centers,
hospices, old age homes and more. Most of these institutions will have varied needs,
which will differ vastly in terms of their planning needs.

Health care provision in India is different in rural and semi urban settings where it is more
unorganized to today’s super specialty centers where it more institutionalized. The
mechanisms for funding are fast changing to the private sector involvement thereby
pushing up the cost of both setting up hospitals as well as availing health care in these
hospitals. The lowering of interest rates over the years has no doubt helped the cause of
the private sector wherein more entrepreneurs are coming forward to set up hospitals as
it has become affordable to take loans and repay them. The rapid growth of the insurance
sector is equally helping the community to face the problem of spiralling health care
costs.

Stakeholders

There are innumerable stakeholders in the health care delivery domain including the
government, philanthropic trusts, educational institutions, corporate sector, insurance
companies, bio-medical vendors, architects, construction companies, patients, relatives,
the pharmaceutical industry, professionals like doctors and other para-medical staff, and
the funding agencies The industry’s growth will be beneficial to many in the population
due to its wide range of stakeholders. The hospital ownership pattern can be basically
three types:

1. Government owned - central / state / district / autonomous like army, railways etc
2. Not for Profit – Managed by Trusts / Societies
3. For Profit – Corporate Sector

PROJECT CONCEPTUALIZATION

The first step in hospital planning is to freeze the project concept in terms of:

Identification of the market needs and deriving the appropriate size of the project
Determining the possibility of getting skilled manpower

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All the above factors have a bearing on the project cost and its viability in the future. This
process helps understand the need of the community that will be served by the hospital in
the given location. For doing this, one needs to undertake a detailed Market Survey by
collecting secondary data from various sources like the internet, libraries, media
publications, newspaper archives, ministry of health and district health departments
records etc. Unfortunately, India does not have a reliable mechanism for capturing health
related data especially in the private sector. One also needs to undertake primary data
search by conducting interviews with households, practicing doctors and visiting existing
institutions. There can be three types of surveys required:

Household Survey

This is essentially done to understand the health care seeking behavior pattern of the
community as a whole. Sampling techniques are used to map the statistically significant
number of households. The basic information which should be collected and analyzed is
as follows:

1. Demographic details of the family

2. Education & Income details
3. Disease profile in last three years
4. Choice of health care provider for minor & major ailments with reasons
5. Method of payment for availing healthcare
6. Their opinion on deficiency in health care market
7. Critical success factor for the proposed project

Doctor’s Survey

Medical professionals are usually the best judge of deficiencies in the medical market and
should be carefully interviewed to determine a successful project approach in the
geographic services field. The sample of physicians surveyed should include specialists
in all medical and surgical departments, including specialists in diagnostic departments
such as laboratory, imaging, and physical therapy. Basic information Laboratory, image
processing, physical therapy, etc. Collected and analyzed when:

Personal details on specialty, qualification, experience etc

Area of practice and hospital attachments
Patients seen and their drainage area
Referrals to other hospitals/diagnostic centers with reasons for referring
Views on deficiency in health care market and solutions for same
Patient’s capability to pay
Critical success factors for a hospital project in the service area

Institutional Survey

Getting basic feedback on the competitors in the primary service area, which is within a 5-
10 km radius, would be important to assess the strengths and weaknesses of major
players. For national centers of excellence, however, the catchment area could be much

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larger, maybe the whole country, like Tata Memorial Hospital in Mumbai. One would also
need to know the productivity, tariffs, salary structure etc, which will help with preparation
of the feasibility report. The important information to be collected would be as:

Ownership with historical growth pattern

Service Mix (diagnostic, therapeutic, medical, surgical, support services)
Bed mix
Productivity of major services
Tariffs of major services
Bed to manpower ratio
Technology level
Annual revenue/expense in last 2-3 years to understand growth pattern

DATA ANALYSIS

The data collected through secondary and primary sources is then analyzed to arrive at a
facility mix for the proposed project. It will also determine the scale of the project in terms
of its bed size. In case it identifies some atypical need like cancer treatment, it would
perhaps need more research to understand the profitability of such a capital-intensive
specialty. The end result should give definitive information on the following:

Specialties to be practiced in the proposed project

1. Number of OPD rooms

2. Bed mix with break up
3. Number of operation theatres
4. Diagnostic service
5. Blood bank
6. Support services

In case the project is to be developed in phases the facilities to be phased should be

clearly identified as the engineering services and areas for the phased development will
have to be accordingly planned.

DETAILED PROJECT REPORT / FINANCIAL FEASIBILITY

After finalizing the project concept in terms of its facilities and size, the next important
step is to analyse its financial viability. This will also help the promoter in planning the
means of financing the project based on its profitability and capability of servicing the debt
proportion.

The first step of the feasibility process is to identify the cost of the project in a realistic
manner. This is done by way of producing a detailed project report (DPR). Many projects
have failed midway through the construction process because it was identified that the
cost overrun would be more than 50% of the estimated budget.

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Hospital buildings are very complex in terms of their engineering needs and hence
specialized agencies are required to plan these and identify the cost. The cost of the
project should be broken down under the following heads:

1. Civil Works including RCC, masonry, doors, windows, interior, and facade treatment
2. Electrical Work
3. Plumbing & Fire Fighting
4. Air Conditioning
5. Landscape & Site Development
6. Elevators
7. Medical Equipment Broken Down Under Departmental Heads
8. Non-Medical Equipment Like Kitchen, Laundry, Computer Hardware & Software Etc
9. Hospital Furniture and Fixtures
10. Professional Fees
11. Pre-Operative Expenses
12. Municipal Taxes & Deposit
13. Interest During Construction
14. Contingency

The estimates for all the above should be compiled meticulously after detailed
discussions with experts and undertaking adequate research. Financial institutions also
require sufficient back up data to accept the costs before accepting the project for
funding.

INCOME ASSUMPTIONS

After compiling the project cost, the next important step is to ascertain the income from
the project from various heads. Whilst doing this, one would rely heavily on institutional
market research to understand the industry benchmarks for making assumptions. Income
assumptions will need to be made for the following income heads:

1. Room rents for all categories of beds like general ward, twin/single rooms, ICU,
NICU etc.
2. Departmental income for diagnostic services
3. OPD & IPD Consultations
4. Surgical Operations (Major and Day Care Interventions)
5. Health Check Schemes
6. Pharmacy
7. Emergency
8. Deliveries
9. Blood Bank
10. Emergency
11. Any specialty service like LINAEC, IVF, Angioplasty, Minimal Invasive Surgery,
Organ Transplant etc. will need to be separately assessed

EXPENSE ASSUMPTIONS

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The next important step is to compute all the important expenditure heads for the project
operations. These heads would include the following:

1. Salaries and wages – these should be computed on a cost to company basis and
should take into a staffing pattern inclusive of those for leaves, contract labours etc.
2. Departmental expenses in terms of consumables. This could be arrived as
percentage expense to the departmental income by taking industry benchmarks
3. Professional fee payable to doctors for rendering clinical services. This would differ
from assuming a flat salary to incentive-based remuneration. Again, industry
benchmarks will have to be followed for same. Some hospitals have a mix of both
the options
4. Energy costs in terms of electricity, water, medical gases, generator
5. Food expenses for patients and staff
6. Laundry & linen expenses for patients and staff
7. Housekeeping expenses can be calculated on a per sq. ft basis for the building
8. Stationery expense
9. Telecommunication
10. Conveyance and car maintenance
11. Marketing expenses
12. Repairs and maintenance
13. Insurance, Legal and Audit charges
14. Miscellaneous expenses
15. Depreciation
16. Interest cost for loans taken
17. Taxes for corporate hospital

FINANCIAL STATEMENTS

After computing the income and expense statements as mentioned above, one arrives at
the various financials, such as the Profit & Loss statement, Balance Sheet, Cash Flow,
and Break-Even Analysis. After computing these statements, once we can undertake
sensitivity analysis by subjecting the project assumptions to certain changes and
evaluating the impact on profitability, like:

Change in debt to equity ratio

Change in interest rates on the loan taken
Change in capacity utilization over the five-year period
Effect of cost escalation

FUNCTIONAL & SPACE PROGRAMS

Once you have agreement on a capital investment strategy and a facility mix (derived
from the detailed project report), it is time to undertake programming. The detailed project
report (DPR) may have been done for a long-range planning strategy, a short-term need
or maybe both. The functional program and the space program are to be prepared for the
short-term project or for phases of a longer-term project for which planning has already

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been done in totality, like a teaching hospital. It serves as a common policy document
which outlines the parameters and vision of the project for all the members of the
planning and design team. It should also contain all the necessary information for the
architectural design team to commence conceptual and schematic design. The
components of the functional and space program for each department of the proposed
healthcare facility can read as follows:

Listing of planning assumptions

An assessment of the situation on the ground (as existing)
The planning objectives and a vision for the future
Existing and proposed workloads
Proposed time of operation
Existing and proposed staffing
Operational and support systems assumptions
Equipment list for the proposed department

Functional adjacencies and access requirements of the various departments

The space program consists of a list of the various spaces in the department in square
feet and meters.

The space program provides a list of all rooms or areas required for each function and the
total area required for the function. The above approach flows from the functional
requirements. This document defines the functional requirements of the project in keeping
with the facility & service mix brief provided by the clients. These functional requirements
are defined in terms of the following parameters:

The services accommodated,

The potential workload, &
The key operational premises

ROOM DATA SHEETS

The room data sheets are an extension of the space program. Usually confined to an A3
sheet, it can contain a plan of the room, minimum dimension of the space, a list of major
items of medical or other equipment to be housed within that space, and any unique
temperature, humidity, lighting etc. conditions.

Without the plan, the same information can be given could an Excel sheet, and the plan
can be added after schematic design is done to complete the sheet. At this stage, the
room data sheets could only be generic to help the non-healthcare architect plan the
furniture, fixture and equipment plan (FFE).

For the room data sheets to be of optimal use, they would need to be prepared after the
FFE is in place.

ZONING

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Zoning of a site is a concept every architect is familiar with, so I will just give a brief
description for the benefit of my healthcare professional readers. On a site that has
multiple usages by which I mean buildings housing differing kinds of functions it is useful
at the onset of design to block out appropriate areas that each usage will occupy. This is
done by considering the following factors:

The functional and spatial relationships between the various buildings/usages.

The topography of the site.
The vehicular and pedestrian circulation connections between the buildings.
Any special site features such as trees, existing buildings, water bodies, HT lines
etc.
Orientation of the buildings with respect to sunlight and prevailing winds

In the conceptualization, design, construction and commissioning of any successfully run

HealthCare facility project, the services of some or all of the following types of consultants
will be required-

1. Hospital Consultant/Facility Planner

2. Consulting Architect / Architect
3. Municipal Architect / Local Architect
4. Structural Consultant / MEP (Mechanical, Electrical, Plumbing) Consultants
5. Project Management Consultants
6. Lighting Consultant
7. Networking Consultant
8. Safety/Security Consultant
9. Fire Safety Consultant
10. Logistics Consultant
11. Acoustic Consultant
12. Quantity Surveyors
13. Public Health Engineering Consultant
14. Environment Clearance Consultant
15. Bio-Medical Waste Consultant
16. Infection Control Risk Assessor
17. Kitchen Design Consultant
18. Laundry Design Consultant
19. Audio-Visual Coordinator
20. Chartered Accountant
21. Geo-Technologist
22. Land Surveyor
23. Landscape Architect
24. Interior Design Consultant / Graphic Designer
25. Bio-Medical Engineer / Medical Equipment Consultant
26. The Client / Client’s Representative
27. Hospital Administrator / CEO of Proposed Facility
28. User Groups

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Enumerated below are the agencies who would be collectively involved in the
construction of the hospital:

1. Excavation contractor
2. Civil contractor
3. Plumbing
4. Firefighting
5. Electrical
6. HVAC
7. Elevator
8. MGPS
9. Pneumatic Tubes
10. Nurse Call
11. IBMS
12. Hard Flooring & Dado
13. Casework, millwork
14. False Ceiling
15. Painting
16. Wall coverings
17. Crash guards / corner guards
18. Doors
19. Windows
20. Loose furniture
21. Artworks
22. Façade works
23. Landscape
24. Signage
25. IV tracks, curtains
26. Steel storage
27. Medical furniture
28. Display screens
29. Equipment – medical, non-medical
30. Low voltage applications – access control, CCTV, RFID

THE PROCEDURE FOR HOSPITAL SET UP IN INDIA

Registration under the clinical establishment act, 2017

This act was enacted by the central government and is being adopted by the states of
India. It needs a one-time registration for a premise to be operated as a hospital. The
registration must be done by the respective state government that has adopted this act.
For registration, hospitals should fulfill the minimum requirement under the category in
which they fall. Each state has described the procedure of registration of the hospitals
that fall within their territory.

Registration under companies’ Act, 2013

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This act is applicable when the hospital established it under the ownership of a
corporation. The act needs the corporation to be registered and fulfils the requirements of
incorporation like memorandum of association, articles of association, capital structure
formation, securities allotment, account audits, etc.

Director Index No (DIN NO) for each director

This comes under the Ministry of Corporate Affairs, Government of India. It is a

compulsory registration required for each director who wants to be a part of a corporation.
It is a onetime registration for directors.

Registration under societies registration act, 2001

In case the hospital is being established under the ownership of society, the society
registration act is required.

Locations of the Hospital

This is required to be chosen well, because if there are already some hospitals in the
locality, then it would be difficult to get in patients. Also, the hospital must be set up in an
area that has a good transportation facility or is close to a railway station. One must look
for non-agricultural land particularly designed for hospitals. All the electricity supply, as
well as the water supply, should be easily available and that is required to be checked
before purchasing any land for the hospital set up.

Facilities Offered

The facilities offered by the hospital should be decided by the management depending on
the locality of the hospital. It might be generalized into pathology, ICU treatment;
orthopedic, as well as other specialized services should be specified. Also, the facilities
linked to electricity, AC rooms, water, hygiene maintenance, etc, should be checked
before providing any specialized services.

Permits

Land and construction

A hospital could be set up only on no- agricultural land that could be used. The numerous
approvals, as well as permissions required from the local authority and the government
should be obtained before starting any hospital.

Electricity and water

A hospital needs approximately 100 liters of water per bed each day. The water
requirement for the various hospitals would be different from project to project based on
whether the hospital is a primary, specialized hospital, etc. The concerned municipal
authority’s permission should be obtained to make the water and electricity facilities
available.

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Sewage

Well planned sanitary measures for disposal of waste as well as a drainage system which
includes tanks, pipelines, etc. and permission from the local authorities should be
obtained.

Biomedical Waste

The large hospitals must have an incinerator for disposal of bio-disposal waste, for
instance, body parts or tissues. A smaller hospital is not able to afford such a cost and it
needs minimal space and additional machinery installations, which are expensive for a
small hospital set up. The Municipal corporation’s permission would also be required for
such disposal of waste and it must not be harmful to the people living in a nearby
location.

Fire and Health License

Approval of the Fire Department is required for a large hospital as well as a Health
certificate from the local authority after installation of all the beds and equipment within
the hospital. A NOC from the Fire department should also be required for small hospitals
and it would be the responsibility of the hospital management to prove that the hospital
would not cause any harm or loss of life and needs to be procured from the local
municipal council.

REGULATIONS RELATING TO EMPLOYMENT OF STAFF

Employment of employees (Doctors, Nurses, Pharmacists) only after proper

credentialing
Prevention of sexual harassment of women employees at the workplace
Responsibility of the employer for the safety of workforces
Rules governing the employment of staff
Immunization / other measures for the protection of staff from Occupational Health
hazards.

SIGN BOARDS
Rules for the size, contents as well as the correct place for signboards (IMC Regulations
2002)

Information that requires be displayed at the Hospital are:

1. Certificate of registration of hospital with the municipal authorities

2. IMC/SMC registration certificate (IMC Regulations, 2002)
3. Charges for consultation as well as other procedures/services (IMC Regulations
2002)
4. Clinic timings, closed days

FSSAI license for operating a kitchen

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The FSSAI license comes from the Food Safety and Standards Authority of India under
the Ministry of Health and Family Welfare, Government of India. The license is necessary
if the hospital runs an in-house kitchen for the patients as well as attendants.

Permit to store LPG cylinder

If the hospital store has an LPG cylinder in large quantities for use in the hospital’s
kitchen or hospital purposes, the hospital must have a permit from the Controller of
Explosives under the Petroleum act, 1934.

Pharmacy registration for medical shop

This comes under the Office of the Drug Controller. There are different licenses for
medical shops attached to hospitals (IP) and standalone medical shops. There are
minimum requirements for the registration like the minimum size of the shop (250 – 300
ft) as well as requirements of Air conditioner and Refrigerator. This license is valid for 5
years.

Trademark registration

The Indian Trademarks Act 1999 is not a mandatory activity and is essential only if the
hospital wants to trademark its logo or name.

Vehicle registration for ambulances

The ambulance bought by the hospital must be registered with the RTO, the Transport
Department, and the state government.

Arms licenses under arms act 1959

If arms are possessed by the hospital or its employees (for example by security guards),
a license for the same should be available.

PLANNING THE HOSPITAL INFRASTRUCTURE

One must take care of these things:

Qualifications of Doctors as well as their registration numbers

Working hours for Nurses as well as their shift timings
Medical equipment as well as instruments purchased
Computers as well as other hardware devices set up
Engineers as well as staffs required for maintenance, plumbing, medical gas
pipelines, air conditioning, etc.

LICENSE REQUIRED

1. Regulations Building Permit and Licenses (From the Municipality)

2. No objection certificate from the Chief Fire Officer “License under Bio-Medical
Management and Handling Rules, 1998.

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 3. No objection certificate under Pollution Control Act.
4. Narcotics and Psychotropic substances Act, 1985
5. Vehicle Registration Certificates (For all hospital vehicles.)
6. Atomic energy regulatory body approvals (For the structural facility of radiology
dept, TLD badges, etc)
7. Boilers Act, 1923(If applicable)
8. MTP Act, 1971 (MTP stands for Medical termination of pregnancy. To be displayed
in the Gynaec and Obs department)
9. License for the Blood Bank (To be displayed in the Blood Bank)
10. Transplantation of Human Organs Act 1994(If applicable)
11. PNDT Act, 1996 (PNDT stands for Prenatal diagnostics test. To be displayed in the
Radiology department that this is followed
12. Dentist Regulations, 1976
13. Drugs & Cosmetics Act, 1940
14. Electricity Act, 1998
15. ESI Act, 1948 (For contract employees)
16. Environment Protection Act, 1986
17. Fatal Accidents Act 1855
18. Guardians and Wards Act, 1890
19. Indian Lunacy Act, 1912 (Applicable only if a Psychiatry dept is there in the hospital)
20. Indian Nursing Council Act 1947 (Whether nurses are registered with NCI).
21. Pharmacists registered with Pharmacy Council of India.
22. Insecticides Act, 1968
23. Lepers Act Maternity Benefit Act, 1961
24. Minimum wages act, 1948 (For contract employees)
25. Pharmacy Act, 1948
26. SC and ST Act, 1989
27. Protection of Human Rights Act, 1993
28. Registration of Births and Deaths Act, 1969
29. Urban Land Act, 1976
30. Right to Information Act 2005

The registration for transplantation of human organ Act, 1994 (in case the hospital varies
out human organ transplantation or organ harvesting, it shall be registered under this Act)
Excise permit to store spirit (to store spirit beyond a certain quantity, the hospital must
obtain a permit from state excise department). Multiple medical laws along with ethics are
required to be followed at every step. A set of rules and eligibility criteria were put forth by
our government for hospitals, which offer services for central government health scheme
beneficiaries.

HOSPITAL PROJECT COMMISSIONING

Unlike most other buildings, health facilities are complex buildings incorporating multiple
clinical disciplines. They need to be planned and designed to accommodate various
functions that have to strictly follow laid down operational policies. It is not just the

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building but other asset classes such as MEP and HVAC services that follow strict design
norms, not to mention the medical devices that can often cost as much as or more than
the building itself. Establishing the facilities under these circumstances is just half the
task. Hospitals, by and large are complex, expensive to operate and maintain. It is
therefore essential to synchronize the commissioning and hand over in a seamless
manner so as to minimize any problems in future.

The commissioning team would prepare a project implementation plan / program based
on the objectives of the project promoters, the nature of the hospital, timelines for
commissioning the facility, the various assets and services that need to be incorporated,
the building plans, etc.

The major categories of systems to be commissioned would be:

1. Building envelope
2. Safety systems
3. MEP systems
4. HVAC systems
5. Medical Gas Pipeline Systems (MGPS)
6. Nurse Call Systems (NCS)
7. Pneumatic Tube Systems (PTS)
8. Fire protection and alarm systems
9. Information technology
10. Vertical transports
11. Material handling
12. Interiors including lighting, furniture and finishes
13. Landscapes
14. Exterior lighting

It is important to write and execute policies and protocols and SOPs to ensure that the
skill sets for clinical and managerial areas are maintained to achieve complete patient
care. Some more aspects covered under commissioning assistance are:

Human Resource

Structuring of Organizational Chart

Distribution of Staffs in various grades
Salary structuring grade-wise

Manpower Planning

Job Description of all the employees

Employee Manual

Training Modules

Induction Program

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 Basic etiquette for Housekeeping, Nurses & Ward boys
Communication etiquette for front office staffs
Code of conduct
Grooming
Basic Etiquette for Housekeeping, Nurses & Ward boys

Information System (IT) Management:

Evaluation Program
IT Integration & Planning
Module Selection
Technology Evaluation And Finalization
Selection of It Hardware
Implementation of IT
Assistance of Data Masters
Website Framework
Integration With HIS
Mobile App Framework
Security Guidelines For IT
BMS (Building Management System)
Public Address System
EPBX
CCTV
Queue System
Nurse Call Integration With His
E- ICU Management
Integration of Various Medical Equipment’s With His

Operations Management:

Induction Program
Workflow Management
Departmental Flow chart
SOP’s of Every Department As Per NABH
Tariff Design

Marketing Management:

Template for Monthly Marketing

Yearly Marketing calendar
Template for Travel plan for Marketing executives
Health check-up plan
Internal Marketing

Branding Activities

Brand identity: Logo letterhead visiting cards, envelops etc.

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 Brochure Design
Signage Program
Stationary Program
Finalization of Linen
Ambulance Design
Hoarding Design

Marketing and Branding are the final steps when it comes to planning any hospital which
is important for two main things-

1. Create awareness regarding the new facility

2. Put the hospital on the map

CONCLUSION

Architectural planning and design of applicable healthcare/hospital facilities requires a

holistic yet focused approach and proper understanding of population, healthcare
demographics, quality, patient preferences, evidence-based outcomes, medical
technology, available healthcare professionals, etc. to be able to give birth to a truly
effective healthcare facility.

It is a superficial macro-level study. For more details, kindly contact us on

hospaccx.india@gmail.com or log on to www.hospaccxconsulting.com

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Related Team Members

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