Monitoring Tools for Setting up the Hospital Project: Initial Planning, Building and Equipment [1st ed. 2023] 9819962021, 9789819962020

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Monitoring Tools for Setting up the Hospital Project Initial Planning, Building and Equipment Ajay Garg

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Monitoring Tools for Setting up the Hospital Project

Ajay Garg

Monitoring Tools for Setting up the Hospital Project Initial Planning, Building and Equipment

Ajay Garg Director Hospital Administration Teerthanker Mahaveer University Moradabad, Uttar Pradesh, India

ISBN 978-981-99-6202-0    ISBN 978-981-99-6203-7 (eBook) https://doi.org/10.1007/978-981-99-6203-7 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore Paper in this product is recyclable.

For Medical Administrators, Architects, Planners, Project Managers, and Site Engineers First and foremost, we would like to thank God. We could never have done this without the faith we have in God, the Almighty. Dedicated to: My wife, Mohini Garg who was the main person by my corner, pushing me to share my experience by writing this book. You are my love and inspiration! Thanks for not just believing but knowing that I could do this! I Love You Always and Forever! To my children, Dr. Megha Garg and Parth Garg and my son-in-law Samarth Bachkheti for the hard work that you put into this book, and all the suggestions and improvements that you made to it have not just made this book better but have also strengthened our bond. I wish the three of you all the happiness and success in this world. – Ajay Garg

Preface

Hospital buildings are exceptionally complex compared to other commercial structures, making them challenging to plan, design, construct, and operate. The satisfaction of patients, staff, and their families is directly linked to the hospital’s design. The effectiveness of the hospital is greatly influenced by meticulous planning, design, and construction. Once the hospital building is in the planning or design stage and ready for implementation, it is crucial to monitor the project on a daily basis. Inadequate monitoring can lead to difficulties and impracticality in making changes or modifications to the building. Considering the substantial investments involved in hospital projects, it is essential to monitor all aspects of the project from the very beginning to promptly address any issues. Efficient monitoring during the implementation phase significantly reduces errors, ensures timely completion of tasks, and contributes to the overall success of the project. Hospital projects encompass a wide range of issues, including planning, procurement, construction, staffing, equipment, departmental setup, commissioning, and operationalizing services. Monitoring all these issues daily without proper tools is humanly challenging, if not impossible. Therefore, based on my extensive experience in planning, designing, and monitoring numerous hospital projects, ranging from small nursing homes to large corporate hospitals, I have developed a comprehensive set of monitoring tools in the form of checklists. This book contains 17 chapters that cover almost all the aspects of implementing and constructing a hospital project. The chapters address various critical issues, such as initial planning, feasibility reports, architectural drawings, material procurement, space planning, construction steps, support services setup, equipment planning, staff planning, departmental setup, testing, and commissioning. Having spent 30 years in the healthcare industry, I felt compelled to share my experiences to facilitate the monitoring of hospital projects. It is important to note that these chapters are based solely on the practicality of working conditions as per my personal experience. While I have attempted to incorporate the norms of accreditation agencies like JCI and NABH, it is advisable for project promoters to consult vii

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Preface

the applicable norms and regulations of their respective countries or governing bodies. Details provided in these chapters may be accurate for some countries or individuals, but not necessarily for others, as space and facility requirements vary. Thus, you are encouraged to consider the issues that are relevant and beneficial to you, while disregarding those that do not apply. I have tried to write this book in a very easily understandable English language. This book may be a great help to Medical Administrators, Architects, Planners, Project Managers, and Site Engineers. Moradabad, Uttar Pradesh, India

Ajay Garg

Highlights of the Book

The checklists in the form of tables given in the book help in • Posing the compulsion on the promoters to rethink on his/her decision on setting up the hospital/college based on a few self-answering questions. • Considering the issues to be taken care of while preparing the Detailed Project Report (DPR). • Considering the issues involved in conducting feasibility studies. • Listing out the architectural drawing to be prepared. • Calculating the total space required for the hospital or college. • Considering the issues involved in actual construction inside the building. • Considering the issues involved in construction outside the building. • Landscaping and development of the site. • Considering the issues related to the support services like Electricity, Plumbing, MGPS, HVAC, Net Working, CCTV, Fire Services Public Announcement, etc. • Considering the issues involved during the planning of the medical and non-­ medical equipment and procurement of the same. • Considering the issues involved in the planning and appointment of staff. Framing the policies for employees. Formation of various committees.

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How to Use the Checklists Given in the Book

• This book is basically a checklist to help the promoters and designers with self-­ assessment and monitoring the ongoing project on a day-to-day basis. • This book shall be used by the Promoter, Planner, Designer, Chief Engineer, or the Site In-charge. • The Chief Engineer or the Site In-charges shall judiciously maintain the checklists, fill them up daily, make corrections, fix the new targets, review the previous day’s work and update the checklist. • Once you start filling these checklists and using the monitoring tools, a lot of your energy will be saved as it will reduce the quantum of rounds. It is not humanly possible to remember all the activities all the time, but if it is in a written form, just by glancing at it, you will remember the task or activity. • Chief Engineer or the Site engineer shall summarize the checklist daily and submit the progress report to the top management. • Start filling out checklist 1 for your self-assessment about the inception of the idea of the hospital. First of all, decide your requirement in terms of facilities, departments, and services you wish to start in phase 1. Also, you have to well plan future expansion like –– –– –– –– –– –– –– ––

Departments you wish to start Number of beds to be provided including the ward-wise breakup of bed Equipment to be procured Services to be provided Land area available Building area allowed as per bylaws of the city Funds availability in terms of amount and period The demand of the area. Please access the services and facilities in demand by the community, and the type of diseases generally existing in the community.

• Start filling out this book immediately upon inception of the idea, as the first chapter of the book will help you in assessing what you are planning and what you want to have in the proposed hospital.

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How to Use the Checklists Given in the Book

• Please be clear that these checklists are designed for a full-fledged multi-­specialty hospital setup. All the activities may or may not be related to you. The activities that are not related to your setup may please be ignored. • Initially, the promoter, planner, and designer shall access the ideal time frame required for the completion of the entire project. • This time frame shall then be divided into different phases, like the planning phase, designing phase, approval phase, construction phase, equipment installation phase, manpower requirement phase, testing and commissioning phase, etc. • The designers shall then access the period required for each phase. Keep in mind the phases which can run simultaneously with another phase. Also, the designers shall estimate the time required for each construction activity like excavation, foundation, column and beam casting, slab casting, brick/block work, plaster, electrical and plumbing works, etc. • It is advised to start filling up the checklists phase-wise. Initially, the checklist of construction activities shall be considered. • Other checklists like Human Resources, Equipment, Licensing, etc. can be taken care of in later stages. • Based on the period required for each activity, start filling up the start date and end date of the particular activity. • You may find that some activities can run parallel to each other, whereas some activities may be linked to other activities. For example, once the brick/block work is over the electrical, plumbing, and MGPS activities can be carried out simultaneously. On the other side, plastering of the wall can only be commenced when all the electricity and plumbing pipeline are laid down. Hence, plastering is a linked activity. • You are advised to fill up these lists with the lead pencil so that they can be modified as and when required just by erasing the same.

Acknowledgement

I am thankful to the Chancellor and Vice-Chairman of Teerthanker Mahaveer University, Moradabad, India, for providing us with the platform for learning and gaining experiences in the field of health care. Without your support and input, it would have been difficult to write this book and share my experiences. Here, I would also like to thank Mr. Abhishek Kapoor for providing me with all the help to write this book. Extending my gratitude towards Dr. Rohit Varshney, I would like to thank him for his constant support towards the vision, his regular discussions, and brainstorming sessions during the compilation of this book and his guidance on many small tasks. I would also like to thank him for helping me in compiling and sharing his experiences in a few chapters of this book. I would like to appreciate Ms. Himanshi for her invaluable assistance in the compilation of this book. Lastly, I would like to thank each one who believed in my vision and supported me throughout this amazing journey. I hope this book helps everyone in some way and collectively I can make the medical society achieve great heights. Thank You! Ajay Garg

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Introduction

Due to their complexity, planning, designing, and constructing, hospital buildings involve a multitude of tasks and activities. Therefore, it is crucial to closely monitor the project on a day-to-day basis. Efficient monitoring during the implementation stage greatly reduces errors, ensures proper scheduling, and facilitates timely completion of the project. Inadequate monitoring can lead to significant mistakes or omissions, making it difficult or impractical to make changes or modifications to the building. Hospital projects encompass a wide range of tasks and activities, including planning, procurement, construction, staffing, equipment acquisition, departmental setup, commissioning, and testing, all the way to operationalizing the hospital services. To facilitate proper monitoring of the project, the use of monitoring tools is necessary. Therefore, this book provides a series of monitoring tools in the form of checklists to assist in the effective management of hospital projects. It is important to note that these chapters are based on the practicality of working conditions as per the author’s personal experience. While efforts have been made to highlight the norms of accreditation agencies such as JCI and NABH, project promoters are advised to consult the relevant norms and regulations applicable in their respective countries. This book can be immensely valuable to medical administrators, architects, planners, project managers, and site engineers in understanding and scheduling all the tasks and activities involved in setting up a hospital project. Written in easily understandable English, it can also serve as a valuable resource for students studying hospital management, engineering, architecture, hospital promotion, planning, and design. Ajay Garg

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Contents

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 Initial Planning of the Proposed Hospital Project��������������������������������    1 1.1 Purpose of a Hospital������������������������������������������������������������������������    2 1.2 Status of the Hospital������������������������������������������������������������������������    4 1.3 Promoters’ Details����������������������������������������������������������������������������    5 1.4 Area of Coverage������������������������������������������������������������������������������    5 1.5 Geographical Details������������������������������������������������������������������������    6 1.6 Demographic Details������������������������������������������������������������������������    7 1.7 Other Hospitals’ Details��������������������������������������������������������������������    8 1.8 Planned Services of the Hospital������������������������������������������������������   10 1.9 Feasibility Reports and DPR Details������������������������������������������������   23 1.10 Budget and Source of Funds ������������������������������������������������������������   24 1.11 Site Details����������������������������������������������������������������������������������������   27 1.12 Building Details��������������������������������������������������������������������������������   31 1.13 Formation of the Legal Entity of the Organization��������������������������   35 1.14 Land Details��������������������������������������������������������������������������������������   36 1.15 Funding ��������������������������������������������������������������������������������������������   37 1.16 Hiring Consultants/Staff ������������������������������������������������������������������   38 1.17 Electrical Works��������������������������������������������������������������������������������   40 1.18 Water Supply and Sewerage System������������������������������������������������   44 1.19 Contact Details����������������������������������������������������������������������������������   47 Further Reading ����������������������������������������������������������������������������������������   48

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 Detailed Project Report (DPR) and Techno-Commercial Feasibility Report (TCFR) ����������������������������������������������������������������������������������������   49 2.1 Details of Projections������������������������������������������������������������������������   50 2.2 Other Issues Relating to the DPR ����������������������������������������������������   55 2.3 The Final DPR����������������������������������������������������������������������������������   61 2.4 Evaluation and Approval of the DPR������������������������������������������������   63 Further Reading ����������������������������������������������������������������������������������������   65

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 Room Requirement and Building Area Calculation����������������������������   67 3.1 Factors for Space Planning ��������������������������������������������������������������   68 3.1.1 Functional Areas ������������������������������������������������������������������   68 3.2 Room/Space Requirement����������������������������������������������������������������   70 3.3 Room Sizes ��������������������������������������������������������������������������������������   72 3.4 Zoning ����������������������������������������������������������������������������������������������   73 3.5 Room Requirement and Area Calculation of a Hospital Building����   74 3.5.1 Entrance Lobby Area������������������������������������������������������������   74 3.5.2 OPD, Emergency and Diagnostic Activities ������������������������   74 3.5.3 Diagnostic Services��������������������������������������������������������������   74 3.5.4 The Department of Radiotherapy������������������������������������������   74 3.5.5 Emergency Services��������������������������������������������������������������   96 3.5.6 Other Treatments������������������������������������������������������������������   96 3.5.7 Intensive Care Units��������������������������������������������������������������   96 3.5.8 Therapeutic Services������������������������������������������������������������   96 3.5.9 Intermediate Care Area ��������������������������������������������������������   96 3.5.10 Administrative/Ancillary Services����������������������������������������   96 3.5.11 Hospital Services������������������������������������������������������������������   96 3.5.12 Engineering Services������������������������������������������������������������  125 3.6 Summary ������������������������������������������������������������������������������������������  125 Further Reading ����������������������������������������������������������������������������������������  128

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 Schematic Design and Contract Documents������������������������������������������  129 4.1 Confirmation of the Building Planning��������������������������������������������  130 4.2 Architectural Drawings ��������������������������������������������������������������������  131 4.2.1 Site Plan��������������������������������������������������������������������������������  132 4.2.2 Concept Drawings����������������������������������������������������������������  133 4.2.3 Floor Plan������������������������������������������������������������������������������  133 4.2.4 Cross Section������������������������������������������������������������������������  133 4.2.5 Elevation ������������������������������������������������������������������������������  134 4.2.6 Landscape ����������������������������������������������������������������������������  134 4.2.7 Finishing Drawing����������������������������������������������������������������  134 4.2.8 Working Plan������������������������������������������������������������������������  134 4.2.9 Section Drawings������������������������������������������������������������������  135 4.2.10 Structural Drawings��������������������������������������������������������������  135 4.2.11 Column Layout ��������������������������������������������������������������������  135 4.2.12 Plinth Beam Layout��������������������������������������������������������������  135 4.2.13 Lintel Beam Layout��������������������������������������������������������������  136 4.2.14 Roof Beam and Shuttering Layout ��������������������������������������  136 4.2.15 Excavation Drawings������������������������������������������������������������  136 4.2.16 Electrical Drawings��������������������������������������������������������������  136 4.2.17 Plumbing Drawings��������������������������������������������������������������  137 4.2.18 Fire Fighting and Detection Drawings����������������������������������  137 4.2.19 Shop Drawings����������������������������������������������������������������������  137 4.2.20 Furniture Layout Drawings��������������������������������������������������  138

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4.2.21 Furniture Design Drawings��������������������������������������������������  138 4.2.22 Hospital Signage Drawings��������������������������������������������������  138 4.2.23 As-Built Drawings����������������������������������������������������������������  138 4.2.24 PERT Charts�������������������������������������������������������������������������  139 4.2.25 General Note ������������������������������������������������������������������������  139 4.3 Contract Documents��������������������������������������������������������������������������  139 4.3.1 General Information About the Project��������������������������������  141 4.3.2 Construction Contract Agreement����������������������������������������  142 4.3.3 Scope of Work (SOW)����������������������������������������������������������  142 4.3.4 Construction Schedule����������������������������������������������������������  142 4.3.5 General Conditions ��������������������������������������������������������������  142 4.3.6 Special Conditions����������������������������������������������������������������  143 4.3.7 Specifications������������������������������������������������������������������������  143 4.3.8 Bill of Quantities (BOQ)������������������������������������������������������  143 4.3.9 Cost Estimate������������������������������������������������������������������������  143 4.3.10 Drawings ������������������������������������������������������������������������������  143 4.3.11 Other Documents������������������������������������������������������������������  144 Further Reading ����������������������������������������������������������������������������������������  145 5

 Civil Construction Works of the Hospital Building������������������������������  147 5.1 Pre-Construction Activities ��������������������������������������������������������������  148 5.2 MAP/Drawing Approvals������������������������������������������������������������������  149 5.3 Engagement of Contractors��������������������������������������������������������������  150 5.4 Selection of the Vendors for Materials Supply ��������������������������������  153 5.5 Starting Preparing for Construction��������������������������������������������������  156 5.6 Layout and Excavation of Land��������������������������������������������������������  158 5.7 Building Construction����������������������������������������������������������������������  159 5.8 Foundation of the Building ��������������������������������������������������������������  160 5.9 Works from the Basement Up to the Plinth Level����������������������������  161 5.10 Civil Works ��������������������������������������������������������������������������������������  164 5.11 Flooring��������������������������������������������������������������������������������������������  166 5.12 False Ceiling ������������������������������������������������������������������������������������  168 5.13 Woodwork����������������������������������������������������������������������������������������  170 5.14 Aluminium Work������������������������������������������������������������������������������  171 5.15 Wall Guards��������������������������������������������������������������������������������������  173 5.16 Curtain Track, IV Rods, and Corner Guards������������������������������������  173 5.17 Painting Walls and Ceiling����������������������������������������������������������������  174 5.18 Painting Wooden Doors and Windows����������������������������������������������  175 5.19 Painting MS Iron Surfaces����������������������������������������������������������������  176 5.20 Lifts/Elevators ����������������������������������������������������������������������������������  177 Further Reading ����������������������������������������������������������������������������������������  178

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 Electrical Works of the Hospital Building ��������������������������������������������  179 6.1 Internal Electrical Works Inside a Hospital Building ����������������������  179 6.2 Centralised Electrical Works������������������������������������������������������������  182 6.2.1 HT Substation Works������������������������������������������������������������  182 6.2.2 The LT Panel Room��������������������������������������������������������������  186 6.2.3 Diesel Generator (DG) Sets��������������������������������������������������  187 6.2.4 Uninterruptible Power Supply (UPS) Systems ��������������������  188 6.2.5 Earthing��������������������������������������������������������������������������������  189 6.2.6 Lightning Arrestors ��������������������������������������������������������������  190 6.2.7 The Solar Electrical System��������������������������������������������������  190 6.3 The Street Lighting System��������������������������������������������������������������  191 Further Reading ����������������������������������������������������������������������������������������  193

7

 Water Supply and Drainage Works of the Hospital Building��������������  195 7.1 Sanitary Works Inside a Hospital Building��������������������������������������  195 7.2 Central Works of Water Supply and the Drainage System ��������������  197 7.2.1 The Water Supply System����������������������������������������������������  197 7.2.2 The Hot Water Supply System����������������������������������������������  203 7.2.3 The Drainage System������������������������������������������������������������  204 7.2.4 Rainwater Harvesting������������������������������������������������������������  206 7.2.5 Irrigation Water Supply��������������������������������������������������������  206 7.2.6 Sewerage Treatment Plant/Effluent Treatment Plant������������  207 7.2.7 The Drinking Water Supply System ������������������������������������  207 7.3 The Steam Supply System����������������������������������������������������������������  208 7.4 Other Miscellaneous Works of Drainage Outside the Building��������  209 Further Reading ����������������������������������������������������������������������������������������  210

8

 HVAC (Air Conditioning) Works of the Hospital Building������������������  211 8.1 Air Conditioning (HVAC) Works Inside the Hospital Building ������  212 8.2 Central Control Works of Air Conditioning (HVAC) System����������  214 8.2.1 HVAC Plant Room����������������������������������������������������������������  218 8.2.2 Cooling Towers ��������������������������������������������������������������������  219 8.2.3 Air Handling Units/Fan Coil Units ��������������������������������������  220 8.2.4 Ducting����������������������������������������������������������������������������������  221 8.2.5 Grills, Diffusers, and Registers ��������������������������������������������  222 8.2.6 Electrical Control������������������������������������������������������������������  222 8.2.7 Testing and Commissioning��������������������������������������������������  223 Further Reading ����������������������������������������������������������������������������������������  223

9

 Fire Safety Works of the Hospital Building������������������������������������������  225 9.1 Firefighting and Detection Works Inside the Hospital Building������  225 9.2 Control Station of Firefighting and Detection System����������������������  227 9.2.1 Fire Pump Room ������������������������������������������������������������������  232 9.2.2 Fire Hydrant System ������������������������������������������������������������  235 9.2.3 Wet Riser������������������������������������������������������������������������������  236 9.2.4 Downcomer��������������������������������������������������������������������������  236

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9.2.5 Fire Detection System (Smoke/Heat Detectors) ������������������  237 9.2.6 Smoke Extraction System ����������������������������������������������������  239 9.2.7 Automatic Sprinkler System ������������������������������������������������  241 9.2.8 Pressurisation of the Lift Wells, Stair Cases, and Lift Lobbies����������������������������������������������������������������������������������  241 9.3 Firefighting Outside the Hospital Building��������������������������������������  242 Further Reading ����������������������������������������������������������������������������������������  243 10 ELV,  ICT, IBMS, and Information Technology Works of the Hospital Building��������������������������������������������������������������  245 10.1 CCTV System Inside the Hospital Building����������������������������������  245 10.2 Central Control Station for CCTV System ������������������������������������  246 10.3 Public Announcement (PA) System Inside the Hospital Building����������������������������������������������������������������������  248 10.4 Control Station of Public Announcement (PA) System������������������  249 10.5 Electronic Private Automatic Branch Exchange (EPABX) System Inside the Hospital Building������������������������������  250 10.6 Control Station of EPABX System ������������������������������������������������  251 10.7 IT Networking and Wi-Fi System Inside the Hospital Building����  252 10.8 Control Station of IT Networking and Wi-Fi����������������������������������  253 10.9 Television System ��������������������������������������������������������������������������  255 10.10 Nurse Call System��������������������������������������������������������������������������  256 10.11 Access Control System ������������������������������������������������������������������  257 10.12 IBMS����������������������������������������������������������������������������������������������  258 10.13 Pneumatic Tube System (PTS) Inside the Hospital Building ��������  259 10.14 Control Station of Pneumatic Tube System (PTS) ������������������������  260 Further Reading ����������������������������������������������������������������������������������������  261 11 Medical  Gases Pipeline System (MGPS) Works of the Hospital Building��������������������������������������������������������������������������  263 11.1 Medical Gases Pipeline System (MGPS) Inside the Hospital Building ����������������������������������������������������������  263 11.2 Central Plant Works of MGPS System ������������������������������������������  265 11.2.1 Manifold Room������������������������������������������������������������������  269 11.2.2 Pump Room for Air������������������������������������������������������������  270 11.2.3 Pump Room for Vacuum����������������������������������������������������  272 11.2.4 Liquid Oxygen Gas System������������������������������������������������  273 Further Reading ����������������������������������������������������������������������������������������  274 12 Construction  Works Outside the Main Building����������������������������������  275 12.1 Internal Roads ��������������������������������������������������������������������������������  275 12.1.1 Reinforced Cement Concrete (RCC) Roads ����������������������  277 12.1.2 Plain Cement Concrete (PCC) Roads ��������������������������������  278 12.1.3 Tiled Roads ������������������������������������������������������������������������  278 12.1.4 Black Bitumen Road ����������������������������������������������������������  279 12.2 Elevation of Building����������������������������������������������������������������������  279

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12.3 Roof Treatment ������������������������������������������������������������������������������  281 12.4 Main Gates��������������������������������������������������������������������������������������  282 12.5 Security Posts����������������������������������������������������������������������������������  283 12.6 Landing Bay and Porches ��������������������������������������������������������������  284 12.6.1 RCC Structure��������������������������������������������������������������������  285 12.6.2 Steel Structure��������������������������������������������������������������������  286 12.6.3 Common Activities for the Landing Bay����������������������������  286 12.7 Boundary Wall��������������������������������������������������������������������������������  287 12.8 Landscaping and Plantation������������������������������������������������������������  288 12.9 Car Parking Lots ����������������������������������������������������������������������������  289 Further Reading ����������������������������������������������������������������������������������������  291 13 Ancillary Activities and Implementation ����������������������������������������������  293 13.1 Other Ancillary Works��������������������������������������������������������������������  293 13.2 Facilities for Patients����������������������������������������������������������������������  295 13.3 Facilities for Attendants������������������������������������������������������������������  296 13.4 Systems Details������������������������������������������������������������������������������  298 13.5 Approvals, Licences, Sanctions, and Registrations������������������������  299 13.6 Final Testing of the Equipment and the Services����������������������������  303 13.7 Start and Go������������������������������������������������������������������������������������  304 Further Reading ����������������������������������������������������������������������������������������  306 14 Equipment  Planning, Procurement, Installation and Management ��  307 14.1 Planning of the Medical Equipment in Terms of Requirements and Specifications����������������������������������������������������������������������������������  308 14.1.1 General Issues to Be Considered while Planning and Purchasing the Medical Equipment������������������������������������  311 14.1.2 Points to Be Considered While Planning the Medical Equipment ��������������������������������������������������������������������������  312 14.2 Identification of the Vendor of Medical Equipment������������������������  314 14.2.1 Warranty������������������������������������������������������������������������������  314 14.2.2 Maintenance Contracts�������������������������������������������������������  314 14.2.3 Availability of the Workshops and Service Engineers��������  314 14.2.4 Period of Spare Part Availability����������������������������������������  315 14.2.5 Cost of Consumables����������������������������������������������������������  315 14.2.6 Life Expectancy of the Equipment ������������������������������������  315 14.2.7 Vendors Evaluation ������������������������������������������������������������  315 14.2.8 Checking Regulations ��������������������������������������������������������  316 14.2.9 Assistance in Getting the Licenses or Approvals����������������  316 14.3 Procurement of the Medical Equipment ����������������������������������������  316 14.3.1 Inviting Financial and Techno-Commercial Quotations ����  316 14.3.2 Comparative Statement of Financial and Techno-Commercial Quotations ��������������������������������������������������������������������������  316 14.3.3 Demonstration of the Equipment����������������������������������������  318 14.3.4 Discussion and Negotiations����������������������������������������������  318 14.3.5 Preparing the Purchase Order ��������������������������������������������  319

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14.4 Purchase Order and its Contents ����������������������������������������������������  319 14.4.1 Purchase Order Number������������������������������������������������������  319 14.4.2 Purchase Order Date ����������������������������������������������������������  320 14.4.3 Name of the Vendor������������������������������������������������������������  320 14.4.4 Details of the Items ������������������������������������������������������������  320 14.4.5 Taxes and Duties ����������������������������������������������������������������  320 14.4.6 Technical Details����������������������������������������������������������������  321 14.4.7 Currency Fluctuations��������������������������������������������������������  321 14.4.8 Delivery and Installation Period ����������������������������������������  321 14.4.9 Installation and Commissioning ����������������������������������������  322 14.4.10 Payment Terms��������������������������������������������������������������������  322 14.4.11 Warranty������������������������������������������������������������������������������  323 14.4.12 Up Time Guarantee ������������������������������������������������������������  323 14.4.13 Site Preparation������������������������������������������������������������������  324 14.4.14 Training������������������������������������������������������������������������������  324 14.4.15 Post-Sales Maintenance������������������������������������������������������  325 14.4.16 Period to Attend After-Sale Service������������������������������������  325 14.4.17 Financial Guarantee Against Post-Sale Service������������������  325 14.4.18 Availability of Spares����������������������������������������������������������  325 14.4.19 Testing and Handing Over��������������������������������������������������  325 14.4.20 Annual Maintenance or Comprehensive Maintenance Contract������������������������������������������������������������������������������  326 14.4.21 Government or Regulatory Approvals��������������������������������  327 14.4.22 Other Conditions����������������������������������������������������������������  327 14.4.23 Up-Gradation Clause����������������������������������������������������������  327 14.4.24 Dispute Dissolution������������������������������������������������������������  327 14.5 Inspection of the Equipment Delivered in Terms of Quality and Quantity������������������������������������������������������������������������������������������  333 14.5.1 Inspection of the Material at the Time of Delivery������������  333 14.5.2 Inspection of the Material at the Time of Installation��������  333 14.6 Inventory and Documentation of the Equipment Received������������  334 14.7 Installation, Commissioning and Testing of the Equipment ����������  335 14.7.1 Proper Location of Installation ������������������������������������������  336 14.7.2 Area Requirement ��������������������������������������������������������������  336 14.7.3 Power Supply Requirements for Electrical Medical Devices��������������������������������������������������������������������������������  337 14.7.4 Positioning of the Medical Equipment ������������������������������  338 14.7.5 Environmental Conditions��������������������������������������������������  339 14.7.6 Other Issues������������������������������������������������������������������������  339 14.7.7 Installation of the Equipment����������������������������������������������  340 14.7.8 Commissioning and Testing of the Equipment ������������������  341 14.7.9 Installation and Testing Reports������������������������������������������  341 14.8 User Training and Certification������������������������������������������������������  342 14.9 Handing Over the Equipment ��������������������������������������������������������  343 14.10 Monitoring Performance at Regular Intervals��������������������������������  344

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14.11 Maintenance, Safety and Care of Medical Equipment ������������������  344 14.11.1 Equipment Checking����������������������������������������������������������  347 14.11.2 Cleaning Issues ������������������������������������������������������������������  349 14.11.3 Infrastructure-Related Issues����������������������������������������������  351 14.11.4 Other Issues������������������������������������������������������������������������  352 14.12 Condemnation, Disposal and Replacement of the Equipment��������  352 14.12.1 Reasons for Replacement and Condemnation��������������������  352 14.12.2 Life Span of Medical Equipment����������������������������������������  352 14.12.3 Condemnation Process��������������������������������������������������������  353 14.12.4 Replacement of the Equipment������������������������������������������  355 Further Reading ����������������������������������������������������������������������������������������  356 15 Department Wise Equipment Detailing ������������������������������������������������  357 15.1 Emergency and Triage��������������������������������������������������������������������  358 15.2 Indoor Wards and Patient Rooms����������������������������������������������������  364 15.3 Intensive Care Units (ICU’S)����������������������������������������������������������  366 15.4 Robotic Surgery������������������������������������������������������������������������������  368 15.5 Cardiology and Interventional Cardiology ������������������������������������  369 15.6 Pulmonology ����������������������������������������������������������������������������������  373 15.7 Neurology ��������������������������������������������������������������������������������������  375 15.8 Neuro Surgery ��������������������������������������������������������������������������������  377 15.9 Psychiatry����������������������������������������������������������������������������������������  380 15.10 Nephrology ������������������������������������������������������������������������������������  381 15.11 Urology ������������������������������������������������������������������������������������������  382 15.12 Gastroenterology, Hepatology and Pancreatology��������������������������  384 15.13 Plastic, Cosmetic, Burn and Vascular Surgery��������������������������������  386 15.14 Gynaecology and Obstetrics ����������������������������������������������������������  388 15.15 In Vitro Fertilisation (IVF)��������������������������������������������������������������  389 15.16 Paediatric (Neo Natal ICU)������������������������������������������������������������  391 15.17 Orthopaedic and Rheumatology ����������������������������������������������������  393 15.18 Ophthalmology ������������������������������������������������������������������������������  394 15.19 Otorhinolaryngology (ENT) ����������������������������������������������������������  397 15.20 Dermatology, Cosmetology and Venereology��������������������������������  400 15.21 Oncology����������������������������������������������������������������������������������������  402 15.22 Operating Rooms����������������������������������������������������������������������������  405 15.22.1 General Items in All Operating Rooms������������������������������  405 15.22.2 Operative Room CTVS������������������������������������������������������  415 15.22.3 Operating Room ENT ��������������������������������������������������������  416 15.22.4 Operating Room Eye����������������������������������������������������������  417 15.22.5 Operating Room Gynaecology ������������������������������������������  418 15.22.6 Operating Room Neurosurgery������������������������������������������  418 15.22.7 Operating Room Urology ��������������������������������������������������  419 15.22.8 Operating Rooms Orthopaedic ������������������������������������������  420 15.23 Radiology����������������������������������������������������������������������������������������  421 15.24 Pathology����������������������������������������������������������������������������������������  435

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15.25 Microbiology����������������������������������������������������������������������������������  440 15.26 Biochemistry ����������������������������������������������������������������������������������  444 15.27 Pain Clinic��������������������������������������������������������������������������������������  448 15.28 Blood Bank ������������������������������������������������������������������������������������  449 15.29 CSSD����������������������������������������������������������������������������������������������  451 15.30 Dental����������������������������������������������������������������������������������������������  452 15.31 Physiotherapy����������������������������������������������������������������������������������  455 15.32 Occupational Therapy ��������������������������������������������������������������������  457 15.33 Furniture and Fixtures��������������������������������������������������������������������  463 15.33.1 Patient Furniture������������������������������������������������������������������  463 15.33.2 Civil Furniture��������������������������������������������������������������������  464 15.34 Backup Services������������������������������������������������������������������������������  465 15.35 Hospital Laundry����������������������������������������������������������������������������  466 15.36 Miscellaneous Small Instruments ��������������������������������������������������  467 Further Reading ����������������������������������������������������������������������������������������  468 16 Manpower  Planning, Hospital Committees and Staff Policies������������  469 16.1 Staff Requirement ��������������������������������������������������������������������������  471 16.1.1 Administration��������������������������������������������������������������������  471 16.1.2 Medical Care����������������������������������������������������������������������  473 16.1.3 Investigations and Support Departments����������������������������  477 16.1.4 Technicians ������������������������������������������������������������������������  478 16.1.5 Nursing Care ����������������������������������������������������������������������  481 16.1.6 Housekeeping����������������������������������������������������������������������  482 16.1.7 Dietary��������������������������������������������������������������������������������  483 16.1.8 Accounts and Finance ��������������������������������������������������������  485 16.1.9 Medical Record������������������������������������������������������������������  486 16.1.10 Public Relation Department������������������������������������������������  487 16.1.11 Marketing and Branding ����������������������������������������������������  487 16.1.12 Information Technology (IT)����������������������������������������������  488 16.1.13 Human Resources ��������������������������������������������������������������  489 16.1.14 Purchase������������������������������������������������������������������������������  491 16.1.15 Stores����������������������������������������������������������������������������������  492 16.1.16 Reception and Communication������������������������������������������  493 16.1.17 Linen Supply Department ��������������������������������������������������  494 16.1.18 Transport ����������������������������������������������������������������������������  494 16.1.19 Security ������������������������������������������������������������������������������  495 16.1.20 Electricity����������������������������������������������������������������������������  496 16.1.21 Heating, Ventilation and Air Conditioning (HVAC) ����������  496 16.1.22 Water Supply and Drainage������������������������������������������������  498 16.1.23 Medical Gas Pipeline System (MGPS)������������������������������  498 16.1.24 Building Maintenance��������������������������������������������������������  499 16.1.25 Biomedical Maintenance����������������������������������������������������  501 16.1.26 Pharmacy����������������������������������������������������������������������������  501 16.1.27 Library��������������������������������������������������������������������������������  502

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16.1.28 Other Staff��������������������������������������������������������������������������  502 16.2 Procedure for Staff Appointment����������������������������������������������������  503 16.3 Committees ������������������������������������������������������������������������������������  505 16.4 Human Resource Policies ��������������������������������������������������������������  508 Further Reading ����������������������������������������������������������������������������������������  510 17 Policies  and Standard Operating Procedures (SOP)����������������������������  511 17.1 Policies��������������������������������������������������������������������������������������������  512 17.1.1 Hospital Policies ����������������������������������������������������������������  512 17.2 Standard Operating Procedures (SOPs)������������������������������������������  517 17.2.1 Administrative Services������������������������������������������������������  518 17.2.2 Emergency Department������������������������������������������������������  526 17.2.3 Outpatient (OPD) Services ������������������������������������������������  531 17.2.4 Inpatient Department (IPD) Services����������������������������������  534 17.2.5 Operation Theatre Services������������������������������������������������  539 17.2.6 Delivery Room��������������������������������������������������������������������  539 17.2.7 Imaging Department Services��������������������������������������������  549 17.2.8 Clinical Laboratory Services����������������������������������������������  552 17.2.9 Blood Bank Services����������������������������������������������������������  556 17.2.10 Nursing Services ����������������������������������������������������������������  560 17.2.11 Medico-Legal Services ������������������������������������������������������  563 17.2.12 Accounts/Financial Management���������������������������������������  566 17.2.13 Human Resources Department ������������������������������������������  570 17.2.14 Central Sterile Supply Department (CSSD) ����������������������  574 17.2.15 Dietetic Services ����������������������������������������������������������������  577 17.2.16 Laundry and Linen Services ����������������������������������������������  577 17.2.17 Medical Records Department (MRD)��������������������������������  582 17.2.18 Ambulance Services������������������������������������������������������������  585 17.2.19 Housekeeping Services ������������������������������������������������������  587 17.2.20 Physiotherapy and Rehabilitation Services������������������������  590 17.2.21 Front Desk Services������������������������������������������������������������  592 17.2.22 Security Services����������������������������������������������������������������  592 17.2.23 Stores, Purchase, and Materials Management��������������������  598 17.2.24 Biomedical Engineering Department����������������������������������  601 17.2.25 Pharmacy����������������������������������������������������������������������������  605 17.2.26 Maintenance Departments��������������������������������������������������  608 Further Reading ����������������������������������������������������������������������������������������  613 Glossary������������������������������������������������������������������������������������������������������������  615

About the Author

Ajay  Garg, FCA, DHA, SAP (FI)  Ajay Garg has been in the field of healthcare planning, designing, and administration for the last three decades. He has worked for about 28 years with various hospitals like Narinder Mohan Hospital and Heart Centre, Ghaziabad; Jeevan Rekha Hospital, Kashipur; Teerthanker Mahaveer Medical College, Moradabad; etc. He has also completed various hospital projects like Krishna Hospital (Kashipur), Narayan Hospital (Rudrapur), Le-Crest Hospital (Vasundra, Ghaziabad), and TSM Medical College and Hospital (Lucknow) as a hospital consultant. He had already authored a book titled Manual of Hospital Planning and Designing published by Springer Nature. Additionaly, he has also authored a book titled Monitoring Tools for Setting up the Hospital Project - Department-Wise Planning published by Springer Nature.

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Chapter 1

Initial Planning of the Proposed Hospital Project

Typically, when a promoter envisions establishing a hospital, the process of planning commences immediately. The initial considerations revolve around the questions of ‘where, why, and when’ the hospital should be established. The answers to these questions are contingent upon various factors and the promoter’s personal perspective. These factors might include the promoter’s location, work environment, assumptions about expected patient load, and the presence of other hospitals in the area. However, the question arises as to whether planners should consider factors lacking evidence or documented assessments. To address this, promoters shall pose critical questions to themselves, as outlined in the checklists provided in this chapter. Once these questions are addressed, and the city or location is finalized, geographical data is collected, the next step is to conduct and surveys to compile a feasibility report. This report is based on surveys in the proposed hospital’s vicinity and nearby areas, aiming to assess the hospital’s potential for success in that location. To enhance clarity and confidence in the project’s prospects, the report shall be substantiated with supporting documents, including evidence of the actual survey, analysis, and underlying assumptions. The subsequent step involves preparing a detailed project report (DPR), a comprehensive set of documents illustrating the outcomes and projections in the project’s planning and design phases. The DPR consists of projections and plans, encompassing financial calculations, detailed project scheduling, delineation of roles and responsibilities, timeframes for project completion, and resource requirements for project execution. During this planning stage, a project blueprint is prepared on paper, facilitating an in-depth study and analysis of the steps required to transform the investment into a feasible and profitable venture. Site selection for the hospital project comes next, with consideration of factors such as the land size required for the necessary hospital facilities. While determining land size, compliance with construction regulations and government guidelines © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_1

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1  Initial Planning of the Proposed Hospital Project

specific to the region is imperative. This includes factors like maximum land coverage, floor area ratio (FAR), building height limits, setback area requirements, and more. Site selection also takes into account the land’s location, accessibility, utility availability, transportation access, road network, safety, environmental pollution, provision for protection from winds, earthquakes, floods, etc. In the planning phase, promoters must plan and decide on the issues like number of beds, clinical and non-clinical departments, the range of services, diagnostic facilities, surgical departments, and supporting units like pharmacies, laundry, kitchen, mortuary etc. that are intended to be provided in the proposed hospital. The next steps involve establishing the promoter’s legal identity, whether as a trust or a company. Following this, the project’s funding structure, encompassing resource acquisition and allocation, is finalized. Subsequently, plans are made for hiring a team of consultants and workers, along with preliminary considerations for electrical load, water supply, and drainage systems. The checklists provided in this chapter serve as valuable tools to guide promoters in making informed decisions during the planning process, ultimately facilitating effective planning without major setbacks.

1.1 Purpose of a Hospital See Table 1.1. Once a promoter decides to establish a hospital, they should seek clarity by addressing several crucial questions to understand the purpose of the hospital project and ensure the correctness of their decision. The first introspective question that the promoter should ask is, ‘Why did I choose to initiate a hospital project?’ There can be multiple motivating factors behind this choice. For instance, the promoter might hail from a family of medical professionals, possess a genuine passion for healthcare, view the hospital business as a profitable investment opportunity, or aspire to engage in social service by providing healthcare to the ill, potentially offering charitable treatment to the underprivileged. Diverse promoters may have distinct reasons for embarking on a hospital project. Therefore, it is essential to first respond to this fundamental question before proceeding further. Once this is clarified, the subsequent question to address is, ‘What is the purpose of the hospital?’ Is the promoter aiming to establish a commercial venture to generate profits, considering the creation of a medical college alongside a teaching hospital, or planning to operate a government hospital in a public-private partnership (PPP) model? This question holds significance because the hospital’s purpose can influence the project’s design and plans. For example, the architectural design and interior aspects of a commercial hospital must meet higher standards compared to

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1.1  Purpose of a Hospital Table 1.1  Purpose of a hospital Activity Why and how did the promoter thought of setting up a hospital? What will be the purpose of this hospital? What will be the motive and philosophy of this hospital? What is the profession of the promoter? Is he/ she a medico or a non-medico? If a non-medico, what are his/her plans to manage the hospital? What will happen to the hospital after the death of the promoter? Are his/her children interested in continuing with the hospital project? Are you a promoter? If not, who are the actual promoters of the hospital? Whether the promoter wants to incorporate charitable programmes in the hospital? If YES, what type of charity is intended to be provided? What will be the extent of the charity (in percentage)?

Status :-

:- Commercial hospital

Teaching hospital

:- A charitable hospital

A commercial hospital

PPP mode govt. hospital Other (please specify)

:-

:-

:-

:- Yes

:- Free beds

No

Concessional rates

Totally free

:-

those of other hospital types. The design, layout, and interiors will also vary between a charitable hospital and a hospital affiliated with a medical college, considering the latter’s role as a teaching institution. Furthermore, the promoter must define the hospital’s philosophy, making it clear whether the institution is primarily profit-oriented or a charitable healthcare provider, potentially falling under categories like government hospitals, clinics, nursing homes, etc.

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1  Initial Planning of the Proposed Hospital Project

Another aspect to consider is hospital management. If the promoter has a medical background, they may choose to assume management responsibilities themselves. However, if the promoter lacks a medical background, they need to decide on the hospital’s management approach. An additional crucial matter is succession planning for the hospital. The promoter should have a clear understanding of who will manage the hospital after their death. Is there interest and commitment from their children or heirs to continue the hospital project? If the hospital’s core purpose is charitable, the promoter must determine the nature of the charity they intend to provide. Will it be a free-of-charge hospital, operate with concessional rates, or offer services alongside free or subsidized bed options? The extent of charitable initiatives also needs to be defined, outlining the scale and scope of the promoter’s philanthropic intentions.

1.2 Status of the Hospital See Table 1.2. The promoter must now determine the legal status of the hospital. Will it be operated as a privately owned establishment, a partnership firm, a registered charitable trust/society, a private/limited company, or another form, such as a hospital under the government-owned Public-Private Partnership (PPP) model or one affiliated with a medical college? Once the decision on status is made, the process of initiating registration with the appropriate governing body will commence. This registration shall culminate in the acquisition of a registration number and an accompanying certificate. The certificate of registration shall include essential details, such as the date of registration, registration number, the hospital’s name, and the name of the registering authority, all bearing the signature and stamp of the respective authority. Table 1.2  Status of the hospital Activity What will be the status of the hospital?

Whether registration is done or not If yes, registration no. Date of registration Registering authority

Status :- Individual Pvt. Ltd. Co. :- Yes :::-

Charitable trust Ltd. Co.

Partnership firm Others_________ No

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1.4  Area of Coverage Table 1.3  Promoters’ details Activity Promoters’ name Promoters’ address Promoters’ mobile/telephone no. Promoters’ fax Promoters’ mobile Promoters’ e-mail Promoters’ website (if any) Promoters’ experience

Status ::::::::-

Off.-

Res. -

1.3 Promoters’ Details See Table 1.3. Acquire and complete the information about the promoters. In the case of multiple promoters, the details of each individual involved must be provided. The required particulars shall include the names of the promoters, their correspondence addresses, residential addresses, contact numbers (both mobile and landline), fax numbers, email IDs, any associated website (if applicable), and most importantly, the professional background and experience of the promoters.

1.4 Area of Coverage See Table 1.4. Upon finalizing the decision to establish the hospital, surveys must be conducted to evaluate the viability of the proposed venture. This process will enable the promoter to confirm the soundness of their decision to establish the hospital. To begin, the catchment areas, from which patients are anticipated to access the hospital’s services, shall be clearly defined. A comprehensive list of these catchment areas, including cities, villages, and towns, shall be compiled, alongside key demographic details such as population, distance from the hospital, per capita income, primary occupations, prevalent diseases, and the relevant jurisdiction of the local police station. This data will be invaluable for the future marketing team once the hospital is operational. Additionally, a comprehensive record of other hospitals within the specified catchment area shall be compiled. The assessment shall encompass various criteria, including the size of these hospitals, available facilities, bed capacity, number of medical practitioners, specialists, and super-specialists, hospital charges, patient volume, local perceptions of the hospital’s reputation, and public satisfaction levels.

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1  Initial Planning of the Proposed Hospital Project

Table 1.4  Area of coverage Activity What will be the expected area of coverage, the residents of which may avail of the services of the proposed hospital? How many will be cities or villages in which the hospital will provide services? What is the approximate population in the coverage area, that is expected to avail of the services of the proposed hospital? Details of the other hospitals in the coverage area and vicinity along with the details like bed strength of these hospitals and full details of services being provided by them. Details of small hospitals, nursing homes, and individual practitioners in the coverage area and vicinity.

Status ::::-

:-

Likewise, an evaluation of nursing homes and clinics within the designated catchment area is imperative. This assessment shall incorporate factors such as the size of these nursing homes or clinics, available facilities, bed capacity, specialized services offered, charges, patient traffic, and the reputation of these nursing homes. This thorough survey will assist the promoters in estimating the expected patient inflow for the proposed hospital. Moreover, it will enable them to anticipate potential competition and challenges that may arise once the hospital becomes operational.

1.5 Geographical Details See Table 1.5. Once the promoter has made the definitive decision to undertake the hospital project, acquiring the geographical particulars of the potential hospital site becomes essential. These particulars shall be gathered for all the identified pieces of land until the final selection is made. These particulars will serve as the basis for the promoter’s ultimate choice of land, and the following details shall be collected: 1. The precise location of the land and its longitudinal and latitudinal coordinates, along with the directional orientation based on a compass. 2. The road on which the plot is situated, including the road’s width and the approach roads leading from the main thoroughfare. 3. Distances from key locations such as the railway station, bus terminal, airport, and taxi stand. Closer proximity to these points will facilitate easier access for patients to the proposed hospital. 4. Evaluate the availability and efficiency of local transportation options for reaching the proposed hospital. A robust public transport network will enhance public accessibility to the hospital. 5. Determine the jurisdiction of the local police station for the proposed site.

7

1.6  Demographic Details Table 1.5  Geographical details Activity The exact location where the proposed hospital is planned The road on which the proposed hospital will be located Distance from the railway station Distance from the coach station Distance from the airport What shall the local mode of transport to and from the proposed hospital Police station jurisdiction Distance from the police station/Chowki Distance from the nearest fire station

Status :::::::::-

Table 1.6  Demographic details Activity The total population of the city. The main occupation of the public. Per capita income of the public in that area. Living standards of the residents in that area. Individuals paying capacity in the area. Main industries in the area. Estimated number of central Govt. offices/employees residing in the area. Estimated number of state Govt. offices/employees residing in the area. Usually, what type of diseases prevail in the proposed area, and what is the present-day option to tackle them? What is the literacy level of the population in the area? How well the population is aware of the health insurance? What is the awareness of health insurance and approximately how much percentage of people who are covered the health insurance Is there any scope for medical tourism in the area?

Status :::::::::::::-

1.6 Demographic Details See Table 1.6. The time has come to gather the demographic data concerning the population residing within the catchment area of the proposed hospital. The following aspects need to be addressed during the collection of this demographic data. Firstly, concerning population statistics, data shall be compiled regarding the total population in the area, including the count of males, females, children, and the specific religions to which they are affiliated. Evaluate the primary occupations of the local populace within the catchment area, such as those engaged in agriculture, service-oriented roles, manufacturing industries, or trading activities.

8

1  Initial Planning of the Proposed Hospital Project

Examine the per capita income of the community within the region, along with an assessment of their paying capacity and living standards. A higher per capita income and greater financial capacity indicate a likelihood of better affordability for the healthcare services provided by the hospital. Identify the major industries present in the vicinity and their quantity. A higher concentration of industries suggests a potential increase in the patient base that may utilize the services offered by the proposed hospital. Evaluate the number of employees and their family members residing in the catchment area. The more the number of such employees, the more will be the footfall of patients in the hospital because these employees generally need not pay out of their pocket for hospital treatment. It is usually paid by the concerned state or central government. Conduct an analysis of the prevalent types of diseases within the catchment area and ascertain the available options for managing these illnesses. Determine whether healthcare centres catering to these specific diseases are accessible within the region, or if patients need to travel a considerable distance for treatment. This analysis will aid the promoter in planning the range of services required to be offered by the proposed hospital. Collect data about the literacy rate and unemployment rate prevalent in the targeted catchment area. A higher literacy rate and lower unemployment rate are indicative of enhanced health awareness among the local populace, resulting in an increased number of patients utilizing the hospital’s services. Gather information on the number of individuals in the area who possess knowledge about health insurance schemes. Greater awareness of health insurance implies a higher likelihood of patients seeking the hospital’s facilities, as these individuals typically do not bear the expenses for hospital treatments directly, with such costs generally covered by insurance companies. Assess the potential to attract international patients by facilitating medical tourism through the provision of relevant facilities.

1.7 Other Hospitals’ Details See Table 1.7. Given that other hospitals in the catchment area will serve as the main competitors of the proposed hospital, it is imperative to conduct a thorough listing and assessment of these competing healthcare facilities. A comprehensive list must be prepared for these hospitals, categorized based on their respective bed capacities, which will aid in determining the scale of the hospital as either large, medium, or small. During the compilation of this detailed list, several crucial factors necessitate evaluation, including the hospital’s name, philosophy of the hospital (whether charitable, commercial, or government-operated), its size, distance from the proposed hospital, available facilities and services, number of patient beds, attending

9

1.7  Other Hospitals’ Details Table 1.7  Other hospitals’ details Activity How many hospitals above 500 beds How many hospitals between 300–500 beds How many hospitals between 100–300 beds How many hospitals below 100 beds How many nursing homes are located in the nearby areas and what average IPD beds are available in each nursing home? How many practitioners are practising in the nearby areas? Out of all these, approx. how many are super- specialists? What about the availability of doctors in the city or nearby areas who can provide service to the proposed hospital? Specialists Super specialists General doctors

Status :- Name Distance from our hospital :- Name Distance from our hospital :- Name Distance from our hospital :- Name Distance from our hospital :-

Services available Services available Services available Services available

:::-

:::-

physicians, specialists, and super-specialists, diagnostic facilities available, charges of the hospital services, patient traffic, local reputation, and public satisfaction levels. Similarly, an exhaustive listing shall be conducted for nursing homes within the designated catchment area. This listing shall encompass pertinent details, such as the nursing home’s name, distance from the proposed hospital, size, available amenities, bed count, specialized services offered, charges, patient volume, and local reputation. Furthermore, a comprehensive directory of clinics and practitioners operating within the catchment area is necessary. This listing will serve as a resource for approaching skilled practitioners for potential collaboration with the proposed hospital. The directory shall incorporate essential information, including the physician’s name, area of expertise, clinic name, distance from the proposed hospital, patient traffic, local reputation, and any arrangements made by the practitioner for admitting and operating on their patients. Special attention shall be dedicated to identifying super-specialists practising in the area. Throughout this assessment, the surveyor must bear in mind that the proposed hospital will also require physicians, specialists, super-specialists, technicians, and nurses upon its operational launch. Therefore, when conducting the survey and compiling lists of physicians, specialists, and super-specialists within the area, the surveyor shall prominently highlight potential candidates who could be recruited as part of the proposed hospital’s medical team.

10

1  Initial Planning of the Proposed Hospital Project

1.8 Planned Services of the Hospital See Table 1.8. After completing all necessary surveys, conducting thorough data analysis, and making the final decision to proceed with the planning phase of the proposed hospital project, the subsequent critical stage involves planning the following aspects: 1. Determining the speciality and super-specialties departments to be incorporated. 2. Identifying the diagnostic services that will be offered. 3. Estimating the number of beds required for each category of wards. The initial consideration revolves around the size of the hospital. Choices include establishing a small hospital with a capacity of no more than 50 beds, a medium-­ sized hospital accommodating up to 100 beds, a large hospital with a bed count not exceeding 300, or an extensive hospital with more than 300 beds. This decision is necessary because the departments, services, and spaces in the hospital shall depend on the size of the hospital. Why do the spaces depend on the size of the hospital and the number of beds in the hospital? This is because the area required for the hospital services is in proportionate ratio with the number of beds. As per international standards, per bed usually requires up to 600 sq. ft. (all spaces put together) space in the building. Therefore, bed strength is an important decision to be taken before starting planning. In addition to the bed count, prudent budgeting is of equal significance. Hence, a preliminary budget must be established well in advance. Given that all operations hinge on financial resources, the promoter must operate within the predefined project budget. While the promoter may harbour ambitious plans and visions, adherence to the allocated budgetary constraints is imperative. Subsequently, the decision-making process shall encompass the identification of the specific speciality and super-speciality departments to be included. Both the promoter and the planners must decide on the particular specializations that the hospital will offer. The speciality departments may include: • • • • • • • • • • • • •

Anaesthesiology Dentistry Dermatology ENT General surgery Gynae and obs. Internal medicine Ophthalmology Orthopaedic Paediatric Physiotherapy Psychiatry Any other (Pl. specify)

Activity How big hospital does the promoter want? How many beds are to be provided in the hospital? (each bed may require about 600 Sq. Ft. of building area) What are the rough budget projections for the project? Which departments are to be provided in the proposed hospital?

Table 1.8  Planned services of the hospital

Super-Speciality Burns and plastic surgery Cardio-thoracic surgery Cardiology Dental surgery Diabetes and endocrinology Gastro medicine

Anaesthesiology Dentistry Dermatology ENT General surgery

:- Speciality

:-

Status :- Very big :-

Oncology medicine

Nephrology Neurosurgery Neurology

Multi-organ transplant Neo Natology

Gynae and Obs. Internal medicine Psychology Ophthalmology Any other (Pl. specify)

Medium

(continued)

Renal transplant Rheumatology Transfusion medicine Urology

Pulmonology

Paediatric surgery

Orthopaedic Paediatric Physiotherapy Psychiatry

Small

1.8  Planned Services of the Hospital 11

No No No No No No No No No

Yes Yes Yes Yes Yes Yes Yes Yes Yes

:::::::::::- Microbiology Clinical pathology Serology Immunology Haematology Clinical chemistry Histopathology

No No

:- Yes :- Yes

Has the evening OPD to be provided? Are the facilities of critical care to be provided? If yes which ICCU Medical ICU Surgical ICU Neo-Natal ICU Paediatric ICU Respiratory ICU CTVS ICU Neuro ICU If any other (please specify) Are the diagnostic facilities to be provided? If yes, which Pathology

No No

:- Yes :- Yes

Status Gastro surgery

Is the free OPD required? Is the private OPD required separately?

Activity

Table 1.8 (continued) Oncology surgery

Yes Yes Yes Yes Yes Yes Yes

How many beds How many beds How many beds How many cribs How many beds How many beds How many beds How many beds

If yes, what system When in the morning/ evening Timing

No No No No No No No

Any other (Pl. specify)

12 1  Initial Planning of the Proposed Hospital Project

Cardiology Pulmonology Gastroenterology Neurology Urology Diabetes and Endocrinology Nephrology Neuro surgery Oncology medicine If any other (please specify) Is a separate emergency department required? Are there any plans to handle trauma cases? Will the medico-legal cases be handled?

Other investigations relating to

Radiology

Activity

No No No

Status If any other (please specify) :- X-ray Ultra sound CT scan MRI Nuclear medicine Mammography If any other (please specify) :- Which investigation (Pl. specify) :::::::::::- Yes :- Yes :- Yes

How many beds are in the triage?

Yes Yes Yes Yes Yes Yes

No No No No No No

(continued)

1.8  Planned Services of the Hospital 13

Is the indoor admission facility required? If yes, what will be the breakup of the beds? VIP suits Deluxe rooms Private rooms

Are the day care observation beds required? Is the minor OT required? Are the separate diagnostic equipment required in the emergency department? If yes which diagnostic equipment is required to be kept separately in an emergency? Will the surgeries be performed? If yes, which department?

Activity If yes, how many MLC cases are expected? What type of emergency cases are normally seen in this area?

Table 1.8 (continued)

:::::No. of beds No. of beds No. of beds

Gastro surgery Yes

Eye

ENT

:- Yes :- Cardio-thoracic surgery Dental surgery Endoscopic surgery

:-

Stabbing :- Yes :- Yes :- Yes

Status ::- Burn

No

No

No No No

Any other (Pl. specify)

Neuro surgery

Plastic surgery Urology

Others

Gynae and Obs. Laparoscopic surgery Multi-organ transplant Orthopaedic surgery

RTA

Paediatric surgery

No. of free beds (if any) No. of free beds (if any) No. of free beds (if any)

How many beds How many

Poisoning Rape

General surgery

Gunshot

Rape

14 1  Initial Planning of the Proposed Hospital Project

Status No. of beds No. of beds No. of beds No. of beds No. of beds No. of beds No. of beds

:- Yes :- What will be the size? :- Yes :- Yes :- Whole blood :- Yes

Is a library required in the hospital? If yes

Is an eye bank required? Is a blood bank required? If yes Are the services of alternate medicine to be provided?

No

:- Yes

Who will set up and operate the IPD pharmacy

No

No No

No

No

No

:- Yes

:- Yes

:::::::-

Who will set up and operate the OPD pharmacy?

Activity Semi-private rooms Isolation bed/rooms/ward Male general ward Female general ward Gynae ward Paediatric ward Other transitory beds like post-op, pre-op, pre- and post-labour, dialysis, endoscopy recovery, etc. Does the hospital require a self-owned ambulance?

How many reading areas

Components

How many If no, what will be the system for the pharmacy? If no, what will be the system for the IPD pharmacy?

Which type

No. of free beds (if any) No. of free beds (if any) No. of free beds (if any) No. of free beds (if any) No. of free beds (if any) No. of free beds (if any)

ALS

(continued)

Apheresis

How many books are to be kept

Simple

BLS

1.8  Planned Services of the Hospital 15

Activity Acupuncture Holistic medicine Homoeopathy Ayurveda Ricky Naturopathy

Table 1.8 (continued) ::::::-

Status Yes Yes Yes Yes Yes Yes No No No No No No

16 1  Initial Planning of the Proposed Hospital Project

1.8  Planned Services of the Hospital

17

Similarly, the promoters need to decide the services of which super-speciality departments have to be provided in the hospital. The following can be the super-­ speciality departments: • • • • • • • • • • • • • • • • • • • • • •

Burns and plastic surgery Cardio-thoracic surgery Cardiology Dental surgery Diabetes and endocrinology Gastro medicine Gastro surgery Multi-organ transplant Neo natology Nephrology Neuro surgery Neurology Oncology medicine Oncology surgery Paediatric surgery Pulmonology Radiation oncology Renal transplant Rheumatology Transfusion medicine Urology Any other (Pl. specify)

The subsequent consideration pertains to the Outpatient Department (OPD). The planning team and promoters must proactively determine whether the facility will provide services through a free OPD system or exclusively through a paid OPD model. Additionally, deliberations are necessary concerning the potential implementation of an evening OPD. The timing of the OPDs has also to be decided. The next important decision is about the configuration of the OPD block layout. Before outlining the physical arrangement, a choice must be made regarding the design approach for the OPD layout. This may involve determining whether the OPD block will be structured as a Centralized Outpatient Department, a Decentralized Outpatient Department, or whether the OPDs will be situated in a Separate Block. Subsequently, attention turns to the schematic blueprint for the OPD complex. Planners must determine whether the OPD complex will be designed as a Single Corridor OPD, a Double Corridor OPD, or a Clustered OPD Block, based on the overarching layout concept. The next crucial decision revolves around the provision of Intensive Care Units (ICU). Essential considerations include the number of ICUs to be launched initially, along with the designated bed capacity for each unit. Furthermore, there is a need to establish expansion plans for the ICUs, including provisions for adding more ICUs

18

1  Initial Planning of the Proposed Hospital Project

or increasing the bed capacity within each existing ICU. Both the promoters and planners must specify which ICUs will be initiated immediately and which ones are planned for future development. Potential types of ICUs might be: • • • • • • • • • • • •

Cardiac ICU Medical ICU Surgical ICU Neo-Natal ICU Paediatric ICU Respiratory ICU CTVS ICU Neuro ICU Neuro surgical ICU Burn ICU Gynae ICU If any other (Pl. specify)

Another important consideration that necessitates careful consideration is the establishment of diagnostic facilities. Initially, it is essential to determine whether the hospital intends to incorporate in-house diagnostic facilities encompassing radiology, clinical laboratory services, and other pertinent investigations. If affirmative, the subsequent decisions must address the following queries. Regarding the Clinical Laboratory, in the Pathology Section, careful planning is required for establishing subsections such as clinical pathology, histopathology, anatomical pathology, molecular pathology, derma pathology, gynaecology pathology, hematopathology, forensic pathology, toxicology, neuropathology, cytopathology, renal pathology, pulmonary pathology, immunopathology, and oral maxillofacial pathology, among others. Similarly, in the microbiology section, the decision to establish subsections is critical, including bacteriology, immunology, virology, mycology, parasitology, microbial physiology, microbial cytology, microbial ecology, general store, nematology, cellular microbiology, microbial genetics, microbial systematics, microbial taxonomy, systems microbiology, generation microbiology, phylogeny, molecular microbiology, and nano microbiology, among others. Concerning the biochemistry section, planning shall encompass subsections such as clinical biochemistry, metabolism, immunology, genetics, enzymology, molecular biochemistry, cell biology, and related fields. Regarding the investigation facilities in the Department of Radio-Diagnosis, it is imperative to establish a clear blueprint before the planning phase commences. This includes determining the specific radiological investigations the promoter intends to initiate, as well as establishing plans for future expansion or the introduction of additional radiological investigations. Normally radiological investigations are • CT scan • MRI

1.8  Planned Services of the Hospital

• • • • • • • • • •

19

X-rays Ultrasound Mammography PET-MRI PET-CT Spect CT Digital Subtraction Angiography (DSA) Densitometry Gamma camera Cyclotron/radio pharmacy, etc.

In addition to determining the intended modalities of investigations to be incorporated within the radiology department, it is crucial to make decisions regarding the immediate installation of a specific number of machines for each modality. Furthermore, the promoter must establish a coherent strategy concerning the future inclusion of new modalities and the expansion of the existing number of machines for each modality. For other diagnostic facilities to be provided in the proposed hospital, the promoter shall decide on the investigations relating to a particular speciality like 1. Cardiology: Echocardiography, Electrocardiogram (ECG), Holter analysis, Ambulatory Blood Pressure (ABP), Thread Mill Test (TMT), Tilt Table Test, Thallium Scan, Nuclear Heart Scan, Dobutamine Stress Test, Cath Lab, etc. 2. Pulmonology: Sleep Lab, Spirometry, Body Box Diffusion, six Min walk Test, Seno Test, Bronchoscopy, TBNA, ICTIC enter, DOTS Centre, etc. 3. Neurology: Brain Stimulation Test, Trans Cranial Doppler, EEG Lab, Neuro-­ physiotherapy, NVC/EMG and BERA test, Speech and Swallowing Clinic, etc. 4. Nephrology: Dialysis. 5. Urology: Uro dynamics study, Uro flow meter, etc. 6. Gastroenterology: Gastro endoscopy, colonoscopy, etc. Next in line is the strategic planning for the Emergency Department. A decision needs to be taken about the size of the emergency department. The size of the emergency shall depend on the number of emergency cases expected to arrive in the emergency department. The initial decision involves establishing the number of beds in the triage. The second is whether the trauma shall be provided and if yes, up to which level. This means that levels of the emergency and trauma centre need to be established. Moreover, a decision must be made regarding the hospital’s involvement in medico-­legal cases (MLC). If the hospital plans to accommodate such cases, a projection of the expected case volume for this department is necessary. Furthermore, an assessment is vital to ascertain the anticipated types of cases likely to be encountered in the emergency department, encompassing scenarios such as burn cases, sexual assault, gunshot wounds, stabbings, road traffic accidents, and poisoning cases, among others. This evaluation is required because the

20

1  Initial Planning of the Proposed Hospital Project

planning and designing of the emergency department may vary depending on the type of cases generally received in the department. Subsequently, advance decisions are essential concerning the provision of an observation ward/room within the emergency department. If an observation ward is to be included, predetermined considerations shall cover the allocation of beds and the required facilities, such as medical gas and power supply, monitoring equipment, and ventilation provisions. Additionally, decisions must be made regarding the potential performance of surgeries within the emergency department. If surgical interventions are envisaged, the scale of surgeries shall be specified, including whether only minor surgeries will be conducted or if provisions for major surgeries are necessary. For minor surgeries, minor operation theatres suffice, whereas major operation theatres may be required for conducting complex procedures within the emergency department. If separate diagnostic facilities for radio-diagnosis or clinical laboratories are to be incorporated within the emergency department, these decisions must be made during the planning phase, considering potential spatial requirements for the operational and equipment aspects of such facilities. Moving on to the surgical domain, the promoter must pre-determine the specific surgical departments to be included within the proposed hospital, both for the immediate phase and as part of future expansion plans. Increased surgical departments will necessitate additional space requirements. Generally, the surgical department is like • • • • • • • • • • • • • • • • • • •

General and bariatric surgery Urological Cardiac surgery including CABG Dental surgeries Gynaecological and obstetrical Eye ENT Plastic surgery Multi-organ transplant Neuro surgery Oncology surgery Orthopaedic surgery including joint, knee, hip, elbow, and shoulder replacement Paediatric surgery Paediatric neuro surgery Robotic surgeries Endoscopic surgeries Vascular surgery Cosmetic, reconstructive, and micro surgery Spinal surgery, etc

Now coming to the indoor patient areas of the proposed hospital. During planning, it is necessary to plan how many indoor beds are to be provided in the hospital.

1.8  Planned Services of the Hospital

21

This plan shall clearly define the category of indoor beds along with the number of beds in each category. Generally, the following are the categories of indoor beds: • • • • • • • • •

VIP suits Deluxe rooms Private rooms Semi-private rooms Isolation bed/rooms/ward Male general ward Female general ward Gynae ward Paediatric ward

To elaborate on each bed category, the VIP room or what is commonly referred to as the suites represents the most superior indoor area. This space is designated for a single patient and includes a room for the patient along with a family room. It is equipped with a comprehensive range of facilities such as a patient bed, bedside locker, step stool, overbed table, sofa set, chairs, centre table, attendant bed, refrigerators, a small pantry, an attached toilet, a dining table and chairs, a cupboard, and a television, among others. Deluxe rooms are an upgraded version of private rooms, offering a single patient a room furnished with amenities like a patient bed, bedside locker, step stool, overbed table, sofa set, chairs, centre table, attendant bed, refrigerator, an attached toilet, and television, among others. In a private room, a single patient is accommodated and provided with essential facilities including a patient bed, bedside locker, step stool, overbed table, chairs, attendant bed, refrigerator, an attached toilet, and a television, among other essentials. A semi-private room, also known as a sharing bed, is a space where multiple patients share a single room. Typically, it is recommended for two patients to occupy one room, but the number can exceed two, up to a maximum of four patients. Each patient in this room is provided with specific amenities such as a patient bed, bedside locker, step stool, overbed table, chairs, curtain partitions, attendant bed, television, and a cupboard. The attached toilet is shared among the patients. The isolation bed/room/ward is specifically designated to house patients with communicable diseases, aiming to prevent cross-infection within the hospital. The number of beds allocated for such cases depends on the expected inflow of patients with such conditions. These beds can be either single bedrooms or wards with multiple beds. However, it is recommended to opt for a single-bed occupancy room instead of a multiple-bed ward. These isolation rooms are equipped with necessary infection control provisions and are situated in a segregated area of the hospital. They are designed to be either negatively or positively pressurized based on specific requirements, furnished with essentials such as a patient bed, bedside locker, step stool, overbed table, refrigerator, hand wash facilities, an attached toilet, a cupboard, and television, among others.

22

1  Initial Planning of the Proposed Hospital Project

General wards, often referred to as economy wards due to their lower bed charges, accommodate more than two beds, with the capacity reaching up to 30 beds in a single ward. It is advisable not to exceed 30 beds to ensure the provision of adequate and quality patient care. However, there are no such fixed norms or regulations on the number of beds to be accommodated in the ward. The number of beds in the ward is subject to the discretion of the promoters and planners. These wards can be classified based on departments (medicine ward, surgery ward, paediatric ward, gynaecology ward) or based on gender (male general ward, female general ward). Facilities within the ward include patient beds, bedside lockers, overbed tables, curtain partitions, attendant chairs/beds, attached toilets, and cupboards. Additionally, aside from indoor patient beds, there are other types of beds such as transit beds or recovery beds used after medical procedures or surgeries. Transit beds can be found in areas like triage and observation wards, post-operative units for short-term patient recovery, or patients undergoing procedures such as dialysis or endoscopy. Decisions need to be made regarding the provision of ambulances, specifying the type (ACLS, BLS, etc.), and determining the number of ambulances required, ensuring appropriate parking space and facilities for drivers. Depending on the number of ambulances, provisions may need to be made for an automobile workshop. In terms of the Pharmacy, it is essential to determine whether separate pharmacies for outpatient (OPD) and inpatient (IPD) patients are necessary or if a single pharmacy will suffice. Allocation of space for the pharmacy shall be considered during the planning phase. In cases where the promoter does not intend to establish pharmacies, alternative systems for providing medicines to both OPD and IPD patients must be devised. When considering the inclusion of a library within the hospital, careful planning is essential. Determining the size of the library and estimating the number of books to be stocked is crucial. Furthermore, if reading areas are to be provided, decisions shall be made concerning the number of reading areas and the seating capacity. The decision is required for setting up the eye bank. Operating eye banks requires a license and is governed by acts, rules, and regulations of the country or state. Hence, the spaces have to be allotted for eye bank, which shall comply with such acts, rules, and regulations of the appropriate authority. Similarly, a decision that needs to be taken about the blood bank is whether it will stock whole blood or blood components and apheresis. Operating blood banks requires a license and is governed by acts, rules, and regulations of the country or state. Hence, the spaces to be allotted for blood banks shall comply with such acts, rules, and regulations of the appropriate authority. Lastly, the inclusion of alternative medicine facilities such as Homeopathy, Ayurveda, Holistic Medicine, Acupuncture, Naturopathy, and Reiki shall be carefully considered. If the decision is affirmative, appropriate space allocation must be incorporated for these alternative medicine services.

1.9  Feasibility Reports and DPR Details

23

1.9 Feasibility Reports and DPR Details See Table 1.9. Detailed Project Reports (DPRs) are a set of bankable documents which provide details of capital investment, the projected number of patients expected, estimated earnings and expenses, outputs of working and projections. DPR is detailed and elaborated projections and plans for the project indicating overall calculations, financials, roles and responsibilities, detailed programme of the project, time planning for the project, and details of activities and resources required for completion of the project. Table 1.9  Feasibility reports and DRP details

Activity Has the DPR been prepared based on the data provided? Has the area survey been done by the agency? Has the detailed technical feasibility report been prepared? Has the detailed financial feasibility report been prepared? Have the contract drawings been prepared Has the review been done, from the practical point of view, for executing the project? What shall be the estimated period for completion of the project? What are the inherited and other foreseeable external risks involved in the project? Has the planning been done for the measures for risk mitigation and risk management?

Status of works Start End Not Responsible date date Complete In-progress started person :- Yes No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

Remarks

24

1  Initial Planning of the Proposed Hospital Project

The initial stage of preparing the DPR involves the gathering of diverse data sets, including the total capital investment, projected patient inflow, anticipated local healthcare service rates, and estimated operational costs for the hospital. A comprehensive analysis of the region, considering the presence of other medical facilities, clinics, prevalent disease patterns, and the prevailing pricing structures, is undertaken either by the hospital’s personnel or by engaging a specialized agency for this purpose. Has the comprehensive feasibility report been developed and compiled? If so, has it been formally presented to the management for careful assessment and evaluation? Furthermore, has the compilation of contract drawings, which constitutes an integral component of the DPR, been finalized and subsequently presented to the management for necessary approval and review? The management must conduct a pragmatic assessment of the project, particularly concerning the prospects of success in the designated area. This assessment shall encompass a thorough consideration of the local dynamics, existing infrastructure, and the potential impact of the project on the community. Has the risk mitigation report been meticulously formulated and structured? This report shall be prepared conscientiously, to comprehensively understand the potential risks associated with the project, analyse their underlying causes, and devise effective solutions to counter and manage the anticipated risks effectively.

1.10 Budget and Source of Funds See Table 1.10. After the promoter and planners have determined the services and amenities to be offered at the hospital, created the Detailed Project Report (DPR), and confirmed the project’s feasibility, the next phase involves contemplating the means of financing. The initial step involves estimating the approximate capital investment necessary for establishing the hospital project. When calculating the capital expenditure, the following expenses are to be incorporated in the projected outlay: 1. Cost of land 2. Building part

(i) Cost of structure (ii) RCC bunkers (if radiotherapy has to be provided) (iii) Civil construction (iv) Site development and external works (v) Electrification works including fittings (vi) External electric works

1.10  Budget and Source of Funds

25

Table 1.10  Budget and source of funds

Activity What is the approximate budget for the project of the proposed hospital? What will be the source of funding for the project? If self-­ financing, are the funds ready? If loans are planned, has the approval been taken for the same? Has the margin money been arranged If, the company, has the share capital has been raised Whether any Grants expected

Status of works End Not Start date date Complete In-Progress started :- In million

Responsible person Remarks US $ in million

:- Self-­ financing

Other (Pl. specify)

Loans

:- Yes

No

How much

:- Yes

No

For how much amount

:- Yes

No

:- Yes

No

For how much amount For how much amount

:- Yes

No

Whether any :- Yes subsidy expected Whether any :- Yes donations expected in cash Whether any :- Yes donations expected in kind

No



No

No

(vii) Sanitary works including the fittings (viii) Air conditioning (ix) WTP and STP (x) Central pipe gas supply line system (xi) Generators

For how much amount For how much amount For how much amount For what items

26

1  Initial Planning of the Proposed Hospital Project

(xii) Fire fitting equipment (xiii) Nurse call system (xiv) Bed elevators (xv) Dumb waiters (xvi) Civil furniture (xvii) Hot water and solar heating system (xviii) Audio visual system (xix) Curtains/blinds/scrub (xx) Signage system (xxi) EPABX (xxii) Special items (xxiii) Expenses during the construction period 3. Medical equipment for all the departments 4. Misc. disposable items 5. Misc. small instruments 6. Linen 7. Consumables 8. Backup services 9. Furniture and fixtures With the estimated funding requirements for the envisioned hospital project in place, the focus now shifts to strategizing the acquisition of funds. It is crucial to always bear in mind that insufficient funds can potentially jeopardize the project. Insufficient funds can lead to project stalling, causing delays, cost escalations due to inflation, loss of potential earnings due to delayed operation, and increased interest burdens on the already disbursed amounts, thereby inflating the overall project expenses. There can be various sources from where the funds can be arranged. 1. Self-Financing: If the promoter intends to solely finance the project, it is imperative to ensure the availability of necessary funds in advance. 2. Term Loans from Banks or Financial Institutions: If a portion of the funds is to be procured from banks, the proposal for financing must be submitted on time, and arrangements for the margin money shall be made well in advance. 3. Share Capital: In the case of the proposed hospital functioning as a Private Limited or Limited company, efforts to raise share capital must be initiated on time. 4. Grants: If the proposed hospital is eligible for grants, applications for such grants shall be promptly filed. 5. Subsidies: If the proposed hospital is entitled to receive subsidies, proposals for securing such subsidies shall be promptly set in motion. 6. Donations: If the promoter seeks monetary or in-kind donations for the hospital project, comprehensive plans shall be formulated and potential donors shall be approached well in advance to ensure timely contributions.

27

1.11  Site Details

1.11 Site Details See Table 1.11. Given that most decisions have been made and planning is underway, the time has come to choose and confirm the site for the proposed hospital. Selecting a suitable site for constructing a hospital is a crucial undertaking, involving careful consideration of various factors. The initial consideration pertains to determining the necessary land size for the hospital construction, which depends on the design and local construction regulations. Concerning the design aspect, it is well understood that hospitals typically demand substantial space due to the diverse range of services they offer, as compared to any other typical commercial buildings. Therefore, the planner must have a clear understanding of the services intended for the hospital, such as inpatient department (IPD), intensive care unit (ICU), outpatient department (OPD), diagnostics, interventions, as well as provisions for storage, administrative areas, and waiting rooms. Table 1.11  Site details

Activity The site selected or not Whether the requirement of the covered area of the building has been calculated What are the by-laws for total floor area ratio (FAR) allowed in the city/area? What is the requirement for set back area in the city/area? What is the maximum permissible land coverage allowed in the city/area?

Start date :- Yes

Status of works End Not date Complete In-progress started No

:- Yes

No

:- Yes

No

Responsible person Remarks

:-

:-

(continued)

28

1  Initial Planning of the Proposed Hospital Project

Table 1.11 (continued)

Activity What is the maximum permissible height of the building allowed in the city/area? Based on the area coverage, and by-laws, calculate how much land area is required How easy is the approach to the site? What is the exact location of the land? What about the availability of transportation to the site? How safe is the site concerning crime, theft fire, etc.? Are the utilities like water supply, electricity, and sewerage available on the land or near the land How is the road network in the area? How polluted is the environment near the land? What is the history of strong winds and earthquakes in the area? If flood-prone area, what are the flood protection measures taken in the area?

Start date

Status of works End Not date Complete In-progress started

:-

:-

:-

:-

:-

:-

:- Yes

:-

:-

:-

:-

No

Pl. give details

Responsible person Remarks

1.11  Site Details

29

Table 1.11 (continued)

Activity Has the land survey been done?

What is the size of the plot? What is the shape of the plot? What are the dimensions of the plot? Does the land require land filling?

Start date :- Yes

Status of works End Not date Complete In-progress started No If yes, what is the report?

:::- Front

Depth

East side

:- Yes

No

:- Yes Has the soil analysis of the site been done?

No

If yes, how many feet filling is required If yes, what is the report?

:- Yes

No

Has the levelling of land been done?

Responsible person Remarks

West side

Once the services are identified, the next step involves a meticulous assessment of the space required for current as well as potential future expansions over a minimum period of 20 years. A comprehensive evaluation of the total covered area needed for the hospital building is essential. To calculate the total required area, first of all, the rooms required for these services shall be worked out. Once the room list is finalized, the sizes of the rooms have to be decided. Multiplying the sizes of the rooms with the number of rooms, the total area required in the hospital building is calculated. To these figures, the spaces required for future expansion shall be added. Depending on the building type and design, to this area, an allowance for circulation spaces like corridors, elevators, ramps, and staircases, shall be added which typically ranges from 30% to 40% of the total area. Upon establishing the total covered area required for the hospital, another critical factor to be considered is the land space necessary to accommodate the calculated covered area. This determination relies on the norms, regulations, and guidelines stipulated by government agencies or development authorities for constructing commercial buildings. Some key considerations include

30

1  Initial Planning of the Proposed Hospital Project

1. Total FAR allowed: FAR means the Floor Area Ratio. Different cities may have different FAR. Based on the allowed FAR, the area of land shall be calculated. 2. Set Back Area: Generally, norms are prescribed by the authorities defining the Set back areas to be kept around the building for all commercial buildings. Generally, the set back area has to be left on all four sides of the hospital building. 3. Maximum Permissible Land Coverage: Authorities also lay down the norms of land coverage that are allowed out of the total land area of the site. The land coverage may vary from 25% to 50%, depending on the city, town, etc. 4. Maximum Permissible Height of Building: Authorities may also lay down the norms of building height that are allowed in the area. There can be various ­factors affecting the maximum height like the zone of the earthquake and average wind pressure, distance from the airport, etc. Considering all these rules, regulations, norms, and guidelines as defined by the respective Govt. Agency or the Development Authorities, along with the covered area as calculated above, the land space required for the hospital building is worked out. Now the promoter knows how much land is required for the proposed hospital. As a hospital is a special type of building and has to deal with the sick and general public, a few factors need to be considered while finalizing the land: • Approach to the site: The approach to the hospital site shall be convenient for the community and the service vehicles, including firefighting vehicles, etc. • Location of the Land: The distance from the main road to the location of the land shall be considered. The nearer the main road from the land, the easier will be the approach to the hospital. The frontage of the land is also an important factor to be considered. The wider the frontage—the better will be the design of the hospital building. • Availability of Transportation: For easy access to the hospital, a good public transport facility shall be available in the area. There can be different modes of transport like Local Trains, Local buses, Taxis, and Auto and Manual rickshaws, etc. • Security: The area around the hospital shall have sufficient security measures to safeguard patients, families, personnel, and the public. • Availability of Utilities: Facilities with reliable utilities like water, gas, sewer, and electricity supply shall be available near the hospital site. The electricity supply line shall be near the hospital and shall have a dependable and stable voltage and frequency. The water supply shall be adequate to cater to normal usage plus fire-fighting requirements. The sewerage line shall be very near the hospital building. • Roads Network in the area: There shall be a proper and adequate road network for an easy approach to the hospital. The roads shall be wide enough for quick and easy traffic movement to and from the hospital. • Environmental Pollution: The chosen site shall have the least environmental pollution.

1.12  Building Details

31

• Wind and Earthquake: Before finalizing the land, the history of the wind pressure and the earthquake in the area shall be assessed. • Flood Protection: If the planned site is prone to occasional floods, the area to be chosen must have adequate measures to handle the flood situation. Once the land selection process is complete, the next step involves initiating the groundwork for soil analysis, providing crucial insights to architects and structural engineers for designing a secure building structure. The primary task involves conducting a land survey. During this phase, the surveyor is tasked with measuring: 1. Precise dimensions and boundaries on all sides of the plot. 2. Angles of the plot. 3. Elevation levels of the land from the main road. Assessing the land levels at various points enables easier land levelling if necessary. Upon completion of the land survey, the surveyor translates the findings into AutoCAD and forwards the data to the architects for further detailed work, such as site plans and layout plans. Subsequently, soil analysis becomes a critical aspect. This process aims to evaluate the land’s properties and its weight-bearing capacity. The surveyor excavates holes at different points on the land to obtain soil samples for laboratory analysis. If the land filling is required from outside soil, it is always advised to fill up the land once the foundations are laid down because it is better if the excavation of the land for foundations is done from the raw land instead of filled-up land. This will improve the strength of the foundation. Secondly, the retaining wall will be available to hold the filled-up soil.

1.12 Building Details See Table 1.12. The next important issue which requires careful thinking, planning, and decision is the building, in terms of quality, facilities, interiors, landscaping, the concept of green building, air-conditioning, etc. The first decision that is required is the type or class of building. The promoter shall answer what he/she is aiming for about the proposed building. The buildings can be classified as follows: (i) State-of-the-art building (ii) Super class building (iii) Medium class building (iv) Lower medium-class building (v) Lower class building (vi) Building in temporary sheds, etc.

32

1  Initial Planning of the Proposed Hospital Project

Table 1.12  Building details Activity What type or class of building is required?

What type of flooring is required? Is the false ceiling required? What type of doors/ windows are required? What type of interiors are required? What type of landscaping is required? What type of elevation is required? What type of roads are required? What type of rooms are required? Is the central air conditioning required? If yes which technology Are the provisions for spaces required for future expansion? Are the provisions required for supply of central medical piped gas? If yes, which gases Computer networking Music system/P.A system Telephone exchange Cable TV Filtered drinking water Extra pipelines Are the lifts required? Is the ramp required?

Status :- State-of-­ the-art Lower medium :- Marble

Stone

Mosaic

:- Yes

No

What type

Super class Lower class

Medium class Temporary structure PCC

:- Wooden

Aluminium

POP/sheet/ board Iron

:- Super

Medium

Ordinary

:- Super

Medium

Ordinary

:- Plain

Stone

Other

:- Tar coal

PCC

RCC

Brick :- Very spacious :- Yes

Stone Medium

Other Reasonable

No

:- Splits/ windows :- Yes

VRV

Chilled water plant If yes, how much percentage

Ductable splits

:- Yes

No

:- Oxygen

Compressed air

Vacuum

:- Yes :- Yes

Nitro-­ oxide No No

::::::-

No No No No No No

How many lines Source Dish

Yes Yes Yes Yes Yes Yes

No

How many How many

1.12  Building Details

33

Numerous factors collectively determine the classification of a building type and category. Some of these considerations include: Flooring Type: The selection of flooring significantly impacts the aesthetics and ambience of a building. However, it also substantially influences the project budget. Thus, careful consideration is necessary to determine the most suitable flooring material, ranging from options such as Italian marble, granite, ceramic tile, stone, mosaic, or basic PCC (Plain Cement Concrete). False Ceiling: A decision must be made regarding the necessity of a false ceiling. Typically, in hospital buildings, a false ceiling accommodates various service pipes and cables, making it a crucial consideration. Moreover, the type of material for the false ceiling, such as POP (Plaster of Paris), board or metal grid ceiling, or gypsum board ceiling, needs to be determined in advance, along with the corresponding framework for installation. Doors and Windows: The promoter also needs to choose the type and materials for the doors and windows, ranging from options like wooden flush doors, aluminium doors, UPVC (Unplasticized Polyvinyl Chloride) doors, stainless steel doors, or simple iron doors. Interior Design: The interior design significantly influences the building’s ambience and comfort, but it also impacts the overall construction cost. Therefore, the promoter must decide whether to opt for high-class, medium-class, or standard interiors based on the allocated budget. Landscaping: Similar to the interior design, landscaping choices profoundly affect the overall appearance and feel of the building. Consequently, the promoter must decide whether to invest in high-class, medium-class, or standard landscaping, considering the budget constraints. Building Elevation: The building’s elevation primarily contributes to its appearance and constitutes a significant portion of the overall construction expenses. The choices for building elevation include plain cemented elevation, tile or stone elevation, metal sheet elevation, or glass elevation. Internal Roads: The decision-making process also involves selecting the type of internal roads within the hospital premises, which can be tar coal roads, PCC roads, RCC roads, or interlocking tiles, and some may prefer brick or stone roads. Sizes of the rooms: A hospital is a place where the minimum space required for the effective performance of service is essentially required. The designer shall not reduce such spaces, otherwise providing services will be difficult. However, some promoters prefer more spacious spaces, some want medium spaces and some compromise with reasonable spaces. The decision is required well in advance before starting the design of the hospital. Air Conditioning: Another pivotal decision revolves around the air conditioning of the hospital building, including whether to implement air conditioning throughout the entire building or selectively in specific areas. Additionally, the choice of technology for air conditioning, such as central chilled water systems, VRV (Variable Refrigerant Volume) systems, ductable splits, or window air conditioners, must be determined accordingly.

34

1  Initial Planning of the Proposed Hospital Project

Provisions for Future Expansion: Deliberate planning for future expansion spaces is essential, necessitating a forward-thinking approach of approximately 20 years. Careful consideration is crucial to avoid the risk of either having surplus unutilized areas or facing a shortage of space for future expansion. The promoter, planner, and designer must collectively determine the percentage of space to reserve for potential expansion. Moreover, decisions are required regarding the expansion of specific departments or services that might be necessary in the future. Medical Gas Pipeline System (MGPS): Decision-making is also imperative concerning the centralized supply of medical gases. If a centralized supply is deemed necessary, it is advisable to centrally provide all required gases, including oxygen, suction, compressed air, nitrous oxide, carbon dioxide, and argon, among others. Information Technology (IT) Network: The designer needs to decide whether an IT network shall be integrated into the hospital building. If affirmative, strategic planning must outline the locations where computer systems are essential, alongside early decisions on the placement of switches. Public Address (PA) System: It falls upon the designer to determine the necessity of a Public Address system within the hospital premises. If deemed necessary, meticulous planning is required to decide the locations for speakers and the announcement microphone. Electronic Private Automatic Branch Exchange (EPABX): The inclusion of an EPABX system for internal communication warrants a decision from the designer. In case of an affirmative decision, the planning stage shall involve the determination of locations where intercoms will be necessary, as well as the strategic positioning of the primary EPABX control unit. Cable Television (TV) Network: If a cable TV network is to be integrated within the hospital, the locations for television sets must be identified. Additionally, the system for receiving television signals, whether through DTH (Direct-to-Home), local cable vendors, or a dedicated dish for the hospital, needs to be decided. Drinking Water Facilities: If the provision of filtered drinking water is a priority, the designer shall assess the required drinking water capacity in litres per hour and accordingly design a reverse-osmosis (RO) plant. Early decisions must be made regarding the placement of drinking water taps and the RO plant. Extra pipelines: Under the present scenario, it may be difficult for the designer or planner to assess the requirement of electrical pipelines that may be required in future. Therefore, it is recommended that a few extra pipelines shall be laid down or concealed in the wall that can be used in future for any such purpose. Lifts and Elevators: The decision shall be taken in advance if the promoters are planning for the lifts and elevators or are otherwise will manage with the staircases and/or ramps.

1.14  Land Details

35

1.13 Formation of the Legal Entity of the Organization See Table 1.13. Depending on the legal status of the ownership of the proposed hospital, the formation of the entity shall be completed in time, so that further activities of the proposed hospital can be commenced. The status can be an individual proprietorship, partnership firm, limited or private limited company, society, or a trust. Excluding individual ownership, the terms and conditions among the promoters must be determined, and a comprehensive agreement reflecting these terms shall be duly signed by all promoters in the presence of a witness. If the entity is of company, society, or trust, the Memorandum and Articles shall be prepared and registered with the concerned authorities as nominated by the government of the state or country. Applicable registration fees are to be submitted to complete the registration process. Upon successful registration, the entity shall obtain the corresponding certificate of registration or incorporation, as relevant to the entity type.

Table 1.13  Formation of the legal entity of the organization

Activity Settlement of the terms and conditions between the promoters Drafting the memorandum and articles of association Finalizing the memorandum and articles Registration of the memorandum and articles Paying the registration fees Incorporation of company

Status of works Not Start End Responsible date date Complete In-progress started person :- Yes No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

Remarks

1  Initial Planning of the Proposed Hospital Project

36

1.14 Land Details See Table 1.14. As previously mentioned in this chapter regarding site selection, once the site has been chosen and finalized, the subsequent step involves the acquisition and purchase of the land for the proposed hospital. Before making any advance payments for the land purchase, the promoter must conduct a thorough verification process to ensure a clear title for the land. This verification entails addressing and examining specific issues such as: 1. Reviewing land records from the registering authority to confirm the land’s title. 2. Acquiring a non-encumbrance certificate as evidence that the land is free from any kind of debt. 3. Ensuring that the land is not pledged as collateral to any bank or financial institution by requesting the original title deeds from the current landowner. 4. Verifying the chain of title deeds of the previous owners of the land. 5. Confirming that the land is devoid of any outstanding taxes, duties, penalties, or similar obligations. 6. Ensuring that the land is freely transferable without any associated lock-in period. Table 1.14  Land details Activity Has the land been finalized Checking the land records from the registering authority as all the clearances of the dues till date and that the land has no encumbrance Giving advance for land Clearance of purchase of land from Govt. Registration of land Applying for the conversion of land for commercial use (if required)

Start End Status of works date date Complete In-progress Not started :- Yes No :- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

If yes, what is the status of the conversion?

Responsible person Remarks

1.15 Funding

37

Upon the promoter’s satisfaction with the land’s ownership and the absence of any liens, the advance payment is to be made to the current owner, followed by the signing of a purchase agreement containing the agreed-upon terms and conditions by both parties. If any permissions are necessary from relevant authorities, boards, or the government, these shall be obtained well in advance before disbursing the advance or finalizing the purchase agreement. Once all requirements are fulfilled, the title deed for the land purchase shall be prepared and registered in the name of the hospital’s ownership entity. Appropriate registration fees shall be paid to the designated registering authority as stipulated by the state or country’s government. After registration, it is essential to obtain the original title deed along with the entire chain of earlier title deeds from the seller. Certain lands are designated for specific purposes by state or governmental authorities, such as residential, commercial, agricultural, institutional, or industrial use. Therefore, the land’s designated use must be suitable for the construction of the proposed hospital. If the current land use does not align with the hospital’s intended purpose, appropriate measures shall be taken to seek a conversion of the land use from the relevant authorities.

1.15 Funding See Table 1.15. Now that the land acquisition is complete and the design and drawings are underway, the next crucial step is to arrange the necessary funds. Concerning the financial requirements throughout the construction phase, it is important to note that the Table 1.15 Funding

Activity Opening the bank account Submission of the project report to the bank for the term loan Follow up with the bank for a loan Submitting the required clarification to the bank Approval of the term loan Documentation of loan papers

Status of works Start End Not Responsible date date Complete In-progress started person :- Yes No :- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

Remarks

38

1  Initial Planning of the Proposed Hospital Project

entire sum of funds isn’t immediately necessary. The fund requirements are staggered over the construction period. Despite this phasing, it is imperative to strategically plan and secure the arrangement and sources of funds to ensure their availability as and when needed. Failure to do so could be significantly detrimental to the project, potentially leading to a complete standstill. In case the funds are self-financed, entire funds for the project shall be separated and kept in a separate account, so that they can be utilized as and when required. On the other hand, if the funds are to be financed by some bank or a financial institution, the initial step involves submitting the DPR to the bank or financial institution along with the request letter and forms (as per guidelines of the concerned bank or financial institute) for a term loan. Maintain regular communication with the bank or financial institution to monitor the status of the term loan approval. Provide any necessary clarifications, additional information, and documents as requested by the bank or financial institution throughout the process. Upon approval of the term loan, obtain the sanction letter from the bank or financial institution and complete the necessary documentation formalities, ensuring all relevant documents are signed. Furnish the bank with the disbursement schedule as part of the process. Following the completion of these formalities, proceed to open a current account with the bank designated for the disbursement of the funds.

1.16 Hiring Consultants/Staff See Table 1.16. Now is the opportune moment to hire consultants and personnel for the ultimate preparations and initiation of the construction process. Typically, the following experts shall be engaged for a hospital project: (i) Hospital Project Planner: Required to plan all the intricacies, details, spaces, and equipment planning of the hospital. (ii) Hospital Project Designer: For designing the building including zoning and flow of men and materials. Deciding the location of all the departments and services. (iii) Architect: Preparing the detailed drawings and layout plans of the building including site plan, floor plan, elevation plan, cross-section plans, floor plans, landscape plan, MEP plans, interior plans, etc. (iv) Structural Engineer: For designing the RCC structure of the building. (v) Electrical Consultant: For designing the electrical plans and drawings of the building including internal electrical and external electrical drawings. (vi) MEP Consultant: For planning and designing MEP services like Plumbing, Water supply, MGPS, Firefighting and detection, CCTV, IT Networks,

39

1.16  Hiring Consultants/Staff Table 1.16  Hiring consultants/staff Status of works Activity Have the following consultants been hired Hospital project planner Hospital designer Architect Structural engineer Electrical consultant MEP consultants Air conditioning consultant Biomedical consultant Have the following staff members been hired Project engineer Civil engineer Junior engineers Electrical engineer MEP engineer Biomedical engineer Purchaser Accountant Lesioning officer Security officer and security staff Safety officers and safety supervisors

Start date

End date

Not Responsible Complete In-progress started person

:- Yes

No

::::-

Yes Yes Yes Yes

No No No No

:- Yes :- Yes

No No

:- Yes

No

:::::-

Yes Yes Yes Yes Yes Yes

No No No No No No

::::-

Yes Yes Yes Yes

No No No No

:- Yes

No

Remarks

EPABX, and PA systems. The job shall also include preparing layout plans and detailed drawings. (vii) Air-Conditioning Consultant: For planning and designing the air conditioning system of the building and preparing the detailed working drawings. (viii) Biomedical Consultant: For planning and designing the spaces and other spaces required for the installation and commissioning of the medical equipment.

40

1  Initial Planning of the Proposed Hospital Project

These consultants can be engaged either as full-time employees on a salary basis or as visiting consultants, depending on the hospital’s policies and the mutual convenience agreed upon by both parties. In addition to the consultants, a few full-time staff members must be recruited to oversee the project’s daily operations, manage contractor queries and requirements, and ensure the supervision of the construction’s work quality and material standards. Typically, the following staff members are employed. (i) Project Engineer: He/she shall be totally in charge of the project. (ii) Civil Engineer: To monitor the entire construction work of the building. (iii) Junior Engineers: To assist the chief project engineer and the civil engineer. (iv) Electrical engineer: For monitoring the electrical works. (v) MEP Engineer: For monitoring the works of MEP. (vi) Bio Medical Engineer: For monitoring the works related to the installation of the medical equipment. (vii) Purchaser: For handling the day-to-day purchase requirements. (viii) Accountant: To manage the accounts and statement of expenses and party’s account. (ix) Lesioning Officer: Liaison with the government authorities and other suppliers and contractors. (x) Security Officer and Security staff: For keeping watch and vigilance on the construction site and to prevent wastage and theft of the material. Also responsible for restricting the entry of any unwanted person to the site. (xi) Safety Officer and Safety Supervisors: To provide safety to the workers and the site and prevent any type of accident at the site.

1.17 Electrical Works See Table 1.17. Electrical Load Estimation: Before initiating the application process for electricity connection from the supply agency, it is imperative to conduct an accurate assessment of the power load. This involves calculating the power consumption of various components, such as medical equipment, fans, lighting, air-conditioning systems, and elevators within the facility. The outcome of this load calculation aids in designing the requisite electrical equipment, including transformers, circuit breakers, bus bars, etc. The hospital’s overall load is measured in KVA. Based on this, the maximum demand is determined, considering an overall diversity factor of 80% and a power factor of 0.8 (lagging). To meet this electrical load and assuming 80% transformer loading and 97% efficiency of transformers, a sub-station shall be designed. To be on the safer side, a small spare capacity shall be considered and added to work out the total power load that has to be applied.

41

1.17  Electrical Works Table 1.17  Electrical works Activity How much load of electricity shall be required (please calculate the peak load requirement keeping in mind the redundancy) Requirement of sanctioned load electricity Requirement of the connected load of electricity How far is the main supply line of the electricity supply service provider What about the cost of laying the lines from the grid to the transformer of the hospital Will the connection be three phase or single phase? What will be the supply line? Will it be 11 kV or other?

Responsible End Status of works Remarks Start date date Complete In-progress Not started person :- Yes No How much load has been calculated?

:- Yes

No

:- Yes

No

:-

:-

:-

:-

(continued)

42

1  Initial Planning of the Proposed Hospital Project

Table 1.17 (continued) End Status of works Activity Start date date Complete In-progress What will be :the location of the energy meter? No Do you want :- Yes to have a generator? No Do you want :- Yes to have a UPS backup?

What will be the earthing system?

:- Chemical Earthing

What will be the system for lightning protection?

:-

Responsible Not started person Remarks

What capacity? What capacity?

Which areas and machines are to be connected to UPS?

Charcoal earthing with copper plate

After accurately determining the actual electricity load required, the sanctioned load must be evaluated. Generally, the sanctioned load shall be approximately 25% to 50% higher than the calculated actual load to account for potential future increases in electricity demand. If not considered, again the process for sanctioning the increased load may have to be repeated. However, it is crucial to consider that if there are any fixed charges of sanctioned load and those charges are recurring in nature, the careful decision has to be taken that there is no recurring liability towards the fixed charges of sanctioned load. Now coming to the connected load. The connected load shall be near the actual load. However, some extra load of about 10% to 20%, over and above the actual load requirement, shall be approved. Once again, the issue of any fixed charges of connected load shall be carefully considered. If any such charges are recurring in nature, the decision has to be taken that there is no recurring liability towards the fixed charges of the connected load. Furthermore, it is essential to assess the distance of the main supply line from the hospital site and clarify which party will bear the cost of laying the lines from the main supply grid to the hospital’s transformer. Whether it will be borne by the service provider or the hospital. If it has to be borne by the hospital, the provision shall be made in the project cost of the proposed hospital.

1.17  Electrical Works

43

The question of whether the connection will be released from the 440 V line or the 11 kV line needs to be addressed, requiring provision for a Vacuum Circuit Breaker (VCB) near the meter room if connected to the 11 kV line. Depending on the hospital’s size, a decision must be made whether to opt for a single-phase or three-phase power supply, with the latter being the preferred choice in most cases. The location of the energy meter room shall be strategically determined during the site layout planning phase. Typically, it shall be placed at the hospital’s main entry gate to facilitate meter reading without the need to enter the main hospital building. Emergency Power Generation System: If the hospital is planning to install captive generating sets, the rating of the Diesel Generator (DG) shall be decided while planning the load of the hospital. The rating will depend on the areas and the machinery which has to be connected to the generating set. Usually, the Air-Cooled Silent Diesel Generating sets shall be provided as a secondary source of power to meet the power backup for all services. It is always recommended that two or more numbers of DG sets shall be installed to make the DG power supply more flexible and economical. The DG sets shall be located as near as possible to the sub-station and shall be compatible with the Programmable Logic Control (PLC) system panel. The DG sets shall preferably be installed on a raised foundation, which shall be strong enough to tolerate the load and vibrations of the DG set. The DG set is fixed to the foundation with the help of fasteners, and anti-vibration pads shall be installed. Sufficient provision shall be made for an independent exhaust pipe from each DG set and shall be connected to the chimney at 30-m height from the ground to let the smoke out into the atmosphere. Uninterrupted Power Supply System (UPS): Uninterrupted power supply in the hospital is generally used to provide power supply to emergency lighting and for life-saving equipment. Most importantly, the UPS system is provided in the critical units and for sophisticated machines like MRI, CT, and LINAC. The UPS supply is also essential in critical units like operation theatres, all intensive care units, procedural rooms, emergency, etc. Apart from this, a UPS shall also be provided for the hospital server, and IT equipment like computers, CCTV, WIFI routers, fire panels, alarms, etc. The rating and number of UPS shall be designed as per the requirement of the hospital which shall be worked out in detail and area-wise or machine-wise. The rating shall be worked out preferably, with at least a battery backup of 20–30 min with each UPS. Earthing System: Ground earthing shall be provided to all the HT/LT distribution systems. This can be achieved by providing local maintenance-free earth stations and bonding the cables/equipment. Earthing shall also be provided for all the light and power points. The type of ground earthing shall be decided during the planning stage. The earthing can either be a chemical earthing or earthing using charcoal, copper plate, and strip.

1  Initial Planning of the Proposed Hospital Project

44

Lightning Protection: The planners have to decide on the protection system from sky lightning. For this, suitable lightning arrestors, connected to copper strip/ cable shall be provided. A suitably protected zone shall be formed through the mast and connected to earthing stations through copper cable/strip.

1.18 Water Supply and Sewerage System See Table 1.18. The supply of water is necessary for the survival of human beings and similar is the requirement of a proper drainage system. Particularly in the case of hospitals, where the treatment of ill and critical patients is carried out, the water supply and drainage system have to be excellent and dependable. The importance of clean hygiene and good quality water and drainage is critical for any hospital. The quality of water that is supplied and the perfection of the drainage system have a great impact on issues like infection control, the life of the medical equipment, staff, and patients’ hygiene, etc. The reliability of the water supply system is also an important issue. Thus, it shall be ensured that an uninterrupted water supply is available at all times in the hospital building. On the other hand, it shall be ensured that the volume of the water shall not be more than the required volume and water stagnation in the tanks shall be avoided. Table 1.18  Water supply and sewerage system

Activity What will be the source of water? Has the daily consumption been calculated?

Start date

Status of works End date Complete In-progress

Not started

:-

:- Yes

Has the water :- Yes quality been analysed If you own :- Which bore well pump will be installed? What will be :- Overhead the source of tank storage?

No

How much water will be required daily?

No

What will be the capacity of the pump? Individual tanks on the roof

Responsible person Remarks

1.18  Water Supply and Sewerage System

45

Table 1.18 (continued)

Activity Is the water treatment plant required? Is the hot water system to be provided? What will be the system of disposal of the water? If own source

What will be the size of the septic tank? How many chambers are there? How big will the soak pit be? What will be the size of the main drainpipe? Where will be the location of the soak pit? Where will be the location of the septic tank?

Start date :- Yes

Status of works End date Complete In-progress No Type of treatment plant

:- Yes

No

:- Govt. sewerage system

Type of hot water plant

Not started

Responsible person Remarks The capacity of treatment plant The capacity of hot water plant

Septic tanks

:- What source (Pl give details) :-

:-

:-

:-

:-

:-

Source of Water Supply: The planning about the source of supply of water shall be done well in advance. It can be from. (i) Supply from the Water Network Supplier by connecting to their distribution network (maybe Govt. supply or others) (ii) Deep borehole (iii) Underground water wells (iv) Connection to the portable water trucks

46

1  Initial Planning of the Proposed Hospital Project

If water is sourced from a borehole, the type of pumps to be installed, such as submersible or Monoblock pumps, and their appropriate ratings, considering the pump head and output, need to be determined. Has water quality been assessed? If not, a water quality analysis must be conducted during the planning phase. Generally, the Total Dissolved Solids (TDS)/ Parts Per Million (PPM) of raw water range from 80 PPM to 2000 PPM, subject to variation based on the water source. In cases where the PPM exceeds the permissible limit, water treatment is necessary to bring TDS/PPM levels to 0–150 PPM. To ensure a reliable water supply, hospitals are advised to have at least two sources of water, providing a backup in case of any supply failure. The designer shall calculate the anticipated maximum daily water consumption as well as the peak flow requirement. Additionally, assessing water pressure is crucial during the design phase. While designing the water supply system, the designer shall take into consideration the expansion of the hospital that may occur in future. On average at least 25% of spare water capacity in the system shall be considered as a buffer for future expansion. Water Storage: The hospital shall have its resources for storage of water equivalent to 3 days of consumption. The storage sources can be the overhead storage tank or individual storage tanks provided on the rooftop of the building. Water Treatment Systems: Given the need to control microbial growth, the installation of a water treatment plant must be deliberated during the planning phase. Treatment methods may include pasteurization, chemical treatment, chlorine water treatment, water softener plants, silver-copper ionization, reverse osmosis treatment, ultraviolet treatment, ozone water treatment, or distilled water systems. Hot Water System: In the hospital, hot water is needed at places like CSSD, Hand Wash Basins, Kitchen, Scrub Sinks, Instrument washing area, Patient’s bathrooms, and a few Maintenance Areas. Different types of hot water systems are generally provided in hospitals. It can be like electrical hot water generation, hot water generation from boiler/steam by burning fuel, solar hot water generation, or stand-­ alone hot water geysers. Water Drainage System: Hospitals shall have an effective and dependable drainage system. This is still more important because the quality of effluent generated in the hospital is generally infective as compared to the effluent generated in any other commercial building. Also, while designing the drainage system, the quantity of the effluent generated shall be considered. Considering the location of the hospital, the availability of a nearby network of drainage, main holes and connection points shall be assessed. The ground-level differences between the hospital drain and the drainage network shall be assessed. Assess the type of effluent that may be discharged from the hospital like chemical, radiation grease, etc.

Further Reading

47

During the planning of the project, the drainage type shall be assessed. There are various types of materials to be drained from the hospitals. These are wastewater drainage, soil water drainage, stormwater drainage, chemical drainage, and radiation drainage. All these types shall have supersite drainage systems like govt. sewerage system, septic tanks, soak pit, rainwater harvesting pit, etc. It has to be ensured that the detailed planning and designing of all these drainage systems are prepared well in time during the planning and designing phase.

1.19 Contact Details See Table 1.19. Now that everything has been planned, the site has been finalized, the ownership entity has been established, and it is time to collect all the contact details of the proposed hospital, for further correspondence. Since the location has been determined, the complete address of the hospital, including the city, country, and postal code, must be finalized for all further communication. If a telephone number has been assigned to the proposed project, provide the contact number with the relevant STD codes. Other pertinent information such as email addresses and website URLs shall be confirmed and documented. As we are now ready to proceed with the construction of the project, and as the staff has been recruited to carry out the construction activities; the names, designations, contact numbers, and email IDs of all such responsible officials shall be obtained and recorded. Table 1.19  Contact details Name of the proposed hospital Address State Country Pin Telephone no. with STD code) Fax E-mail Website (if any) Persons to be contacted

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1  Initial Planning of the Proposed Hospital Project

Further Reading Ar Z. Modern principles and practice in planning and designing of healthcare services (an overview: latest trends of Design in Indian Hospitals). J Archit Eng Technol [Internet]. 2019 [cited 2021 Jun 8];7(2). https://www.omicsonline.org/open-­access/modern-­principles-­and-­practice-­ in-­planning-­and-­designing-­of-­healthcare-­services-­an-­overview-­latest-­trends-­of-­design-­in-­ indian-­hosp-­2168-­9717-­1000222-­107203.html Century I of M (US) C on A the H of the P in the 21st. Understanding Population Health and Its Determinants [Internet]. The Future of the Public’s Health in the 21st Century. National Academies Press (US); 2002 [cited 2021 Jun 8]. https://www.ncbi.nlm.nih.gov/books/ NBK221225/ Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. India: Springer Singapore. Chapter 2, Inception of the Idea; p.  7 and Chapter 3, Factors Assessing Feasibility of the Hospital; 2022. p. 9–12. Griffin CH, Joint Commission, Joint Commission Resources, Inc., Joint Commission International, AIA Academy of Architecture for Health. Planning, design, and construction of health care facilities: addressing Joint Commission and JCI standards and other considerations—from planning to commissioning. 3rd ed. Oak Brook, IL: Joint Commission Resources; 2015. p. 138. Hernandez LM, Blazer DG, Institute of Medicine (US) Committee on Assessing Interactions Among Social B.  The Impact of Social and Cultural Environment on Health [Internet]. Genes, Behavior, and the Social Environment: Moving Beyond the Nature/Nurture Debate. National Academies Press (US); 2006 [cited 2021 Jun 8]. https://www.ncbi.nlm.nih.gov/books/ NBK19924/ Hospital of Tomorrow. The design perspective - Facilities and Operations [Internet]. [cited 2021 Jun 8]. https://www.asianhhm.com/facilities-­operations/hospital-­design Naghipour M, Langarizadeh M, Razzazi M. Identification of the requirements for designing medical tourism information system of Iran. J Educ Health Promot. 2019;8:118. https://www.ncbi. nlm.nih.gov/pmc/articles/PMC6615129/ World Health Organization, World Bank Group, OECD.  Delivering quality health services: a global imperative for universal health coverage [internet]. Geneva: World Health Organization; 2018 [cited 2021 Jun 8]. http://hdl.handle.net/10986/29970

Chapter 2

Detailed Project Report (DPR) and Techno-Commercial Feasibility Report (TCFR)

A detailed project report (DPR) is a bankable set of documents that are prepared while planning and designing a project. A DPR shows the tentative results and outputs of working based on the assumptions and projections made. It is a document containing detailed and elaborate projections and plans for the project, indicating the overall calculations, financials, roles and responsibilities of the persons involved in the project, the project’s detailed programme, time planning for the project and details of activities and resources required for completion of the project. During the planning stage itself, a blueprint is prepared on paper, which is called a detailed project report (DPR) cum a techno-commercial feasibility report (TCFR). This set of documents provide a detailed analysis and study of what has to be done to convert the investment into a feasible and profitable venture. In this set of documents, top management’s policies and guidelines, their impact on the project span and appraisal of financial viability are all estimated and dealt with in depth. A DPR mainly addresses issues like contract drawings, detailed technical feasibility studies, financial feasibility calculations, execution of the project from a practical point of view, staff planning and the time for completion of the project and highlights the type and nature of inherited or other foreseeable external risks in the project and how they can influence the outcome of the project. Moreover, a DPR should address and provide measures for risk management and risk mitigation. A DPR is a document that also guides the management of the project’s progress and enables comparison of the present circumstances with projections to answer questions like • Can the project be completed in the estimated time? • Is the actual cost of the project within the reasonable limits of cost escalation? • After completion, will the project be able to deliver the desired results relating to both quality and quantity and can patient satisfaction be achieved at a profitable cost.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_2

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2  Detailed Project Report (DPR) and Techno-Commercial Feasibility Report (TCFR)

A DPR should contain general information about the hospital project, the background and experience of the project promoters in the hospital industry, details of ward-wise beds in the hospital, details of the services and departments to be established, schedule of the implementation period of the project, the detailed capital cost of the project, means and resources of finances for the project, working capital requirements and arrangements thereof, assumed operational expenses, assumed rate of hospital services, assumed number of patients and procedures that can be performed, revenue-earning projections, revenue expense projections; profit and loss statements for the next 8–10 years, cash flow statements for the next 8–10 years and financial ratios. A DPR should also contain staff planning, depreciation statements, interest calculation on loans, projected balance sheets for the next 8–10  years, marketing arrangement to be made, mode and means of repayment of term loans and cash credit loans, government approvals required for the project, consents and statutory permissions required for the project from the local authorities and details of collateral security to be offered to financial institutions. A DPR should also provide guidelines for governing all types of contractual agreements that are likely to be entered with various agencies; resolution of any dispute that may arise in the future and arbitration procedures to be indicated; supply, erection, installation, commissioning and guarantee/warranty issues; choosing vendors and vendor shortlisting and networking. A DPR should provide an estimate of the phase-wise fund’s requirement for capital expenditure, a schedule for ensuring an adequate flow of funds for the timely completion of the project, the project phase and a PERT chart depicting the time required for completion of a particular activity or the project as a whole. Once the DPR is prepared, as the final onus of the project vests with the owners, the owner must have an appropriate mechanism and methods to evaluate the DPR. This chapter will help promoters prepare both a DPR and a TCFR effectively and then deeply evaluate the report before making the final decision to approve the project. If any amendment is required in the planning, then that can be carried out before making the final decision.

2.1 Details of Projections See Table 2.1. Before preparing a DPR, the first stage is to solidify the estimations concerning the number of patients, income and expenditure, etc. These estimations play an important role in the formulation of a DPR. Some of the main topics that require estimations are as follows: The number of patients expected in the outpatient department (OPD) per day: OPD patients can be further classified as those visiting speciality departments like medicine, general surgery, orthopaedics, obstetrics and gynaecology, paediatrics, etc., and those visiting super-speciality departments like neurology,

2.1  Details of Projections

51

Table 2.1  Details of projections Activity Has the projection been made for: Outpatient department (OPD) patients per day (in numbers)

Status

:- Yes No If no, why (please give reasons) Bed occupancy per day (in percentages) :- Yes No If no, why (please give reasons) Different types of investigations in the clinical laboratory per :- Yes No If no, why (please day (in numbers) give reasons) Different types of radiological investigations per day (in :- Yes No If no, why (please numbers) give reasons) Different types of other investigations per day (in numbers) :- Yes No If no, why (please give reasons) Has the number of major and minor surgeries per day been :- Yes No If no, why (please worked out (in numbers)? give reasons) How many patients are expected in the emergency :- Yes No If no, why (please department per day (in numbers)? give reasons) Have the projected charges for services been worked out? :- Yes No If no, why (please give reasons) Have the projected, fixed, semi-variable and variable :- Yes No If no, why (please expenses been worked out? give reasons) Has the expected revenue for the next 10 years been worked :- Yes No If no, why (please out? give reasons) Have the expected expenses for the next 10 years been :- Yes No If no, why (please worked out? give reasons) Has the projected cost of building been worked out? :- Yes No If no, why (please give reasons) Has the projected cost of hospital equipment, disposables :- Yes No If no, why (please and consumables and furniture been worked out? give reasons)

gastroenterology, urology, nephrology, etc. Furthermore, estimating patients department-­wise will help gain a clearer picture of the revenue that will be obtained when preparing a DPR. Bed occupancy: This means how many beds will be occupied per day out of the total number of beds available at the hospital. This is calculated in percentage. This percentage will help in calculating daily bed occupancy in each category of indoor wards. Let us understand this with an example. Suppose that we have the following beds: General ward Private ward Intensive care unit (ICU)

100 20 50

Suppose that the estimated occupancy percentage is 40%. Then, the daily bed occupancy will be:

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General ward Private ward ICU

100 × 40% = 40 beds 20 × 40% = 8 beds 50 × 40% = 20 beds

If we multiply this daily bed occupancy by 365 (the total number of days in a year), then we will get the bed day occupancy per year. This figure multiplied by the charges of a bed per day will provide the total revenue obtained from beds per year. Clinical laboratory investigations: As several different tests are conducted at the laboratory, it can be difficult to estimate all of them. The best method is to estimate the number of samples that the laboratory will recieve and the number of tests that it will conduct on a daily basis. Multiplying with 365 yields the total number of tests conducted per year. Regarding the charges of such tests, an average rate is worked out based on the experience, and when the number of tests is multiplied by the average charges, the total income obtained from the clinical laboratory can be derived. Radiological investigations: In this context, several investigations are carried out modality-wise like X-rays, computed tomography (CT) scanning, magnetic resonance imaging (MRI), ultrasound, etc. Hence, the expected number of such investigations should also be estimated modality-wise. One need not go into depth with a different type of investigation for a particular modality. For example, in the case of X-rays, the total number of X-rays can be estimated, but one need not go into details as to how many will be for the chest, how many will be for the knee, etc. Only the total number of X-rays is sufficient for a DPR. Regarding the charges, it is advised to calculate the average charges for all types of tests for a particular modality. The daily estimated figure when multiplied by 365 (days) and the average charge will provide the income earned from radiology. Other investigations: Apart from the above, several other investigations are carried out in a hospital, namely, electrocardiogram (ECG ), echocardiogram, electromyography (EMG), electroencephalogram (EEG), gastroscopy, etc. Depending on the facilities to be provided in the hospital, the estimation of all such investigations can be worked out, and, when the average rate of such investigations is multiplied by 365, we obtain the total income earned from a particular investigation. Surgeries: Coming to a hospital’s major source of income, that is, surgeries, the estimation will be done for the number of major and minor surgeries per day. One need not go into the details of each type of surgery. For example, in the department of general surgeries, there can be several surgical procedures. We need not go through the details of each surgical procedure, and the total surgeries conducted in the department of surgery is sufficient. When the number of surgeries conducted across all departments is totalled, we obtain the total number of surgeries conducted per day. Coming to the charges of surgeries, the average charge of all the surgical procedures is worked out. However, one should concentrate more on the charges of commonly performed surgeries. When the number of surgeries is multiplied by 365 (days) and the average charge, we get the total income earned from surgeries.

2.1  Details of Projections

53

Miscellaneous charges: Along with surgeries, some hospitals levy operating room (OR) charges and OR drug charges. OR charges are levied towards the facilities used in the OR, and OR drugs charges are towards the drugs and consumables used in the OR during surgery. Usually, OR charges are a fixed percentage of surgery charges, and OR drug charges are the actual amount spent on drugs and consumables used. Next are anaesthesia charges, which consist of the fees of the anaesthetist and anaesthesia reagents and drugs used for anaesthetising the patient. Hence, the estimation of revenue from surgeries is worked out simply by multiplying the number of surgeries (as calculated in the above paragraph) and the income under both these heads. The department of emergency: The expected number of patients likely to land in the emergency department is worked out. One need not go into the details of each ailment of the patient landing in the emergency. Just the total number of patients arriving at the emergency department is sufficient. When these numbers are multiplied by 365 (days) and the average emergency charge, we get the income earned from the emergency department. Here, we end with the projections and estimations of the number of patients and bed occupancy. Now comes the schedule of charges of the proposed hospital. The schedule of charges is a statement depicting the amount that the hospital is intending to charge for a service provided and the charges towards investigations, surgeries and procedures. For finalising the schedule of charges, it is better if similar schedules are obtained from two to three other hospitals in the nearby area. These charges can be used to calculate the projected income of the hospital for incorporating it into the DPR. Generally, the heads of income for a DPR are as follows: • • • • • • • • • • • • •

Admission charges Income from bed charges Income from ICUs Doctors visit charges Income from speciality OPD Income from super-specialty OPD Income from clinical laboratory Income from radiological investigations Income from other investigations Income from ventilator charges Income from dialysis Income from the sale of medicines from the pharmacy Miscellaneous income from audiometers, oxygen tanks , BioScan, physiotherapy, incubators, gastroscopy, intubation, catheterisation, bronchoscopy, chemotherapy, Holter, pacemakers, vaccinations, ambulance, radiant warmers, phototherapy, etc. • Income from surgeries • Income from OR charges

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• Income from anaesthesia charges • Income from OR drugs Another important component of a DPR is projected expenses. These expenses can be of varied types. First are fixed expenses, which generally do not vary with the number of patients and remain fixed, irrespective of an increase or decrease in the number of patients, like salaries, insurance, maintenance contracts, etc. Second are semi-variable expenses, which may vary up to some extent depending on the increase or decrease in the number of patients. These can be electricity charges, advertisements, laundry expenses, generator running and maintenance, etc. The third are variable expenses, which strictly vary with an increase or decrease in the number of patients. If the number of patients increases, then these expenses will increase, and vice versa. Such expenses include the doctor’s share, consumable and drug expenses, expenses on ward consumables, etc. Generally, the following are the expenses that are incurred by a hospital. Fixed Expenses • Salary and allowances • Annual maintenance contract • Insurance • Building maintenance • Provident fund Semi-Variable Expenses • Electricity charges • Advertisements • Diet charges • Laundry expenses • Equipment repair • Bad debts • Bank charges • General expenses • Printing and stationery • Postage and telephone • Travelling • Vehicle expenses • Security expenses • Generator running and maintenance Variable Expenses • Doctors’ share on visits, procedures and surgeries • Consumables like OP drugs, cost of medicines, linen consumables, minor instruments/equipment consumables, other ward consumables • Other variable expenses like concession and discount, other unplanned expenses, etc.

2.2  Other Issues Relating to the DPR

55

After estimating, collecting and calculating the figures of various components of the DPR, it is time to start preparing the DPR. Please remember that a DPR should be prepared for at least 10 years. First of all, the projected number of patients has to be calculated by increasing or decreasing the numbers on a year-to-year basis as expected by the planners and promotors. Then, the income has to be calculated for the next 10 years. Similarly, the expenses for the next 10 years have to be calculated by increasing or decreasing the expenses as per the experience of the planner or promoter. This increase or decrease has to be based on some facts and backed up by some reasons or documents. Here, we end with the revenue projection that will be incorporated into the DPR. Now comes the capital expenditure part of the DPR. Capital expenditure is the amount to be spent to construct and equip the proposed hospital. This will include the cost of the land, building, equipment, instruments, first-time consumables and furniture, backup services like generators, medical gas pipeline system (MGPS), computerisation, etc. The cost of land is the price paid/has to be paid for the purchase of land. If the land was purchased earlier, say about 2 years back, its valuation should be done by an approved valuer, and this value will be taken into consideration when evaluating the capital cost of the project. Next is the cost of the building. This includes all civil works, electrical works, sanitary and plumbing works, landscaping, lifts and elevators, finishing the building including installation of doors and windows, flooring, steel works, painting, firefighting, air conditioning, etc. Equipment include all the mechanical and electronic medical equipment for all the departments. Then, the cost of items required for backup services like MGPS, generators, curtain tracks, water coolers, ambulances and modular operation theatres (Ots), etc. should be ascertained. First-time consumables like ward consumables, cleaning items, printing and stationery etc. can also be included in the capital cost and the same will be estimated for the DPR. Next comes the cost of furniture. Generally, a hospital requires furniture for its patients such as patient beds, bedside lockers, over-bed tables, wheelchairs, stretchers, etc. Similarly, office furniture like chairs, office tables, almirahs, filling racks, attendant beds, etc. are also required in a hospital. The cost of both types of furniture should be estimated and added to the capital cost in the DPR.

2.2 Other Issues Relating to the DPR See Table 2.2. Now that we are ready with all the figures and the facts, it is time to start preparing the DPR. The DPR should include the following.

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Table 2.2  Other issues relating to the DPR Activity Has the following been included in the DPR: General information about the project

Status

:- Yes No If no, why (please give reasons) Experience and background of the promoters in the hospital :- Yes No If no, why (please industry give reasons) Ward-wise details of the beds to be provided in the hospital :- Yes No If no, why (please give reasons) Details of the departments and services to be provided in the :- Yes No If no, why (please hospital give reasons) Have the management teams for the project been identified? :- Yes No If no, why (please give reasons) Have estimations been done for the land, buildings and :- Yes No If no, why (please equipment? give reasons) Have infrastructural facilities like power, water supply, :- Yes No If no, why (please transport facilities, etc. been identified? give reasons) What types of effluents are likely to be produced by the :- Yes No If no, why (please hospital and what are the treatment procedures to be adopted? give reasons) Has the manpower requirement and availability been worked :- Yes No If no, why (please out? give reasons) Has the period for completion of the project been defined? :- Yes No If no, why (please give reasons) Have the contract drawings been prepared? :- Yes No If no, why (please give reasons) :- Yes No If no, why (please Have the working capital requirements and arrangements thereof been worked out? give reasons) Have the profit and loss statements for the next 8–10 years :- Yes No If no, why (please been prepared? give reasons) Have the cash flow statements for the next 8–10 years been :- Yes No If no, why (please prepared? give reasons) Have the depreciation statements for the next 10 years been :- Yes No If no, why (please prepared? give reasons) Has the interest on loans for the entire duration of the loan :- Yes No If no, why (please period been calculated? give reasons) Have the projected balance sheets for the next 8–10 years been :- Yes No If no, why (please prepared? give reasons) Have the financial and profitability ratios been prepared? :- Yes No If no, why (please give reasons) Has the break-even analysis been calculated? :- Yes No If no, why (please give reasons) Has the sensitivity analysis—price/volume—been prepared? :- Yes No If no, why (please Has the projected payback period and internal rate of return :- Yes No If no, why (please (IRR) been calculated? give reasons) Have the means and resources of finances for the project been :- Yes No If no, why (please determined? give reasons) (continued)

2.2  Other Issues Relating to the DPR

57

Table 2.2 (continued) Activity Status Have the details of collateral security that can be offered to the :- Yes No If no, why (please financial institutions been allotted? give reasons) Have the financial feasibility calculations been done? :- Yes No If no, why (please give reasons) Has the market survey been conducted by the agency and have :- Yes No If no, why (please give reasons) the required survey forms been submitted along with the report? Have detailed technical feasibility studies been carried out? :- Yes No If no, why (please give reasons)

General information about the hospital project: This information will contain details such as why this hospital was planned, who the promoters are, which areas will the hospital serve, what the facilities of the hospital will be, the mission and vision of the hospital, what category of beds will be available and also information about any special facility being planned in the proposed hospital. The background, qualifications and experiences of all the promoters, particularly in the healthcare sector, will be provided in the DPR. A statement should be prepared containing information about the categories of beds available in each ward along with the number of beds. A statement containing detailed information about the speciality and super-­ speciality departments to be set up in the hospital should be provided. Along with this, a brief note containing information about the facilities to be provided in each department should be provided. Other details that need to be included in the DPR are as follows: (i) A management team deputed to manage the proposed project along with their designation, qualifications and experience (ii) Details of the land like area, location, distance from the main road, approachability, etc. (iii) Details of the building like the total covered area, zoning, class of construction and type of finishing, etc. (iv) Details of all the medical and non-medical equipment to be installed (v) Details of the availability of all the infrastructural facilities like power, water supply, sewerage, transport, firefighting, police station, coach station, railway station and airport, etc. (vi) A detailed note on the production, treatment and disposal of effluents, biomedical wastes, hazardous wastes, etc. Manpower cost estimates: Location-wise staff requirement for all the shifts in the hospital and the number of staff members that may be required, both designation- and category-wise, should be calculated. Once this is done, the numbers should be multiplied by the average salaries and wages in the area. This will provide the total estimated expenditure on salaries and wages.

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Project completion period: The planners and designers should estimate the period required for the completion of the project. Timely completion of the project is the most crucial factor when setting up a hospital project. If the project is not completed on time and gets delayed, then it can have serious effects on the hospital and can be detrimental to it. The reason is that due to inflation, the cost of the project may overrun, interest on the amount invested may increase and there may be loss of income for the delayed period. All the factors combined can have a serious financial impact on the project. Therefore, completion period estimation has to be highly accurate, and efforts should be made by all concerned to complete the project on time. For better control of the time schedule, the best method is to prepare a programme evaluation and review technique (PERT) chart. This chart is similar to a Gantt chart but is structured differently. This chart contains details of all the activities to be carried out, the period required for each activity and the tree chart for connected activities. This chart also defines the start and end dates of each such activity. If the management judiciously sticks to these dates and time frames, then there is a very less chance of the project getting delayed. It should be ensured that all the contract drawings, including the layout plans, are ready and signed by the architect, structural engineer and promoters, as the same is a part and parcel of the DPR. Working capital statement: Once the operations of the hospital starts, there will be a requirement of funds for day-to-day expenses. Such expenses are called revenue expenses. As far as the funds for setting up a hospital are concerned, the same is financed as a term loan by the bank or financial institutions and cannot be used for operating expenses. Therefore, the hospital may require free-flowing funds for its operations. This will be either contributed by the promotors or financed by the bank in the shape of working capital. Hence, based on the projections of surplus/deficit and the fund’s flow statement, the requirement of working capital should be assessed as this statement will be a part of the DPR. Profit and loss statement: Once the figures of income and expenses are ready, the statement of profitability after deducting the expenses from the income figures can be drawn. This statement is called either a surplus or deficit statement or the profit and loss statement. For preparing a bankable DPR, the same has to be repeated for 10  years and profitability has to be calculated for the next 10 projected years. Fund flow statement: This is prepared after deducting the expenses from the income figures, adding back the depreciation (because it is an expense without any cash outflow) and deducting the instalments paid towards the loans. This statement is called a fund flow statement or a cash flow statement. This statement should also be prepared for the next 10 years for the DPR. Depreciation statement for the next 10 years: This statement shows the depreciation of capital assets. The written-down value of the asset and the cost towards the addition of assets is the value on which depreciation is calculated. The rate of depreciation can be as per the norms prescribed by the taxation authorities from time to time. This statement is also required for the next 10 years.

2.2  Other Issues Relating to the DPR

59

Interest on loans: The interest on all the loans, such as term loans, working capital loans or personal loans, should be calculated for the next 10  years or till the period that the loan amount is outstanding, whichever is earlier. Balance sheet and the profit and loss account: A profit and loss account consists of incomes and expenditures, and a balance sheet consists of assets and liabilities along with the schedule of current assets and current liabilities. These statements also have to be prepared for the next 10 years. Financial and profitability ratios: Parameters such as like return on investment (ROI, average of fixed assets), ROI (average of total assets), return on net worth (RONW, average of share capital), debt–service coverage ratio (DSCR), earnings per share (EPS) and debt–equity ratio should be calculated. These ratios are required by investors, banks and financial institutions for assessing the financial health of the proposed hospital project. Break-even analysis: This calculation includes the profit–volume ratio (PVR), fixed expenses/cost and break-even point (BEP). These ratios are required by investors, banks and financial institutions for assessing the period by which the proposed hospital project will be financially viable and able to meet its expenses. Sensitivity analysis: Assume that the projection may not work and either the expenses can be more than estimated or the income can be less than estimated. The first sensitive statement is prepared by increasing the expenses by 5% or 10% and the second statement by decreasing the income by 5% or 10%. This will help in assessing the variations in the financial ratios under sensitive conditions. Payback period: The payback period of the loans from banks, financial institutions and personal loans along with the internal rate of return (IRR) should be calculated. The resources and means of finance as well as the means from where the finances will be arranged for the project from time to time should be mentioned in the DPR. Sometimes depending on the quantum of the loan and as per the policies of the funding agencies, banks may ask for collateral security from the promotors. This security is generally the personal property of the promoter. The promotor should identify such properties well in time so that they can be given to the funding agencies as collateral security as and when demanded. Market survey report: This report, made while planning the hospital project (as explained in Chap. 1 of this book), will be required to prepare the techno-feasibility report and will become a part of the DPR. A techno-feasibility report: Lastly, the promoter should arrange for preparing a techno-feasibility report either using his resources or by hiring an agency to do the job. The techno-feasibility report is prepared based on the market survey report and the financial statements, as prepared above. This report helps in assessing the viability of the project in terms of the investment involved and the returns on such an investment.

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Table 2.3  The final DPR

Activity Does the final DPR include information on the following: Location profile and geotechnical site characterisation

Status of works Start End In Not date date Complete progress started

:- Yes

No

:- Yes

No

Brief write-up on the :- Yes proposed hospital

No

:- Yes

No

:- Yes Organisational details like status, address, capacity, services, etc. Synopsis and project :- Yes at a glance

No

Industry analysis

:- Yes

No

Hospital management issues

:- Yes

No

A key flow chart of the hospital

:- Yes

No

A flow chart of various departments

:- Yes

No

Executive summary

Notes on the list of assumptions for compiling the DPR

No

Responsible person Remarks

If no, why (please give reasons) If no, why (please give reasons) If no, why (please give reasons) If no, why (please give reasons) If no, why (please give reasons) If no, why (please give reasons) If no, why (please give reasons) If no, why (please give reasons) If no, why (please give reasons) If no, why (please give reasons) (continued)

2.3  The Final DPR

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Table 2.3 (continued) Status of works Start End In Not Responsible Activity date date Complete progress started person Remarks :- Yes No If no, why Details of the (please vendors and give suppliers of building reasons) materials :- Yes No If no, why Details of the (please contractors for the give construction and reasons) finishing of the building :- Yes No If no, why Statement of (please challenges in the give hospital industry reasons) No If no, why Hospital equipment :- Yes (please and facility give photographs reasons) A detailed activity-­ :- Yes No If no, why wise PERT chart (please give reasons) :- Yes No If no, why Conclusion by the (please promoter about the give proposed hospital reasons)

2.3 The Final DPR See Table 2.3. Now is the time to finally compile all the information and documents to give the final shape to the DPR, while ensuring that it consists of: 1. A location profile and geotechnical site characterisation: The location of the proposed hospital site, its address and other geotechnical details like coordinates of the site, earthquake seismic zone, flooding history and wind pressure in the area should be described. 2. An executive summary: This should include an overall summary of the entire project, like the name of the hospital, constitution of the hospital, name of the parent company, land area, building area, promoter details, implementation schedule, total project cost, means of finance, technical analysis, financial feasibility, etc. 3. A brief write-up on the proposed hospital: This note should include details like general particulars of the parent owner of the project, shareholding pattern of the parent owner, promoters of the project, expenditure on the project, means

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of finance, the status of the project on the date of preparing the DPR, broad financials of the project, note on why this hospital was planned, philosophy of the proposed hospital, justification of the project, objectives of the hospital, area of coverage, technical analysis, facilities in the hospital, details of the site, physical facilities in the hospital, licenses and permits to be obtained, statutory obligations to be complied with and a note on the operating standards of the hospital. 4. Notes on the list of assumptions for compiling the DPR: A list of all the assumptions that have been considered for preparing the DPR should be provided. The assumptions regarding the building, equipment and projections should be prepared separately and attached to this DPR. 5. Organisational details: The details of the organisational hierarchy, staff requirement to provide round-the-clock services at the hospital, the appointment procedure, qualifications and experience required for appointment, salary scales, etc. should be included in the DPR. Details like status, address, capacity, services, etc. of the hospital and parent owner should also be included in the DPR, 6. Synopsis and project at a glance: This will include the overall synopsis and project details at a glance, like the services and facilities to be provided, justification of the charges levied, etc. 7. Industry analysis: The DPR should consist of the performance of the hospital industry compared with other hospitals in and outside the area. 8. Hospital management issues: The DPR should state the details of any issues faced by the management like funding problems, decentralisation of powers, decision-making powers, governance by the high-power committee, etc. 9. The key flow chart: The key flow chart for the hospital should be prepared for the entire organisation, which depicts the flow of men and material. 10. The flow charts of various departments: The working flow charts of all the important departments should be prepared and attached to the DPR. 11. Finalisation of vendors and suppliers: The list of item-wise vendors and suppliers of building materials should be prepared and attached to the DPR. If quotations or proforma invoices of these vendors are available, then they should also be attached to the DPR. 12. Contractors for construction: The list of contractors for building construction and finishing should be identified and attached to the DPR.  If quotations or proforma invoices of these contractors are available, then they should also be attached to the DPR. 13. Statement of challenges: Imagine or work out the statement of challenges that can be faced by the hospital, and attach it to the DPR. Challenges can include non-availability of physicians, nursing staff, technicians, etc.; shortage of funds; less footfall of patients; higher mortality rate; increased nosocomial infection and low patient satisfaction level due to fall in service quality etc. 14. Photographs of hospital equipment and facilities: Photographs of various locations of the hospital like wards, OTs, emergency department, intensive care units, etc. should be added. A few photographs of the main medical equipment

2.4  Evaluation and Approval of the DPR

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like MRI scanners, CT scanners, etc. should also be attached. There are all chances that at the time of preparing this DPR, the photographs are not available; in that case, the photographs can be ignored. 15. A PERT chart: A PERT chart should be prepared and attached to the DPR. 1 6. Conclusion: The final decision on the outcomes should be mentioned in the DPR.

2.4 Evaluation and Approval of the DPR See Table 2.4 Once the DPR is finally prepared, it should be submitted to the management for evaluation by the promotors and other experts. It is advised that for the evaluation of the DPR, the promotor form a committee consisting of experts from the medical field like hospital consultants, designers, architects, biomedical experts, physicians,

Table 2.4  Evaluation and approval of the DPR Status of works Start End Not Activity date date Complete In-progress started Has the DPR been :- Yes No If no, evaluated by the why promoter or other (please experts? give reasons) Have the :- Yes No If no, clarifications and why doubts been (please cleared by the give agency that has reasons) prepared the DPR? Is the promoter :- Yes No If no, satisfied with the why DPR? (please give reasons) Does it seem :- Yes No If no, feasible to go why ahead with the (please project? give reasons) Has the final :- Yes No If no, approval been why given to the DPR (please and project? give reasons)

Responsible person Remarks

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hospital management professionals, financial experts and the agency that prepared the DPR. This committee is called the DPR Evaluation Committee. Copies of the DPR will be given to all the members of the Evaluation Committee for analysing the DPR and for giving their expert opinion. The members shall deeply analyse the contents of the DPR and seek clarifications, details and justifications on the same. After clearing all DPR-related doubts, the promotor should be prepared for a joint discussion on the DPR. Once all the members have gone through the DPR, a joint meeting will be held with all the members of the Evaluation Committee and further discussion will be carried out in the presence of all the members. If all the members are satisfied with the DPR and everyone feels that the project is feasible to proceed further, then the promotor will grant his/her approval to the DPR and give a green signal to go ahead with the project. This DPR will become the guidelines for setting up the project. A copy of this DPR will also be submitted to the bank and financial institutions for funding and sanction of loans. To summarise, a hospital DPR will generally contain the following documents: 1. General information about the proposed hospital project 2. Experience and background of the promoters in the hospital industry 3. Details of the departments and the services to be provided 4. Details of the ward-wise beds planned in the hospital 5. Details of the proposed project:

(a) The number of OPDs (b) The number of intensive care units (ICU) and the number of beds in each ICU (c) The number of private rooms, semi-private rooms, general wards, etc. (d) The number of operating rooms (e) Equipment to be installed (f) Support services to be provided (g) Management teams for the project (h) Details of the land, buildings and equipment (i) Manpower requirement and availability (j) Details of infrastructural facilities (power, water supply, transport facilities, etc.) (k) Effluents produced by the project and treatment procedures adopted

6. Detailed project cost 7. Schedule the implementation period of the project 8. Resources and means of finances for the project 9. Working capital requirements and arrangements thereof 10. Assumed operational expenses 11. The assumed rate of hospital services 12. The assumed number of patients expected to avail the services of the hospital

Further Reading

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1 3. The assumed type and number of procedures likely to be performed 14. Revenue-earning projections 15. Revenue expense projections 16. Profit and loss statements for the next 8–10 years 17. Cash flow statements for the next 8–10 years 18. The financial ratio for bank loans 19. Staff planning 20. Depreciation statements 21. Interest calculation on loans 22. Projected balance sheets for the next 8–10 years 23. Mode and means of repayment of term loans and cash credit loans 24. Marketing and selling arrangements made 25. Details of collateral security that can be offered to financial institutions 26. Government approvals are required for the project. The consent and statutory permissions of the local authorities are required for the project.

Further Reading Chopra H. Project Report on Health care Hospital Service Industry. [cited 2021 Jun 8]; https:// www.academia.edu/19162092/Project_Report_on_Health_care_Hospital_Service_Industry Detailed Project Report (DPR) | Project Management [Internet]. Your Article Library. 2016 [cited 2021 Jun 8]. https://www.yourarticlelibrary.com/project-­reports/ detailed-­project-­report-­dpr-­project-­management/94668 Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. India: Springer Singapore; Chapter 4, Preparation of DPR (Detailed Project Report) cum Techno-Commercial Feasibility Report (TCFR); 2022. p. 13–28. Project Report on Hospital (100 Beds), Feasibility Report, How Much Investment, Know How, Formulations, Profitable Business, How to Start, small scale industry [Internet]. [cited 2021 Jun 8]. https://www.eiriindia.org/ project-­report-­handbook-­hospital-­beds-­with-­formulation-­technology-­1335 Services NPC. Project Reports and Profiles. Hospital, Specialized (Super Speciality) Hospitals, Healthcare, Nursing Home, Diagnostic Center, Trauma Center, Children [Internet]. NIIR Project Consultancy Services. [cited 2021 Jun 8]. https://www.niir.org/profile-­project-­reports/ profiles/hospital-­specialized-­super-­speciality-­hospitals-­healthcare-­nursing-­home-­diagnostic-­ center-­trauma-­center-­children-­s-­hospital-­mental-­hospital-­sanatorium-­medicare-­healthcare-­bus iness-­ideas-­in-­medical-­sector/z,74,0,a/index.html

Chapter 3

Room Requirement and Building Area Calculation

After preparation of a DPR, acceptance of the feasibility studies and final approval of the promoter, the designers and planners will proceed further with the planning of building spaces. To plan the building spaces, the initial step is to calculate the space/room requirement. Calculation of the spaces and areas as per requirement is the foremost task that the designer should undertake. These requirements will be the basis on which the designer will begin the work of preparing architectural drawings. Hospitals are one of the most complex building types and offer a wide range of services through their various departments and support services. These services include, but are not limited to, diagnostic and therapeutic functions performed in operating rooms, emergency, imaging, clinical laboratories, etc. There is also an indoor patient area where patients are admitted for treatment, which can be of different types like intensive care units (ICUs), multi-bed wards, single occupancy rooms, family suites, etc. This is followed by support services, such as food service, housekeeping, laundry, etc. Each of these functionalities of a hospital, including complicated electrical, information technology, mechanical and telecommunications systems, requires specialised expertise in and knowledge of designing. Furthermore, given the various rules, regulations, norms, guidelines and codes of various regulatory bodies or accreditation agencies, which govern hospital design, the designing of hospitals is much more complex. While designing a hospital building, the design process must incorporate the suggestions and inputs from other medical professionals of the hospital, promotors and other key persons of the hospital, who have to perform, work and deliver results. The designer should also understand the requirements of the patients, physicians, visitors, support staff, equipment vendors and other suppliers who may or may not have a direct involvement in the design of the hospital building. What does area requirement mean? The area denotes the space required for a particular department, service or functionality. This space is termed ‘carpet area’. The carpet area is the actual functional area inside the four walls. Another term used

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_3

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is ‘total area’. If wall spaces and movement spaces like ramps, corridors, lifts, staircases, etc. are added to the carpet area, then the resultant area is called ‘total area’. This chapter will help designers to work out the room requirement and the area required for each room and will also help in knowing the ancillary rooms required for each functionality. If this checklist is exported to Excel, then auto calculation of the required area can be worked out.

3.1 Factors for Space Planning See Table 3.1.

3.1.1 Functional Areas Considering the functionality of a hospital, there are different functional areas such as

Table 3.1  Factors for space planning

Activity Have the functional areas been identified? Has the room requirement been worked out? Have the sizes of the rooms been decided? Has the zoning pattern of the hospital been finalised? Has a list of all the rooms with numbers and dimensions been prepared? Has the total room area been calculated? Has the percentage of movement spaces been added to the calculated room area? Has a summary of the total area been prepared?

Status of works Start End In Not Responsible date date Complete progress started person :- Yes No :- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

Remarks

3.1 Factors for Space Planning

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1. Emergency services: An emergency department provides services to patients once the OPD timing is over and to those who are critically sick or injured and also to trauma cases. 2. Entrance area: This is the area where patients or visitors initially land before moving on to any other department or availing any other service of the hospital. 3. OPD services: OPD constitutes outdoor consultation provided to patients who may not be critically sick or to follow-up patients. 4. Diagnostic services: This involves different types of diagnostic investigations that are performed to support the physicians in the actual diagnosis of the disease and to further manage and treat the patient. Diagnostic departments include imaging and clinical laboratories, and a diagnosis can be established with investigations like Cath Lab, electrocardiogram (ECG), electromyogram (EMG), electroencephalogram (EEG), endoscopy, etc. 5. Other treatments: These include support or paramedical treatment departments like physiotherapy or dialysis. 6. Intensive care services: These are the areas where critical patients are admitted for strict monitoring and supervision and suitable treatments are provided. 7. Therapeutic services: These are the areas where surgeries and interventions are performed. These include operating rooms, delivery suites, etc. These areas also include the pre-operative and post-operative areas. 8. Intermediate care areas: Here, patients are admitted as indoor patients for further management and treatment. These can include multi-bed wards, two or three beds in each room on a sharing basis, single occupancy private rooms, deluxe rooms, suites with family rooms, isolation rooms, etc. 9. Administrative/ancillary services: These are areas where the administration staff are accommodated to carry out the administrative functions of the hospital. These areas include the directors’ office, the medical superintendent’s office, the nursing superintendent’s office, information technology department, personnel/purchase/ accounts/marketing/transport offices, etc. 10. Hospital services: These include services such as the kitchen, Central Sterilization Supply Department (CSSD), stores, laundry, mortuary, etc., which provide indirect help in the management and treatment of patients 11. Engineering services: Engineering services come under the support department, which keeps the systems of the hospital alive so that all other services and departments work smoothly. These services include biomedical engineering, mechanical, electrical, heating, ventilation, air conditioning (HVAC), fire protection, medical gases, public health, communication and various other workshops, etc. 12. Other services: These include all other services like transport, security, medical records, housekeeping, conference rooms, library, etc.

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3.2 Room/Space Requirement Once the functional areas are identified, the next step is to prepare a list of rooms that will be required for each function along with the number of rooms and their dimensions in length and breadth. There are several factors and issues based on which the number of rooms required shall be worked out. Some standard questions to be asked are as follows: 1. Have the norms and standards of accreditation agencies like National Accreditation Board for Hospitals and Healthcare Providers (NABH) or Joint Commission International (JCI) been followed? 2. What are the estimates and projections regarding the number of patients expected to utilise the services of the hospital? 3. What is the estimated number of persons expected to arrive at the entrance lobby? 4. How many service counters like registration, cash, admission and discharge and shops are to be provided in the entrance hall? 5. How many and which specialities and super-speciality departments are to be made operational initially and in future? 6. What will be the system for conducting an OPD? Will a single OPD chamber be allotted to each one of the specialities or will there be a sharing system for the OPD chamber based on the available time slot? 7. Are there any departments for which OPDs have to be specifically designed? 8. What are the diagnostic services and procedures that will be provided in the OPD? For example, in ophthalmology, will services like A-scan, B-scan, optical coherence tomography (OCT), etc. be provided? Similarly, in cardiology, will ECG and echocardiography devices, Holter monitoring, tilt testing, treadmill testing (TMT), ambulatory blood pressure (ABP) testing, thallium test, nuclear heart scanning, electrophysiology studies, dobutamine stress echocardiography, etc. be provided? Such services and procedures have to be listed for all the specialities and super-­specialities, to work out the area and room requirements. 9. Will investigations such as X-rays, computed tomography (CT) scanning, magnetic resonance imaging (MRI), ultrasound, mammography, positron emission tomography–CT (PET–CT), PET–MRI, gamma scan, etc. be provided in radiology? 10. Which investigations will be carried out in clinical laboratories in-house and which will be sent to outside labs? Detailed work has to be carried out for all the divisions of the clinical laboratories like pathology (including subdivisions like histopathology, cytology, histology, etc.); microbiology (including subdivisions like parasitology, immunology, virology, etc.) and biochemistry. 11. What are the plans for the induction of new investigations in the future and when? 12. Will the blood bank be dealing with only whole blood or its components as well? What are the plans to provide services for apheresis? 13. Will high-end procedures like angioplasty, transplants, etc. be conducted at the hospital?

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14. Will oncological services be provided? If yes, will radiation therapy be provided? 15. How many and what types of patients are expected to arrive at the emergency department? 16. For surgeries in the emergency department, will the major operating room be provided or will a minor OT suffice? 17. Will paramedical treatment facilities like physiotherapy, occupational therapy, speech therapy, orthotics, etc. be provided at the hospital? 18. Will the dialysis facility be provided? If yes, how many dialysis machines are to be provided? 19. What types of intensive care units have to be provided? These can include the medical intensive care unit (MICU), surgical intensive care unit (SICU), respiratory intensive care unit (RICU), neonatal intensive care unit (NICU), neuro-­ ICU, intensive cardiac care unit (ICCU), gynaecological ICU, paediatric ICU, orthopaedic ICU, pulmonary ICU, etc. 20. How many beds are to be provided in each ICU? Apart from this, future expansion plans should be considered for design. 21. Will units like high-dependency units (HDUs) or step-down ICUs be required? 22. How many operating rooms are to be provided? Will there be any dedicated operating rooms for specialised surgeries like organ transplants etc.? 23. How many delivery rooms are to be provided? Out of these, how many are to be reserved for infectious patients? 24. How many beds are to be provided in each ward and department—e.g. the number of beds planned for the indoor wards, emergency department, triage, pre-­ operative and post-operative rooms, etc. 25. How many single occupancy private rooms, twin- or three-bed rooms on a sharing basis, deluxe rooms and VIP (very important person) suites with family rooms are to be provided? 26. What will be the size of the OPD and inpatient department (IPD) pharmacy? How many patients are expected to purchase drugs/medicines/consumables/ disposables from the pharmacy? What will be the approximate quantum of stock in the pharmacy, and how much area will be required for storage of drugs/ medicines/consumables/disposables? 27. How many administrative staff members are expected to be seated at any moment? 28. Will services like kitchen and laundry be outsourced or operative in-house? 29. Will medical gases be supplied centrally or through stand-alone cylinders? Similarly, will they be supplied through multiple cylinders or should a liquid oxygen plant be installed? The answers to these types of questions will be obtained while initially working out the actual room requirement. However, it is also equally important to keep in mind the future expansion plans and provision for the same while calculating the areas.

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To answer such questions, it is advised that a team of experts be formed, including physicians and statisticians, who can share their personal experiences. Details of these parameters can also be collected from other such hospitals. The feasibility studies conducted earlier can be of great help in answering most of these questions. Once the answers to such questions are obtained, the actual exercise for working out the room requirement can be started. For preparing the list of rooms, the number of rooms required for each service or functionality should be worked out. Another important issue to concentrate on is the requirement of ancillary rooms along with the main service room—e.g. the eye OPD may require a refraction room, a dark room, a laser room and a procedure room, a surgery OPD may require a dressing room, an orthopaedic OPD may require a plaster room, etc. Hence, a detailed working of the ancillary rooms has to be done for each service room.

3.3 Room Sizes Once the list of the required rooms is finalised, then comes the question: what will be the sizes of these rooms? Room sizes first depend on the practical experience of the physicians, second the rules, regulations, norms and codes of the regulating authorities/agencies, third the number of patients expected to avail such services and, lastly, the actual space available for accommodating such rooms out of the total area available. It is recommended that the rooms be of reasonable size and not too big, resulting in the wastage of space, or not too small, which may hamper working in that room. While deciding on the final room sizes, the internal layout plan of the rooms should be considered—i.e. how will the bed/couch be placed, how will the equipment/machinery be placed in the room, which furniture will be required in the room, the number of persons who will be present at a particular point in time and how much working and movement space is required in the room. Based on the above working and layout, the dimensions (length and breadth) of the room can be decided. According to these dimensions, the area of the room can be worked out. It is recommended that such a list be prepared using a spreadsheet. The first column will be the room’s name, the second column the number of rooms, the third the length, the fourth the breadth, the fifth the area per room and the sixth the total area of all such rooms. The block-wise total of this sheet will give the area required for each service and functionality. Once the area of the rooms has been worked out, the area required for movement spaces like corridors, lift wells, lift lobbies, staircases, staircase lobbies, ramps, etc. should be added. These movement spaces cannot be allocated to any particular service or functionality directly but are common to all. The best way to is to add a percentage area, towards these movement spaces, to the room area actually worked out for each service and functionality. Again, the question that arises is: what percentage should be added for the movement areas? The percentage again depends on the rules, regulations, norms, guidelines and codes

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of regulating agencies or is otherwise based on the practical experiences of users. Normally, it is believed that somewhere between 35% and 40% of the total functional area should be added for the movement areas. Once the movement areas is added to the room areas, the total area required for the building can be obtained and finalised. It is this sheet on which the designer will start the work of placing departments, functionalities and services in the architectural drawings.

3.4 Zoning Another important factor while designing a hospital building is the zoning of the hospital. What is zoning? It is grouping different areas, services or departments of a hospital according to functionality and accessibility to patients. The entire building of the hospital is divided into different zones. Normally, hospitals have the following zones: 1. The outer zone—a fast movement zone: The outer zone will accommodate those services and departments that most patients/attendants visit. This zone is usually open to all and should be immediately and easily accessible to the public. Services and departments like the entrance hall, reception, registration, admission and discharge counters, emergency services, outpatient departments, cafeteria, etc. should be placed in this zone. 2. The second zone—a semi-movement zone: Those services and departments that require the physical attendance of areas like radiology, laboratory and pharmacy should be placed in this zone. Here, the patients are generally not in direct contact with the physicians or workers and neither the patients/attendants are frequently required to visit this zone. 3. The inner zone—a limited movement zone: This zone mainly accommodates the indoor wards. Services such as indoor admission, nursing care and management of patients are provided in this zone. This zone should include all the intermediate care areas like multi-bed wards, twin- or three-bed occupancy rooms on a sharing basis, single occupancy private rooms, deluxe rooms and VIP suites with family rooms, etc. Generally, the patients/attendants and guests of the patients are allowed in this zone. 4. The deep zone—a banned zone: This zone accommodates the critical units and the operation theatre complex. As these areas have to be highly sterilised and free from all types of microorganisms and infections, movement in this zone should be strictly banned. This zone should be totally segregated from the other public zones like the outer, second and inner zones. This zone includes functionalities like all operation theatres, ICUs, delivery suites, neonatal ICUs, etc. 5. The isolation zone—a restricted zone: This zone is basically reserved for infected patients, who can easily transmit their disease to other patients or healthy people. Patients suffering from any infectious diseases like tuberculosis,

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coronavirus disease 2019 (COVID-19), etc. are admitted to this zone. Movements in this zone should be restricted and be allowed only after following all the necessary precautions and protocols. 6. The service zone: This zone accommodates other service departments like housekeeping, MGPS, dietary, medical records, laundry, workshops, etc., which provide support services to the functionality of the hospital.

3.5 Room Requirement and Area Calculation of a Hospital Building In each department, various types of rooms/spaces are required for the efficient functioning of the hospital. We have tried to mention all such areas in the table provided below. Please note that these rooms are generally required but are not limited to only these rooms. There can be more rooms other than these. The actual list of such rooms/spaces will depend on the requirement of the individual hospital.

3.5.1 Entrance Lobby Area See Table 3.2.

3.5.2 OPD, Emergency and Diagnostic Activities See Table 3.3.

3.5.3 Diagnostic Services See Table 3.4.

3.5.4 The Department of Radiotherapy See Table 3.5.

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75

Table 3.2  Area for the entrance lobby

Zone/particulars (A)

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

Main entrance Entrance lobby Outside trolley park General waiting spaces Public utility for patients and attendants Reception Registration counter Enquiry counter Queuing tracks Admission counter Discharge counter Cash counter Counter for empanelled patients Health insurance counter Records Pharmacy Room with racks and cupboards for storage of medicines, drugs, consumables, etc. Issue counter with windows Queuing track Refrigerated room Expiry medicine storage Cut strip sorting room Bulk storage Costly medicine storage room Storage room for narcotic drugs (continued)

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Table 3.2 (continued)

Zone/particulars (A) Arcade Snack counter Gift shop ATM (automated teller machine) Book shop Prayer room Other shops—1 Other shops—2 Control rooms for Housekeeping Fire safety Security Electrical safety Transport Water supply Total of sub-zones Service/staff entrance Staff utilities Time keeping office Changing rooms Lockers Total of sub-zones Total of zones

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

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Table 3.3  Area for OPD, emergency and diagnostic activities

Zone/particulars (A)

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total Total covered covered area in square area in square feet metres (G) G = C × F

(H) H = G/10.76

Specialities Medicine block Examination room with exam cubicles Rooms for special clinics, if any Clinical demonstration room for teaching Extra rooms for future expansion Reception and enquiry counter Departmental registration counter Storeroom Record room Public utility for patients and attendants Public utility for staff Sub-waiting area Surgery block Examination room with exam cubicles Rooms for special clinics, if any Clinical demonstration room for teaching Extra rooms for future expansion Reception and enquiry counter Departmental registration counter Storeroom Dressing room—male (continued)

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Table 3.3 (continued)

Zone/particulars (A) Dressing room—female Endoscopy room Changing room Record room Reporting room Minor operation theatre Changing room for OT Sluice room Public utility for patients and attendants Public utility for staff Sub-waiting area Ophthalmology block Examination room with exam cubicles Rooms for special clinics, if any Clinical demonstration room for teaching Extra rooms for future expansion Reception and enquiry counter Departmental registration counter Storeroom Record room Orthoptic Refraction Dark room Dressing room Treatment room

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total Total covered covered area in square area in square feet metres (G) G = C × F

(H) H = G/10.76

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Table 3.3 (continued)

Zone/particulars (A)

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total Total covered covered area in square area in square feet metres (G) G = C × F

(H) H = G/10.76

Public utility for patients and attendants Public utility for staff Sub-waiting area ENT (ear–nose– throat) block Examination room with exam cubicles Rooms for special clinics, if any Clinical demonstration room for teaching Extra rooms for future expansion Reception and enquiry counter Departmental registration counter Storeroom Audiometry Speech therapy room Electronystagmography (ENG) lab Record room Public utility for patients and attendants Public utility for staff Sub-waiting area Dental block Examination room with dental chairs Rooms for special clinics, if any Clinical demonstration room for teaching (continued)

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Table 3.3 (continued)

Zone/particulars (A) Extra rooms for future expansion Reception and enquiry counter Departmental registration counter Storeroom Dental X-rays Dental laboratory Dental surgery Prosthetic dentistry Record room Public utility for patients and attendants Public utility for staff Sub-waiting area Obstetrics and gynaecology block Examination room with exam cubicles Rooms for special clinics, if any Clinical demonstration room for teaching Extra rooms for future expansion Reception and enquiry counter Departmental registration counter D and C rooms Antenatal clinic Family welfare clinic Cancer detection clinic Colposcopy room Ultrasound room

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total Total covered covered area in square area in square feet metres (G) G = C × F

(H) H = G/10.76

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Table 3.3 (continued)

Zone/particulars (A)

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total Total covered covered area in square area in square feet metres (G) G = C × F

(H) H = G/10.76

Sterility clinic In vitro fertilisation (IVF) centre Record room Storeroom Public utility for patients and attendants Public utility for staff Sub-waiting area Paediatric block Examination room with exam cubicles Rooms for special clinics, if any Clinical demonstration room for teaching Extra rooms for future expansion Reception and enquiry counter Departmental registration counter Storeroom Child guidance clinic Child welfare, including immunisation clinic Play area Child rehabilitation clinic, including facilities for speech therapy and occupational therapy Counselling Record room (continued)

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3  Room Requirement and Building Area Calculation

Table 3.3 (continued)

Zone/particulars (A) Public utility for patients and attendants Public utility for staff Sub-waiting area Orthopaedics block Examination room with exam cubicles Rooms for special clinics, if any Clinical demonstration room for teaching Extra rooms for future expansion Reception and enquiry counter Departmental registration counter Plaster room Plaster-cutting room Splint storeroom Storeroom Record room Public utility for patients and attendants Public utility for staff Sub-waiting area Dermatology/VD block Examination room with exam cubicles Rooms for special clinics, if any Clinical demonstration room for teaching

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total Total covered covered area in square area in square feet metres (G) G = C × F

(H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

83

Table 3.3 (continued)

Zone/particulars (A)

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total Total covered covered area in square area in square feet metres (G) G = C × F

(H) H = G/10.76

Extra rooms for future expansion Reception and enquiry counter Departmental registration counter Skin laboratory Treatment room Storeroom Record room Public utility for patients and attendants Public utility for staff Sub-waiting area Psychiatry block Examination room with exam cubicles Rooms for special clinics, if any Clinical demonstration room for teaching Extra rooms for future expansion Reception and enquiry counter Departmental registration counter Counselling EEG room Electroconvulsive (ECT)/recovery Nerve Conduction Velocity (NCV) / Electro Mayo Graph (EMG) room Storeroom Record room (continued)

84

3  Room Requirement and Building Area Calculation

Table 3.3 (continued)

Zone/particulars (A) Public utility for patients and attendants Public utility for staff Sub-waiting area Tuberculosis (TB) and chest block Examination room with exam cubicles Rooms for special clinics, if any Clinical demonstration room for teaching Extra rooms for future expansion Reception and enquiry counter Departmental registration counter Pulmonary Function Test (PFT) room ICTC centre DOT centre Storeroom Record room Public utility for patients and attendants Public utility for staff Sub-waiting area Dietary Examination room with exam cubicles Extra rooms for future expansion Reception and enquiry counter Departmental registration counter Storeroom

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total Total covered covered area in square area in square feet metres (G) G = C × F

(H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

85

Table 3.3 (continued)

Zone/particulars (A)

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total Total covered covered area in square area in square feet metres (G) G = C × F

(H) H = G/10.76

Record room Public utility for patients and attendants Public utility for staff Sub-waiting area Total of sub-zones Super-specialities Cardiology Examination/ consultation room Sub-waiting area Cardiac surgery Examination/ consultation room Sub-waiting area Burns and plastic surgery Examination/ consultation room Sub-waiting area Diabetes and endocrinology Examination/ consultation room Sub-waiting area Geriatric medicine Examination/ consultation room Sub-waiting area Gastroenterology medicine Examination/ consultation room Sub-waiting area Gastroenterology surgery Examination/ consultation room (continued)

86

3  Room Requirement and Building Area Calculation

Table 3.3 (continued)

Zone/particulars (A) Sub-waiting area Pulmonology Examination/ consultation room Procedure room Sub-waiting area Nephrology Examination/ consultation room Sub-waiting area Neurology Examination/ consultation room Sub-waiting area Neurosurgery Examination/ consultation room Sub-waiting area Oncology medicine Examination/ consultation room Sub-waiting area Oncology surgery Examination/ consultation room Sub-waiting area Oncology radiation therapy Examination/ consultation room Sub-waiting area Paediatric surgery Examination/ consultation room Sub-waiting area Urology Examination/ consultation room Sub-waiting area Total of sub-zones Total of zones

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total Total covered covered area in square area in square feet metres (G) G = C × F

(H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

87

Table 3.4  Area for diagnostic services

Zone/particulars (A)

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

Imaging Reception and enquiry counter Departmental registration counter Store for used films Store for unused films and related materials Report delivery room Extra rooms for future expansion Record room Public utility for patients and attendants Public utility for staff Sub-waiting area X-rays Radiography rooms for X-rays Room for portable X-ray machines Changing rooms Barium preparation if required Computerized Radiography (CR) room Dark room if required Sub-waiting area Ultrasound Ultrasound room Changing rooms Sub-waiting area CT scan (continued)

88

3  Room Requirement and Building Area Calculation

Table 3.4 (continued)

Zone/particulars (A) CT scan machine room CT control room for technicians Un-interrupted Power Supply (UPS) room Storeroom Changing rooms Sub-waiting area MRI MRI machine room Control room for technicians UPS room MRI panel room Storeroom Changing rooms Sub-waiting area Mammography Mammography examination room Storeroom Changing rooms Sub-waiting area PET scan PET scan machine room Control room for technicians UPS room Machine panel room Storeroom Changing rooms Sub-waiting area Other new investigations - 1 Machine room Control room for technicians

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

89

Table 3.4 (continued)

Zone/particulars (A)

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

UPS room Machine panel room Storeroom Changing rooms Sub-waiting area Other new investigations - 2 Machine room Control room for technicians UPS room Machine panel room Storeroom Changing rooms Sub-waiting area Support Electrical panel room Central reporting room Museum for teaching Research laboratory Clinical demonstration room for teaching Departmental seminar cum library Staff accommodation Head of department (HOD) room with attached toilet Personal assistant (PA) to HOD Associate professor’s room with attached toilet Assistant professor Senior resident (continued)

90

3  Room Requirement and Building Area Calculation

Table 3.4 (continued)

Zone/particulars (A) Total of sub-zones Clinical laboratories Sample receipt/preparation Reception and enquiry counter Departmental registration counter Store for used materials Store for unused reagents, kits and related materials Cold store for unused reagents, kits Record room Report delivery room Extra rooms for future expansion Public utility for staff Public utility for patients and attendants Sub-waiting area Laboratories Biochemistry Microbiology with separate rooms for all subdivisions Pathology with separate rooms for all subdivisions Histopathology Cytology Histology Support Media preparation Washing and disinfection

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

91

Table 3.4 (continued)

Zone/particulars (A)

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

Clinical demonstration room for teaching Departmental seminar cum library Total of sub-zones Blood Bank Reception and enquiry counter Bleeding room Refreshment/rest room Serology lab Transmissible Tests (TT) lab Component room Apheresis room Blood storage Issue window Blood Bank officer room Record room Doctors’ rest room Sub-waiting area Public utility for patients and attendants Public utility for staff Total of sub-zones Other investigations Cardiac investigations Reception and enquiry counter Registration Echocardiography room TMT room ECG/Holter room (continued)

92

3  Room Requirement and Building Area Calculation

Table 3.4 (continued)

Zone/particulars (A) Store Extra rooms for future expansion Report delivery room Record room Public utility for patients and attendants Public utility for staff Sub-waiting area Cath lab Reception and enquiry counter Registration Cath lab machine room Control room for technicians Machine panel room UPS room Report delivery room Record room Doctors’ changing rooms Staff’s changing rooms Extra rooms for future expansion Scrub station Cath wash Compact Disk (CD) storeroom Storeroom Public utility for patients and attendants Public utility for staff Total of sub-zones Total of zones

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

93

Table 3.5  Area for the department of radiotherapy

Zone/particulars (A)

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) (H) G = C × F H = G/10.76

Reception and enquiry counter Departmental registration counter Record room Store Extra rooms for future expansion Report delivery room Public utility for patients and attendants Public utility for staff Sub-waiting area Treatment area Teletherapy unit Interstitial, endocavitary, surface mould therapy room Intracavitary treatment room Metalling treatment planning equipment, mould room Planning room Medical physics laboratory Chemotherapy/radiotherapy procedures, etc. Control room for technicians Changing rooms for doctors Changing rooms for staff Scrub station Storeroom Public utility for patients and attendants Public utility for staff Radiotherapy Patient beds (continued)

94

3  Room Requirement and Building Area Calculation

Table 3.5 (continued)

Zone/particulars (A) Multi-bed wards with interbed spacing of at least 1500 mm Procedure/examination and treatment room Nurses’ duty room Clean supply room Storeroom Dirty utility/sluice room Ward pantry Ward-side laboratory Clinical demonstration room for teaching Resident doctor and student duty room Extra rooms for future expansion Public utility for patients and attendants Public utility for staff Departmental accommodation HOD’s room with attached toilet PA’s office Associate professor’s room with attached toilet Assistant professor Senior resident Physicist Extra rooms for future expansion Night duty rooms for junior residents Medical consultant room for the night Departmental seminar room cum library

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) (H) G = C × F H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

95

Table 3.5 (continued)

Zone/particulars (A) Post-graduate student rooms Museum for teaching Departmental research laboratory Total of sub-zones Total of zones

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) (H) G = C × F H = G/10.76

96

3  Room Requirement and Building Area Calculation

3.5.5 Emergency Services See Table 3.6.

3.5.6 Other Treatments See Table 3.7.

3.5.7 Intensive Care Units See Table 3.8.

3.5.8 Therapeutic Services See Table 3.9.

3.5.9 Intermediate Care Area See Table 3.10.

3.5.10 Administrative/Ancillary Services See Table 3.11.

3.5.11 Hospital Services See Table 3.12.

3.5 Room Requirement and Area Calculation of a Hospital Building

97

Table 3.6  Area for emergency services

Zone/particulars (A)

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) (H) G = C × F H = G/10.76

Entrance lobby Trolley park General waiting area Public utility for patients and attendants Reception Reception cum enquiry counter Registration counter Queuing tracks Cash counter Admission and discharge counter Record room Attached rooms Examination/procedure/ treatment rooms ECG room Plaster room Medico-legal specimens and records Decontamination room with toilet Portable X-ray room Clean utility Disaster storage room Storeroom Dirty linens Exam resuscitation (triage beds) Triage beds with interbed spacing of at least 1858 mm Waiting area Examination cubicles Emergency medical officer (EMO)’s duty room (continued)

98

3  Room Requirement and Building Area Calculation

Table 3.6 (continued)

Zone/particulars (A) Public utility for patients and attendants Public utility for staff Minor operating suite Minor operating room Scrub/gowning area Dirty utility Staff accommodation Nurses’ duty room Doctors’ duty room Ambulance driver/nursing assistant Emergency operation theatre complex Operation theatre Pre-operative room (______beds) Post-operative recovery room (_____beds) Quick sterilisation room Clean storage room Public utility for staff Dirty utility Instrument/linen wash Storeroom Doctors’ changing room—male Doctors’ changing room—female Staff’s changing room—male Staff’s changing room—female Emergency ward Multi-bed wards with interbed spacing of at least 1500 mm

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) (H) G = C × F H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

99

Table 3.6 (continued) Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Zone/particulars (A)

Total covered area in square feet

Total covered area in square metres

(G) (H) G = C × F H = G/10.76

Storeroom Procedure/examination and treatment room Nurses’ duty room Ward-side laboratory Ward pantry Resident doctor and student duty room Clinical demonstration room for teaching Departmental research laboratory Night duty room for junior residents Public utility for patients and attendants Public utility for faculty Total of zones Table 3.7  Area for other treatments

Zone/particulars (A)

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

Physiotherapy Reception and enquiry Registration Examination room with exam cubicles Thermotherapy Electrotherapy Traction Gymnasium Massage therapy (continued)

100

3  Room Requirement and Building Area Calculation

Table 3.7 (continued)

Zone/particulars (A) Extra rooms for future expansion Clinical demonstration room for teaching Record room Storeroom Public utility for patients and attendants Public utility for staff Sub-waiting area Total of sub-zones Dialysis Dialysis procedure room Dialysis procedure room for positive patients Dialyser wash area Dialyser storage area Changing rooms with attached toilet Dialysis media preparation room Storeroom Reverse Osmosis (RO) plant room Sub-waiting area Total of sub-zones Total of zones

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

101

Table 3.8  Area for intensive care units

Zone/particulars (A)

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

Medical intensive care unit (MICU) Patient beds Intensive care beds with interbed spacing of at least 1828 mm Procedure/examination and treatment room Equipment park/store clean utility Dirty utility/sluice room Ward pantry Ward-side laboratory Public utility for patients and attendants Public utility for staff Waiting area for attendants Staff accommodation Staff’s changing room—male Staff’s changing room—female Resident doctor and student duty room Night duty room for junior residents Nurse’s night duty room Shoe-changing area Total of sub-zones Intensive coronary care unit (ICCU) Patient beds Intensive care beds with interbed spacing of at least 1828 mm Procedure/examination and treatment room (continued)

102

3  Room Requirement and Building Area Calculation

Table 3.8 (continued)

Zone/particulars (A) Equipment park/store Clean utility Dirty utility/sluice room Ward pantry Ward-side laboratory Public utility for patients and attendants Public utility for staff Waiting area for attendants Staff accommodation Staff’s changing room—male Staff’s changing room—female Resident doctor and student duty room Night duty room for junior residents Nurse’s night duty room Shoe-changing area Total of sub-zones Respiratory intensive care unit (RICU) Patient beds Intensive care beds with interbed spacing of at least 1828 mm Procedure/examination and treatment room Equipment park/store Clean utility Dirty utility/sluice room Ward pantry Ward-side laboratory Public utility for patients and attendants

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

103

Table 3.8 (continued)

Zone/particulars (A)

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

Public utility for staff Waiting area for attendants Staff accommodation Staff’s changing room—male Staff’s changing room—female Resident doctor and student duty room Night duty room for junior residents Nurse’s night duty room Shoe-changing area Total of sub-zones Surgical intensive care unit (SICU) Patient beds Intensive care beds with interbed spacing of at least 1828 mm Procedure/examination and treatment room Equipment park/store Clean utility Dirty utility/sluice room Ward pantry Ward-side laboratory Public utility for patients and attendants Public utility for staff Waiting area for attendants Staff accommodation Staff’s changing room—male Staff’s changing room—female (continued)

104

3  Room Requirement and Building Area Calculation

Table 3.8 (continued)

Zone/particulars (A) Resident doctor and student duty room Night duty room for junior residents Nurse’s night duty room Shoe-changing area Total of sub-zones Neurosurgery intensive care unit (neuro-ICU) Patient beds Intensive care beds with interbed spacing of at least 1828 mm Procedure/examination and treatment room Equipment park/store Clean utility Dirty utility/sluice room Ward pantry Ward-side laboratory Public utility for patients and attendants Public utility for staff Waiting area for attendants Staff accommodation Staff’s changing room—male Staff’s changing room—female Resident doctor and student duty room Night duty room for junior residents Nurse’s night duty room Shoe-changing area Total of sub-zones

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

105

Table 3.8 (continued)

Zone/particulars (A)

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

Cardiothoracic and vascular surgery intensive care unit (CTVS ICU) Patient beds Intensive care beds with interbed spacing of at least 1828 mm Procedure/examination and treatment room Equipment park/store Clean utility Dirty utility/sluice room Ward pantry Ward-side laboratory Public utility for patients and attendants Public utility for staff Waiting area for attendants Staff accommodation Staff’s changing room—male Staff’s changing room—female Resident doctor and student duty room Night duty room for junior residents Nurse’s night duty room Shoe-changing area Total of sub-zones Gynaecological intensive care unit (GICU) Patient beds (continued)

106

3  Room Requirement and Building Area Calculation

Table 3.8 (continued)

Zone/particulars (A) Intensive care beds with interbed spacing of at least 1828 mm Procedure/examination and treatment room Equipment park/store Clean utility Dirty utility/sluice room Ward pantry Ward-side laboratory Public utility for patients and attendants Public utility for staff Waiting area for attendants Staff accommodation Staff’s changing room—male Staff’s changing room—female Resident doctor and student duty room Night duty room for junior residents Nurse’s night duty room Shoe-changing area Total of sub-zones Burn intensive care unit (BICU) Patient beds Intensive care beds with interbed spacing of at least 1828 mm Procedure/examination and treatment room Equipment park/store Clean utility Dirty utility/sluice room

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

107

Table 3.8 (continued)

Zone/particulars (A)

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

Ward pantry Ward-side laboratory Public utility for patients and attendants Public utility for staff Waiting area for attendants Staff accommodation Staff’s changing room—male Staff’s changing room—female Resident doctor and student duty room Night duty room for junior residents Nurse’s night duty room Shoe-changing area Total of sub-zones Step-down intensive care unit Patient beds Intensive care beds with interbed spacing of at least 1828 mm Procedure/examination and treatment room Equipment park/store Clean utility Dirty utility/sluice room Ward pantry Ward-side laboratory Public utility for patients and attendants Public utility for staff Waiting area for attendants (continued)

108

3  Room Requirement and Building Area Calculation

Table 3.8 (continued)

Zone/particulars (A) Staff accommodation Staff’s changing room—male Staff’s changing room—female Resident doctor and student duty room Night duty room for junior residents Nurse’s night duty room Shoe-changing area Total of sub-zones Paediatric intensive care unit (PICU) Patient beds Intensive care beds with interbed spacing of at least 1828 mm Procedure/examination and treatment room Equipment park/store Clean utility Dirty utility/sluice room Ward pantry Ward-side laboratory Public utility for patients and attendants Public utility for staff Waiting area for attendants Staff accommodation Staff’s changing room—male Staff’s changing room—female Resident doctor and student duty room

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

109

Table 3.8 (continued)

Zone/particulars (A) Night duty room for junior residents Nurse’s night duty room Shoe-changing area Total of sub-zones Neonatal intensive care unit (NICU) Patient beds Clean baby room Infected baby room Ventilator room Mothers feeding room Equipment park/store Clean utility Dirty utility/sluice room Procedure/examination and treatment room Ward-side laboratory Ward pantry Cloth wash area Public utility for patients and attendants Public utility for staff Waiting area for attendants Staff accommodation Changing room—male Changing room—female Resident doctor and student duty room Nurse’s night duty room Night duty room for junior residents Total of sub-zones Total of zones

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

110

3  Room Requirement and Building Area Calculation

Table 3.9  Area for therapeutic services

Zone/particulars (A) Operation theatre suite Unsterile zone Entrance lobby to the operating theatre complex Administrative area Operation theatre in-charge or manager Head of the anaesthesia department Surgeons’ room for office work Frozen section biopsy laboratory Entry door for changing room Trolley bay Shoe-changing area Linen pre-wash room Instrument washroom Waiting area for attendants Public utility for patients and attendants Protective zone Doctors’ changing room with toilet—male Doctors’ changing room with toilet—female Staff’s changing technicians with toilet—males Staff’s changing technicians with toilet—females Students’ changing room with toilet—males

Total covered area in square feet

No. Covered of No. of area per beds rooms Size unit Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in metres (H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

111

Table 3.9 (continued)

Zone/particulars (A)

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in metres (H) H = G/10.76

Students’ changing room with toilet—females Staff changing class IV with toilet—males Staff changing class IV with toilet–females Entry gate of the pre-operative ward Unsterile storeroom for equipment storage Storeroom for medicines, consumables and disposables Unsterile storeroom Pre-anaesthetic check-up room (PAC) Rest room for staff—males Rest room for staff—females Pantry Surgeons’ rest room Lockers Soiled instruments wash room Soiled linen pre-wash room Observation gallery for students Clean zone Pre-operative room (____beds) Post-operative recovery (___beds) Preparation room Exit gate of the pre-operative ward Dirty utility (continued)

112

3  Room Requirement and Building Area Calculation

Table 3.9 (continued)

Zone/particulars (A) Public utility for patients Sterile zone Main operating theatres Scrub/gowning Clean supply room Instrument trolley layup Septic operation theatre Endoscopy room Sterilisation room Clean storeroom Total of sub-zones Deliver suite Unsterile zone Administrative area Labour room in-charge Gynaecologists’ room for office work Entry door for changing room Trolley bay Shoe-changing area Linen pre-wash room Instrument washroom Waiting area for attendants Public utility for attendants Protective zone Nursing station Trolley park Pre-labour patient beds (___beds)

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in metres (H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

113

Table 3.9 (continued)

Zone/particulars (A)

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in metres (H) H = G/10.76

Eclampsia beds (___beds) Post-natal recovery (____beds) Examination/preparation Public utilities for patient Doctors’ changing room with toilet—male Doctors’ changing room with toilet—female Students changing class IV with toilet—males Students changing class IV with toilet—females Staff changing technicians with toilet—males Staff changing technicians with toilet—females Staff changing class IV with toilet—males Staff changing class IV with toilet—females Unsterile storeroom Duty room for students—males Duty room for students—females Lockers Surgeons’ rest room Pantry (continued)

114

3  Room Requirement and Building Area Calculation

Table 3.9 (continued)

Zone/particulars (A) Soiled linen pre-wash room Soiled instruments wash room Observation gallery for students Delivery area Clean delivery room Delivery room for infected cases Scrub/gowning Clean utility Babu resuscitation area Baby bath area Dirty utility Sterile storage Storeroom Total of sub-zones Total of zones

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in metres (H) H = G/10.76

3.5 Room Requirement and Area Calculation of a Hospital Building

115

Table 3.10  Area for intermediate care units

Zone/particulars (A)

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

General ward: male (____beds) Patient beds Multi-bed wards with interbed spacing of at least 1500 mm Procedure/examination and treatment room Nurses’ duty room Clean supply room Storeroom Dirty utility/sluice room Ward pantry Ward-side laboratory Clinical demonstration room for teaching Resident doctor and student duty room Extra rooms for future expansion Public utility for patients and attendants Public utility for staff General ward: female (___beds) Patient beds Multi-bed wards with interbed spacing of at least 1500 mm Procedure/examination and treatment room Nurses’ duty room Clean supply room Store Dirty utility/sluice room Ward pantry Ward-side laboratory (continued)

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Table 3.10 (continued)

Zone/particulars (A) Clinical demonstration room for teaching Resident doctor and student duty room Extra rooms for future expansion Public utility for patients and attendants public Public utility for staff Note: In the case of hospitals attached to a medical college, general beds or the so-called teaching beds will be separate for all the departments and the numbers of these beds will depend on the guidelines issued by the concerned agency controlling the medical education of the country. Total of sub-zones Departmental rooms HOD’s room with attached toilet PA’s office Associate professor’s room with attached toilet Assistant professor Senior resident Extra rooms for future expansion Night duty rooms for junior resident

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

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Table 3.10 (continued)

Zone/particulars (A)

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

Medical consultant room for the night Departmental seminar room cum library Post-graduate student rooms Museum for teaching Departmental research lab Note: In the case of a hospital attached to a medical college, the department has to be developed separately for all the disciplines where faculty rooms, seminar rooms, museum, etc. have to be provided. The number of rooms to be provided will depend on the guidelines issued by the concerned agency controlling the medical education of the country. Total of sub-zones Semi-private ward (____beds) Patient beds (twin/ triple sharing) with toilet Nurses’ desk Clean supply room Nurses’ duty room Extra rooms for future expansion Ward pantry (continued)

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Table 3.10 (continued)

Zone/particulars (A) Examination and treatment room Storeroom Dirty utility/sluice room Resident doctor and student duty room Public utility for staff Total of sub-zones Private ward (_____beds) Patient beds (single bed) with toilet Nurses’ desk Clean supply room Nurses’ duty room Extra rooms for future expansion Ward pantry Examination and treatment room Store Dirty utility/sluice room Resident doctor and student duty room Public utility for staff Total of sub-zones Deluxe ward (____beds) Patient beds (single bed) with toilet Nurses’ desk Clean supply room Nurses’ duty room Extra rooms for future expansion Ward pantry

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

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Table 3.10 (continued)

Zone/particulars (A) Examination and treatment room Storeroom Dirty utility/sluice room Resident doctor and student duty room Public utility for staff Visitors’ bay Total of sub-zones Family suites (___beds) Patient beds (single bed) with toilet Family room Nurses’ desk Clean supply room Nurses’ duty room Extra rooms for future expansion Ward pantry Examination and treatment room Storeroom Dirty utility/sluice room Ward-side laboratory Resident doctor and student duty room Public utility for staff Visitors’ bay Total of sub-zones Total of zones

Total covered area in square feet

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) (G) F = D × E G = C × F

Total covered area in square metres (H) H = G/10.76

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Table 3.11  Area for administrative/ancillary services

Zone/particulars (A) Hospital administration Dean’s office (in case of medical college only) Toilet Dean’s PA room Secretarial staff Waiting area for visitors Medical superintendent’s office Toilet PA room Secretarial staff Waiting area for visitors Dy. medical superintendent’s office Toilet PA room Secretarial staff Waiting area for visitors Total of sub-zones Nursing administration Nursing superintendent’s office Toilet PA room

No. Covered of No. of area per beds rooms Size unit Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

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Table 3.11 (continued)

Zone/particulars (A) Secretarial staff Waiting area for visitors Dy. nursing superintendent’s office Toilet Total of sub-zones General administration Account officer Personnel officer Purchase officer Marketing officer Secretarial staff Waiting area for visitors Total of sub-zones Hospital information IT manager Server room Computer room Total of sub-zones Total of zones

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

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Table 3.12  Area for hospital services

Zone/particulars (A) Hospital kitchen Receipt area for supplies Entry of staff Airlock entry Changing rooms cum hand wash Storage areas for dry ration/goods Fruit/vegetable storage Refrigerator/s, cool rooms and freezers Bulk storage for tableware, linen, crockery and utensils Pre-preparation Cooking/baking Reheating facilities Packing/plating areas Trolley parking area Loading/distribution Pot wash Dishwashing Waste disposal area Trolley/cart washing area Manifold room and cylinder storage Staff accommodation Kitchen manager Dietician Dietetics staff Public utility for staff Total of sub-zones Central sterile supply Staff change Dirty receipt

No. Covered of No. of area per beds rooms Size unit Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

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Table 3.12 (continued)

Zone/particulars (A) Washing/disinfection Assembly/packing Sterilisation Sterile storage Delivery room Ethyline Oxide (ETO) room Staff accommodation CSSD supervisor Staff room Public utility for staff Total of sub-zones Hospital laundry Dirty receipt Sorting/weighing Mending and tailoring Washing Ironing Packing Clean storage General storage Staff accommodation Laundry supervisor Staff room Public utility for staff Total of sub-zones Medical and general stores Linen and livery store Surgical and dressing store Stationery and printing store Sanitation and miscellaneous store Chemicals and glassware store Furniture store

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

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Table 3.12 (continued)

Zone/particulars (A) Awaiting condemnation store Staff accommodation Stores officer Stores staff Public utility for staff Total of sub-zones Mortuary Entry lobby Body wash Body-holding area Waiting/viewing area Administration Exit lobby Staff area Autopsy area Staff’s changing rooms Pre-autopsy room Autopsy room indoor Autopsy room outdoor Post-autopsy room Autopsy surgeon’s room Instrument wash room Viscera preparation room Viscera store Staff toilet Total of sub-zones Medical records Entry and reception Receipt Compilation desk/sorting room Indexing/coding Computer lab

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

3.6 Summary

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Table 3.12 (continued)

Zone/particulars (A)

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Statistical analysis Dictation room/cubicles Storage for files/register Record scanning room Photocopy/printing room Binding room Storeroom Waste-holding area Staff accommodation Medical record officer Secretarial staff Public utility for staff Total of sub-zones Total of zones

3.5.12 Engineering Services See Table 3.13.

3.6 Summary See Table 3.14.

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

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Table 3.13  Area for engineering services

Zone/particulars (A) Electrical Sub-station Standby generator Workshop Switch room Total of sub-zones Mechanical Lifts Air conditioning plant Air handling unit Cooling towers Total of sub-zones Public health Water supply Sewage disposal Solid waste disposal Incineration Total of sub-zones Fire protection Fire detection Fire fitting (water storage) Fire pump room Fire control room Fire extinguishers Total of sub-zones Communication Telephone exchange Total of sub-zones Medical gases pipeline system Landing bay Manifold room Compressor room

No. Covered of No. of area per beds rooms Size unit Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

3.6 Summary

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Table 3.13 (continued)

Zone/particulars (A) Vacuum room Area for liquid oxygen tanks Total of sub-zones Workshop Electro-mechanical workshop Biomedical workshop Electrical workshop Total of sub-zones Security Supervisor Total of sub-zones Mobile transport Supervisor Total of sub-zones Housekeeping Supervisor Material storage Total of sub-zones Hospital and staff committee (conference) room Conference room Central lecture theatre gallery type Total of sub-zones Total of zones

Covered No. area per of No. of unit beds rooms Size Length Breadth (B) (C) (D) (E) (F) F = D × E

Total covered area in square feet

Total covered area in square metres

(G) G = C × F

(H) H = G/10.76

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Table 3.14  Summary of the total area required for a hospital set-up

Zone Entrance area OPD, emergency and diagnostic activities Emergency services Other treatments Intensive care area Therapeutic services Intermediate care area Administrative/ancillary services Hospital services Engineering services Add movement area for staircases, ramps, corridors (in percentage) Total covered area

Area In square feet

Area Square metres

Further Reading A New Method for Calculating Health Care Spaces [Internet]. [cited 2021 Jun 10]. https://www. hfmmagazine.com/articles/3244-­calculating-­health-­care-­spaces Academy of Architecture for Health. Guidelines for design and construction of hospital and health care facilities. 2001st ed. Washington, DC: AIA; 2002. Almansi K. Developing a technique to calculate the hospital service area and measure the accessibility levels to tertiary hospitals using GIS. Int J Sci Knowl. 2015;6:9. Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. India, Springer Singapore; 2022. Chapter 7, Area Requirement and Planning. p. 41–58. Gibson I.  An approach to hospital planning and design using discrete event simulation. 2007. p. 1501–1509. Griffin CH, Joint Commission, Joint Commission Resources, Inc, Joint Commission International, AIA Academy of Architecture for Health. Planning, design, and construction of health care facilities: addressing joint commission and JCI standards and other considerations—from planning to commissioning. Third edition. Joint Commission Resources: Oak Brook, IL; 2015. p. 138. Jiang S, Verderber S. On the planning and design of hospital circulation zones: a review of the evidence-based literature. HERD Health Environ Res Des J. 2017;10(2):124–46. Lavy S, Hamilton DK, Jiang Y, Kircher A, Dixit MK, Lee J-T. Hospital building and departmental area calculation: comparison of 36 recent north American projects. HERD Health Environ Res Des J. 2019;12(4):174–85. Staff CC. Hospital Space Planners: Planning Hospitals of the Future [Internet]. [cited 2021 Jun 10]. https://blog.cmecorp.com/hospital-­space-­planners-­planning-­hospitals-­of-­the-­future

Chapter 4

Schematic Design and Contract Documents

A schematic design encompasses the complete project design through physical drawings on paper. It helps create a plan for a building by considering planning, design, and budget aspects. It allows you to visualize the building’s appearance once it is finished. Before diving into the schematic design of a building, the designer must consider how different functions, services, and departments in a hospital relate to one another. This involves describing various building systems, such as structural design, civil work, electrical, plumbing, HVAC, mechanical systems, firefighting, IT, CCTV, and more. Schematic drawings shall also outline rough ideas for the building’s interior and exterior finishes. Additionally, they shall cover engineering considerations for the construction and operation of the hospital, specifying spaces, materials, equipment, and systems. These designs extend to floor plans, site layouts, and building elevations. The design process starts with the creation of rough plans and sketches, known as schematics. These illustrate the general layout of departments and rooms, the flow of people and materials, the positioning of doors and windows, and the overall structure of the building. Another crucial factor is soil analysis. It is essential to assess the site’s soil, considering load-bearing capacity and soil type, as the hospital’s structure relies significantly on soil conditions. Architectural drawings are prepared before actual construction begins. They serve as technical representations of the building to be constructed and are typically created using software like AutoCAD on a defined scale. Two key types of architectural drawings are the ‘planning drawing’, which conveys the concept, layout design, and appearance, and the ‘detailed drawing’, which provides in-depth technical construction information. The checklist specifies the various drawings that are usually prepared in this process. The next step is to create construction documents. These documents include specific information about the overall project and additional conditions. They consist of drawings, specifications, the owner’s unique requests, any changes to the original © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_4

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plans, and other materials that can be helpful for contractors and site engineers during the construction process. These documents outline what the contractor and the project’s owner are responsible for, detailing the materials, equipment, and systems to be used, as well as all the elements necessary for building according to the owner’s requirements. When constructing a hospital, different contractors are usually hired for various tasks, such as civil work, electrical, plumbing, HVAC, medical gas pipeline systems, firefighting, and more. Consequently, each contractor may require their own set of construction documents tailored to their specific role. The checklist provides a list of the typical contractors involved in hospital projects. Construction document: A construction document shall include comprehensive information about the hospital project, the scope of work, the construction schedule, general contract conditions, special contract conditions, the construction agreement, technical specifications, a bill of quantities, a cost estimate, a set of drawings, and any other necessary documents based on the project’s specific requirements.

4.1 Confirmation of the Building Planning See Table 4.1. In the preceding planning chapter, the task assigned to the planner and designer was to determine room requirements, room sizes, and the total number of rooms. Table 4.1  Confirmation of the building planning

Activity Has the room requirement list been finalized? Has the total area required for the hospital building been finalized? Has the decision been taken on the number of floors to be constructed? Are the basements to be provided? Has zoning for the entire building been done?

Start date :- Yes

End date

Status of works In Not Responsible Complete progress started person No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

Remarks

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Before moving forward, it is crucial to confirm that this assessment has been carried out and the data has been recorded in an Excel spreadsheet. Summing up these room dimensions along with the necessary spaces for elements like elevators, staircases, restrooms, hallways, and ramps shall yield the overall building area for the proposed hospital. It is imperative to verify that this step has been completed. Now, depending on the regulations and guidelines set by the local development authority or any relevant governing body, such as land coverage, building height, floor area ratio (FAR), and setback area, you can calculate the maximum allowable construction area on the plot. Without these calculations, it would be challenging to proceed. Considering the building height permitted by these regulations and finalizing the ceiling height for each floor shall determine the total number of floors that can be constructed. Have these calculations been finalized? Next, you need to make decisions about the construction of basements. Do you intend to build basements, and if so, how many? Keep in mind that constructing basements is nearly twice as expensive as building on above-ground floors. Basements can also present challenges like water seepage, wastewater management, and ventilation. The subsequent planning task involves zoning for hospital services. Well-­ thought-­out zoning can significantly reduce operational issues within the hospital. It is essential to ensure that the zoning plan for the hospital building has been fully established before proceeding further.

4.2 Architectural Drawings See Table 4.2. Before commencing the actual construction work, it is essential for the project’s stakeholders, including promoters, designers, planners, and project engineers, to ensure that a complete set of drawings has been prepared and endorsed by the architect or the individual responsible for creating the drawings. These sets of drawings shall then undergo a thorough accuracy check and validation by an impartial third party. Once verified, they shall receive approval and signatures from the promoters, designers, planners, and project engineers. All these drawings must be produced in triplicate and shall be on paper of at least A0 size. One set of these drawings shall be laminated and kept at the construction site, under the responsibility of the project engineer for daily reference. The other two copies shall be provided to the promoters and designers. Once all these drawings are prepared, duplicate sets shall be kept ready for submission to the appropriate authorities for map approval.

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Table 4.2  Architectural drawings

Activity Have the following drawings been prepared by the architect Site plan Concept drawings Floor plan Cross section Elevation Landscape Finishing drawing Working plan Section drawings Structural drawings Column layout Plinth beam layout Lintel beam layout Roof beam and shuttering layout Excavation drawing Electrical drawings Plumbing drawings Firefighting and detection drawings Shop drawings Furniture layout drawings Furniture design drawings Hospital signage drawings As-built drawings PERT charts General note

Start date

Status of works End Not Responsible date Complete In-progress started person

::::::::::::::-

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No No No

::::-

Yes Yes Yes Yes

No No No No

:- Yes :- Yes

No No

:- Yes

No

:- Yes

No

:- Yes :- Yes :- Yes

No No No

Remarks

4.2.1 Site Plan A site plan is an architectural representation, including landscaping, that offers a top-down view of a property, encompassing the proposed building. This plan is drawn to a specific scale and displays the layout of structures, landscaping, gardens, internal roads, pathways, parking areas, water features, utility locations, vegetation,

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terrain, water supply and drainage systems, building footprint, trails, and lighting elements, among other elements. The site plan comes into play once the promoters have given their approval to the schematic design. Designers and architects initiate the process by conducting a thorough site analysis, which involves measuring land characteristics such as shape, size, and slope. The architect also gathers information about the soil, vegetation, water features, orientation, and more. This information is then incorporated into the architectural drawing, clearly indicating the allowable land coverage area and the primary building’s placement. The remaining area of the site or plot is designated for landscape design, gardening, roadways, parking, and other hospital-related services, as depicted on the drawing. Additionally, outdoor facilities like Transformer Rooms, Generator spaces, Bio-Medical Waste storage, STP/ETP Tanks, Liquid Oxygen Plants, Security huts, lawns with waiting areas, and other amenities are marked on the site plan.

4.2.2 Concept Drawings Concept drawings serve as the initial project sketches and do not require intricate detailing. They are basic, rough outlines of the building, primarily intended to provide a general overview of its design.

4.2.3 Floor Plan The floor plan illustrates the arrangement and positioning of various rooms, services, and functions within a specific area or level of the building. It offers a detailed representation of room layouts. These drawings aid in assessing various aspects such as the efficiency of human and material movement, the adequacy of working spaces, the proper placement of support rooms, adherence to infection control measures, optimal restroom positioning, appropriate service shafts, adequate circulation space, accessible fire escape routes, consideration of natural light and cross-­ ventilation, correct placement of doors and windows, and the potential for room layout adjustments to enhance the overall design.

4.2.4 Cross Section These drawings provide a vertical perspective on the various elements within a building. They display all the building’s floors stacked vertically. These two-­ dimensional illustrations are valuable for offering a comprehensive view of both the visible and concealed elements, fixtures, and the structure of the building.

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4.2.5 Elevation These drawings depict the building’s outer appearance and its external surfaces. They encompass details like window placement and the enhancement of exterior surfaces using materials like stone, paint, glass, grills, and more. Additionally, these drawings provide information about the building’s height and markings for both external and internal elements, such as doors and windows, including their visible sizes from the outside. These drawings offer insights into the building’s orientation, helping the designer understand its direction, as well as the impact of sunlight and wind relative to the building. Even promoters often prefer to view a 3D representation of the elevation to envision how the building shall appear from an external perspective.

4.2.6 Landscape These drawings illustrate the external aesthetics of the building and provide an aerial view of the entire area where the building shall be constructed. They showcase how the open spaces on the land shall be enhanced and include designated areas for pathways, roads, sidewalks, parking lots, trees, street lighting, parks, pools, gardens, shrubs, hedges, external services, and more.

4.2.7 Finishing Drawing Finishing drawings contain intricate details regarding the finishing touches within the building spaces. This encompasses specifications for flooring, false ceilings, paint colours, plaster textures, doors, bathroom fixtures, electrical fittings, window designs, and other elements. Depending on specific needs, these drawings can be further segmented into separate drawings, each focusing on one or more aspects. For instance, a distinct drawing might highlight the type, pattern, design, material, and size of doors and windows. Similarly, for electrical fixtures, separate drawings can specify their location, type, design, and colour.

4.2.8 Working Plan Working plans, also known as construction plans, are intended for contractors to help them understand the project’s scope of work. These plans assist contractors in estimating and sourcing construction materials in accordance with the overall design. The legend included in the working drawings provides information about

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the various components to guide the contractors. It shall include precise measurements and dimensions for each element, and if necessary, enlarged drawings of specific components shall be included in the final working plan.

4.2.9 Section Drawings These drawings present the complete building structure in a sectional format, essentially slicing the building into layers, which aids in identifying the primary structure of the building.

4.2.10 Structural Drawings Structural drawings are engineering diagrams that focus on the structural elements of the building, including columns, beams, foundations, and slab casting. The structural design is a critical aspect of the building’s overall design because the building’s strength relies on its structure. Typically, these drawings are created and certified by Structural Engineers. Using the floor plans as a guide, the engineer determines the column placements and designs the structure. During the design process, the engineer takes into account factors related to earthquakes, wind speed, soil analysis, flooding, load of the building itself, and the load inside the building. These drawings also provide specifics regarding reinforcement and the composition of the concrete mix to be used.

4.2.11 Column Layout Column layout drawings specifically illustrate the design and placement of columns within the building. This drawing is one of the components of the Structural Drawings. Since the size of columns varies from floor to floor, these plans are created on a floor-by-floor basis and specify the precise size and spacing between each column in the building, as well as marking the location of each column.

4.2.12 Plinth Beam Layout Plinth beam layout drawings provide precise details about the positioning and dimensions, including length, width, and height, of the plinth beam. These drawings also encompass the cross-sectional design of the plinth beams, including specifics like the size of the steel bars and the quantity of bars and rings to be used.

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4.2.13 Lintel Beam Layout Lintel beam layout drawings are prepared to depict the details of the Lintel Beams which are required to be constructed to support structures created above doors and windows to bear the weight above them, as the space below doors and windows is typically vacant without brickwork. These drawings indicate the positions, dimensions, design, and quantity of lintel beams required.

4.2.14 Roof Beam and Shuttering Layout Roof beam and shuttering layout drawings are prepared to depict the shuttering plan for casting the floor’s slab and upper beams.

4.2.15 Excavation Drawings These drawings provide specific information regarding the excavation necessary to initiate building construction. If there’s a basement, the drawing outlines the basement’s details and the required excavation. Additionally, it provides details about excavations for the building’s foundations, which may consist of individual footing columns or a more extensive raft. These drawings indicate the length, depth, and width of the excavation area, as well as information about the extent of excavation, excavation methods, soil removal, and disposal. Various excavation techniques like trenching, wall shafts, tunnelling, and complete removal are used.

4.2.16 Electrical Drawings Electrical drawings, typically prepared by an Electrical Engineer, outline the electrical system required to power and operate the hospital building. These drawings depict the electrical planning for elements like Transformers, Energy meters, Main Panels, Floor Panel Circuit Diagrams, Line layouts, Distribution Boxes, Switch Boards, and Earthing. They also specify the location of electrical fittings and fixtures. Additionally, the drawings include calculations for capacity, design, and a bill of quantity.

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4.2.17 Plumbing Drawings Plumbing drawings pertain to the water supply within the building and the disposal of wastewater. These drawings illustrate the water supply arrangements, including bore wells, government supply line access points, overhead tanks, roof tank layouts, in-building supply line layouts, and sanitary fittings. Likewise, for drainage, the drawing specifies drain pipelines, main holes, STP/ETP tanks, and connections to the main sewerage line. These drawings also showcase rainwater harvesting layouts.

4.2.18 Fire Fighting and Detection Drawings Firefighting and detection drawings focus on setting up firefighting systems, fire detection, and fire escape routes. The firefighting drawings detail the firewater storage tank, pump room, water supply line, yard hydrants, sprinkler line layout, sprinkler points, rooftop tank layout for downcomers, and hydrant locations within the building. For the fire detection system, the drawings indicate the location of the control panel, smoke detectors, hooters, and switches. They also provide escape route diagrams in case of a fire, displaying the routes alongside staircases, ramps, fire doors, and signage placements. Furthermore, these drawings indicate the location of the pressurizing system for lift wells, lift lobbies, and staircases.

4.2.19 Shop Drawings These are construction design drawings that illustrate the precise installation, fitting, or manufacturing process of an object. They are typically created for services such as Air-Conditioning, MGPS, CCTV networks, EPABX networks, IT networks, Public Address System networks, and PTS (Pneumatic Tube System). These detailed line diagrams depict the machine’s placement and the system’s layout. For instance, in the case of MGPS, the drawing outlines the pipeline routes, gas point locations, manifold room design, pump room, and more. Similarly, for air conditioning, the drawing showcases the layout of ducts, chilled water pipelines, AHUs, plant rooms, and cooling towers. These shop drawings are often prepared by contractors, subcontractors, suppliers, manufacturers, or fabricators. However, they must adhere to the original design and specifications provided by the designer.

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4.2.20 Furniture Layout Drawings A hospital’s requirement for furniture varies from room to room including patient furniture and office furniture. Furniture layout drawings are essential for planning the placement of furniture within the hospital. These drawings vary according to room and space requirements, encompassing both patient furniture (e.g. beds, trolleys), and office furniture (e.g. chairs, tables). The drawings provide a layout for each room, indicating the size and dimensions of the furniture.

4.2.21 Furniture Design Drawings Most often, patient furniture has a fixed size and design, whereas office furniture is tailored according to the needs. Furniture design drawings are especially important for customized office furniture, describing the sizes, designs, materials, and fittings needed for manufacturing. These drawings help estimate the furniture’s cost.

4.2.22 Hospital Signage Drawings Designing and providing signage in the hospital is a typical task which requires careful design. Finding signage location and design is even more important. The signage location has to be such that it gives an uninterrupted view of the signage to the people. This drawing depicts the location of the signage along with its design at various locations. The design of the signage may change from one location to another. Therefore, the signage drawing is prepared separately for each floor.

4.2.23 As-Built Drawings At times it happens that during construction, due to some unavoidable circumstances or due to changes in the decision, the construction pattern and design may have to be changed as compared to what was planned in the working drawing or the floor plan. In such cases, As-built drawings are prepared either during the construction process or after the construction is complete. These drawings are prepared for comparison between what has been built versus the original plan to trace out the changes that have taken place during construction.

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4.2.24 PERT Charts PERT Charts, or Program Evaluation and Review Technique charts, provide a timeline for project completion. They outline the start and end dates for each activity, including dependencies between activities. PERT charts are a vital management tool for tracking project progress regularly.

4.2.25 General Note A general note is not a drawing but contains comprehensive information about by-­ laws, legends, construction methods, mapping forms, abbreviations, codes, and other necessary details and clarifications for the construction process.

4.3 Contract Documents See Table 4.3. Please ensure that the construction documents are prepared for the following activities/works: • • • • • • • • • • • • • • • • • • •

Soil analysis Excavation of land Reinforcement steel binding Civil construction Elevation Plumbing and sanitary Electrical and power Air conditioning Site development and landscaping Door windows Fire fighting CCTV system Medical Gases Pipeline System (MGPS) Modular OT Information technology (computerization) Public announcement system False ceiling Flooring Nurse call system

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4  Schematic Design and Contract Documents

Table 4.3  Contract documents

Activity Are the set of construction documents ready for bidding or inviting quotations from the vendors/contractors? Are the following documents ready for inclusion in the contract documents? General information about the hospital project Draft construction contract agreement to be signed while awarding the contract Scope of work (SOW) of the contractor/ vendor Construction schedule General conditions of the contract Special conditions to the contract Specifications of the work and the material to be used for the work Bill of quantities of the work (BOQ) Cost estimate of the contract to be awarded Drawings of the works to be performed Other documents like instructions, clarifications, and understanding for the contractor/ vendor Information about liens Staff requirements

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :- Yes No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes :- Yes

No No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

4.3  Contract Documents

141

Table 4.3 (continued)

Activity Supervision requirements Safety instructions Safe work method statements Contractor pre-­ qualification terms Defect management and liability clauses Test requirements and terms Inspection and test plans Environmental monitoring system Site meetings Quality monitoring, terms, and conditions Terms for extension of time Materials ordering and inspection terms Daily reporting system Disposal of wastage

• • • • • •

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :- Yes No :- Yes :- Yes

No No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes :- Yes

No No

:- Yes

No

:- Yes

No

:- Yes :- Yes

No No

Elevators/lifts Signage Painting and polishing Staircase railing Curtain track system General furniture Each construction document shall contain the following information.

4.3.1 General Information About the Project The document shall encompass general information about the site, including land size and shape, project size, promoter details, project mission, total covered area of the hospital, and the services the hospital intends to offer. This document serves to provide background information about the project to the contractor.

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4.3.2 Construction Contract Agreement The Construction Contract Agreement, included within the construction documents, outlines the draft agreement that shall govern the relationship between the proposed hospital and the contractor once the contract is finalized. This agreement is signed to inform contractors about the terms and conditions within the agreement and legally bind them to perform their tasks.

4.3.3 Scope of Work (SOW) The Scope of Work (SOW) section within the construction documents defines the scope of the contractor’s responsibilities during both the construction period and for addressing defects after construction. This section helps the contractor understand the tasks they must complete before submitting a bid. Along with this the scope of work on the part of the hospital is also defined and written down. Separate SOW documents are created for various construction activities. SOW shall clearly define and elaborate on all the work to be performed by the contractor and how the work has to be performed, i.e. the sequence of the work; equipment, tools, and techniques to be used; safety and security measures to be adopted, and details of the materials to be used. This document shall also define the terms and conditions in case any changes occur in the scope of work during the construction process.

4.3.4 Construction Schedule The construction schedule document contains the work schedule, including the anticipated start date, milestones, expected completion date, and terms and conditions regarding allowances and penalties for schedule variations and delays in the construction schedule.

4.3.5 General Conditions The general conditions describe the conditions like relationships between the owner and contractors; rights and responsibilities of both the parties, etc. The general conditions shall also include the methods to be adopted for dispute dissolution and any other conditions that may be important for the project construction. These conditions offer a legal framework for the overall construction contract.

4.3  Contract Documents

143

4.3.6 Special Conditions The special conditions document is prepared to specify any conditions and clauses that may pertain to a specific activity or a specific portion of the job.

4.3.7 Specifications Specifications include comprehensive technical information, detailed specifications, and other requirements related to the task to be performed. This section provides detailed information about materials, including brand, model, size, quality, finish, and chemical composition. It also defines warranty periods and terms of warranty. Information about the equipment, tools, instruments, and techniques to be employed for the completion of such activity is also provided. Contractors are allowed to seek clarification on these specifications. This section also addresses the terms and conditions for accommodating changes to specifications during the construction process.

4.3.8 Bill of Quantities (BOQ) This document shall contain the details of the itemized materials to be used in the contract along with the quantity of the individual item.

4.3.9 Cost Estimate This section of the construction documentation offers a detailed breakdown of costs associated with all elements to be integrated into the construction project. It also includes an itemized list of the estimated costs of materials, parts, and labour in the construction project. The total cost estimate can be worked out by multiplying the quantity (as stated in the bill of quantity) with the estimated costs and then adding the labour or erection charge.

4.3.10 Drawings The construction documents shall also include a set of simple drawings that can provide a graphic representation of the scope, extent, and character of the work that shall have to be performed by the contractor. This is to make the contractor understand the work in drawings.

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4.3.11 Other Documents Depending on the requirements, the construction documents may or may not include the following documents: 1. Supervision requirements 2. Staff requirements 3. Information about liens 4. Safe work method statements 5. Safety instructions 6. Quality test requirement, schedule, terms, and conditions 7. Inspection and test plans 8. Quality monitoring terms and conditions 9. Contractor pre-qualifications terms 10. Defect management and liability clauses 11. Materials ordering and inspection terms 12. Environmental monitoring system 13. Site meetings schedules 14. Daily reporting system 15. Terms for extension of time 16. Disposal of wastage Once these construction documents for all the activities are prepared, these documents shall be given to the contractors who so ever qualify during the pre-bidding qualifications. The bidder shall be then encouraged to visit the site and to seek clarification if required. Fix the last date for bidding and advise the bidders to bid on or before the last date. The bids shall be submitted in a sealed envelope under receipt from the authorized person of the project. On the pre-determined date, the envelopes are opened in front of the bidders. Comparative sheets are prepared to work out the lowest bidder. Thereafter, the rounds of discussions shall be carried out with the bidders. Owners need to satisfy themselves about the capability of the bidder to perform the task; the work experience of the bidder, the bidder’s earlier experience; the availability of the manpower; availability of the infrastructure like equipment, tools, machines, instruments with the bidder, etc. Once the hospital authorities are satisfied with all these issues, the agreement’s final terms and conditions shall be made understood, rediscussed, and finalized. Lastly, the negotiation shall be carried out on the price and costs. The terms of payment shall also be discussed and agreed upon and documented in the contract agreement. Once the terms and conditions and cost are agreed upon, the contract agreement is signed off by both parties and the work order is issued. Once the contract agreement is signed off, the mobilization advance shall be paid to the contractor to mobilize the workforce along with the tools machinery and safety devices to be used for construction.

Further Reading

145

Further Reading Code C. Understanding the Architects Design Phases: Schematic Design; Design Development; Construction Documents [Internet]. [cited 2021 Jun 10]. http://canadiantimberframes. com/understanding-­the-­architects-­design-­phases-­schematic-­design-­design-­development-­ construction-­documents Construction Document Preparation—Architect Helper [Internet]. [cited 2021 Jun 14]. http:// www.architecthelper.com/our-­services/construction-­document-­preparation Construction Documents Checklist: Ensure You Have the Docs You Need [Internet]. Sitemate. 2019 [cited 2021 Jun 14]. https://sitemate.com/uk/resources/articles/construction/ construction-­documents-­checklist/ Construction Drawing [Internet]. https://www.designingbuildings.co.uk; [cited 2021 Jun 14]. https://www.designingbuildings.co.uk/wiki/Construction_drawing Documents to Include in Your Construction Contracts [Internet]. The Balance Small Business. [cited 2021 Jun 14]. https://www.thebalancesmb.com/ contract-­documents-­for-­every-­construction-­project-­844919 Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. India: Springer Singapore; 2022. Chapter 8, Schematic design; p. 61–62, Chapter 10, Site plan; p.  81–83, Chapter 11, Detailed engineering drawings; p.  85–99, and Chapter 12, Preparation of construction documents; p. 103–106 Gibson IW, Lease BL. An approach to hospital planning and design using discrete event simulation. In: 2007 Winter Simulation Conference [Internet]. Washington, DC: IEEE; 2007. p. 1501–9. http://ieeexplore.ieee.org/document/4419763/ INC U-B. 42 Types of Drawings Used in Building Design- Comprehensive Guide [Internet]. [cited 2021 Jun 14]. https://www.united-­bim. com/a-­comprehensive-­guide-­42-­types-­of-­drawings-­used-­in-­building-­design/ Jamal H. List of Drawings Required for Building Construction | Floor Plan, Elevation, Section, Electrification, PLumbing [Internet]. [cited 2021 Jun 14]. https://www.aboutcivil.org/list-­ drawings-­buildings.html Johnson BJ.  Site planning for planners: the view from the other side. J Educ Built Environ. 2009;4(1):31–56. Marcus CC. Site planning, building design and a sense of community: an analysis of six cohousing schemes in Denmark, Sweden, and the Netherlands. J Archit Plan Res. 2000;17(2):146–63. Schematic Design Phase [Internet]. Western Michigan University. 2015 [cited 2021 Jun 10]. https://wmich.edu/facilities/planning/schematicdesign Site Planning | Landscaping [Internet]. Encyclopedia Britannica. [cited 2021 Jun 14]. https://www. britannica.com/topic/site-­planning Types of Drawings used in Building Construction  - Building Technology Guide [Internet]. The Constructor. 2018 [cited 2021 Jun 14]. https://theconstructor.org/building/ drawing-­types-­construction/24524/

Chapter 5

Civil Construction Works of the Hospital Building

Once the fundamental planning and designing phases of the hospital project have been completed, along with the preparation of all detailed drawings for execution, the construction phase can be initiated. At this stage, the selection of vendors should also have been finalized, signifying that the groundwork for commencing actual construction is now set. Commence the construction procedures. Before initiating the construction, there are a series of preliminary activities that must be undertaken. First and foremost, it is imperative to obtain approval for the maps and drawings in accordance with the governing by-laws of the area or land. It is essential to hire contractors and provide advance payments for the mobilization process, along with issuing instructions for mobilizing the teams. The selection of vendors for the supply of construction materials and subsequent procurement at the site is crucial. The initial steps involve laying the foundation stone and making provisions for necessary construction tools, temporary electricity, and water supply, as well as setting up site offices and stores. The construction process commences with the demarcation of the layout on the land, either for basements (if included in the design) or for the foundation, followed by excavation work and subsequent foundation laying. Upon completion of the foundation, the construction of the building commences, including the casting of columns and beams. The process of shuttering for slab casting begins, and once the slab shuttering is removed, brick/block work shall be initiated. In addition to implementing reinforced concrete cement (RCC) works, the construction process typically includes a range of activities such as civil works encompassing brick/block work, plastering of walls and ceilings, fixing of door/window frames, installation of flooring, doors/windows, and false ceilings, as well as wood, aluminium, steel works, and painting works, among others. Considering the extensive number of activities required on each floor, simultaneous execution on the same floor may not be feasible for all tasks. Some activities can © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_5

147

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run parallel to others, while certain tasks need to follow a sequential order. For instance, wall plastering can only be carried out once all the conduits are laid. To optimize time management, the activities are allocated across different floors. For instance, when the ground floor slab is complete, the casting team can proceed to the first floor for column, beam, and slab casting. Simultaneously, brick/block work can commence on the ground floor. Similarly, as the casting team moves to the third floor, brick/block work can commence on the second floor. Similarly, the work for laying conduits can be started on the ground floor, and so forth. The attached checklist outlines the sequence of such tasks within the proposed building, facilitating the site engineer in planning the commencement and completion dates for each activity and monitoring the current status of each task.

5.1 Pre-Construction Activities See Table 5.1. Given that the construction of a multi-story hospital is classified as a substantial undertaking, it necessitates a strong and stable foundation capable of bearing the weight of the structure. Additionally, the building must be resilient enough to withstand potential hazards such as earthquakes, floods, and lightning. It is crucial to conduct a thorough examination, especially if the land is located in filled areas or in proximity to water sources such as lakes, canals, rivers, or seas. Consequently, the initial step involves a comprehensive analysis of the soil through soil testing. This process entails the engagement of a government-approved agency responsible for collecting various soil samples, which are then sent to a laboratory for thorough chemical analysis. The resulting report provides valuable insights into the ’s load-bearing capacity, serving as a critical reference point for the structural engineer in designing the building’s foundation. Simultaneously, while awaiting the soil testing report, the land must undergo a meticulous survey to ascertain its topographical variations. It is common for the Table 5.1  Pre-construction activities

Activity Soil analysis Survey of the land for checking different levels of the land Removal of debris from the land Removal of unwanted plants, trees, wooden stumps, etc.

Start date ::-

::-

End date

Status of works In Not Responsible Complete progress started person

Remarks

5.2 MAP/Drawing Approvals

149

land levels to differ across the entire plot, necessitating potential landfilling in some areas. This preparatory step can be completed before the soil testing report is obtained. Upon receiving the soil testing report, the final set of structural drawings, alongside other necessary drafts, shall be meticulously prepared for submission to the relevant government authorities for map approval. During this period, it is advisable to clear the plot and surrounding land area of any debris, vegetation, trees, rocks, or wooden stumps that could impede the construction process. Eliminating these obstructions in advance is essential to facilitate the excavation process for laying the foundation or basement without any hindrances.

5.2 MAP/Drawing Approvals See Table 5.2. In virtually all the countries, there exists an established system governing construction and development activities. Typically, government bodies, or other regulatory agencies designated for this purpose, oversee and approve building plans. These entities enforce a specific set of regulations, including permissible Floor Area Ratio (FAR), building height, land coverage, and setback requirements. Additionally, parking area standards must be adhered to the prescribed by-laws. Certain countries also maintain regulations pertaining to service standards such as electricity, water supply, drainage, lightning protection, and pollution control. Table 5.2  Map/drawing approvals

Activity Preparing a final set of drawings for submission to Govt. agency for approval of the drawings Applying for the clearance of the building plan to the concerned Govt. agency Deposit the approval fees Getting the stamped and signed approval of the building plan Approval for excavation of land for basements

Status of works Start End Not Responsible date date Complete In-progress started person :-

:-

::-

:-

Remarks

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5  Civil Construction Works of the Hospital Building

Currently, there is a growing emphasis on the implementation of green building principles worldwide. In accordance with the regulations and standards established by the relevant approval authorities in the respective regions, a comprehensive set of drawings and essential documentation shall be prepared and submitted for approval of the proposed maps and drawings. If there are any charges associated with the approval process for the maps and drawings, the corresponding fees shall be remitted along with obtaining a receipt. Should any discrepancies arise in the submitted maps and drawings, the approving authorities may request revisions. Only upon satisfaction with the compliance of the maps and drawings with the prescribed standards, the permission for construction will be granted. The approved set of maps and drawings shall formally be endorsed and stamped by the approving authorities. A copy shall then be provided to the owner, serving as official authorization to commence the construction work. Likewise, if necessary, written authorization from the relevant authorities should be obtained before commencing any land excavation to establish foundations or basements.

5.3 Engagement of Contractors See Table 5.3. With the completion of the detailed drawings and the approval of the project map from the pertinent authority, the subsequent phase involves the commencement of the construction process. Naturally, the engagement of contractors is essential for the execution of the construction activities. Typically, each specific task requires the involvement of separate contractors. These tasks may include land excavation, civil construction, reinforcement steel binding, plumbing and sanitary work, electrical and power installation, air conditioning, firefighting, CCTV system installation, information technology (computerization), public announcement system setup, modular OT (Operation Theatre), medical gas pipeline system installation, door and window fitting, false ceiling installation, painting and polishing, flooring, elevation work, site development, staircase railing installation, landscaping, elevators/lifts installation, signage placement, curtain track system setup, nurse call system setup, and general furniture installation, among others. Although it is customary for each activity to be managed by individual contractors, some developers prefer to engage a single contractor for the entire project on a turnkey basis. This primary contractor may subsequently appoint sub-contractors for each specific activity. The process of selecting contractors initiates with the release of an advertisement inviting applications from interested contractors. Subsequently, the contractors shall be shortlisted during the pre-bidding qualification round, where their capabilities shall be assessed through initial interviews, scrutiny of references and previous

5.3 Engagement of Contractors

151

Table 5.3  Engagement of contractors

Activity Advertisement for contractors for  Civil work  Bar binder  Electrical works  Carpenter works  Aluminium doors/ windows works  Plumbing works  Plaster of Paris work/false ceiling works  MGPS works  Air-conditioning works  Floor work  Water disposal works STP, WTP, etc.  Painting works  Fire detection and suppression works  CCTV, PA system, EPABX, IT networks  Curtain tracks, wall corners, wall guard works  PTS system  Stainless steel work Initial interview with the contractor who has applied to judge the capacity of the contractor Checking the references of the contractor and accessing the earlier works done by the contractor

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::::::::-

::::-

:::-

:-

:::-

:-

(continued)

152

5  Civil Construction Works of the Hospital Building

Table 5.3 (continued)

Activity Issue the tender documents to the contractors Receiving the bids/ quotations from the contractors Opening of the technical bid Opening of the financial bid Negotiations with the contractors on technical and financial issues. Settle all the terms and conditions Close the deal with the selected contractors Signing the contract agreement Get samples of materials from contractors, if any Payment of mobilization advance

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:::-

:::-

:-

works, and an evaluation of their overall reputation. Emphasis shall be placed on contractors with adequate resources, including manpower and the necessary tools to ensure the timely completion of the project. Following the shortlisting of contractors, the qualified ones receive a set of tender documents. The bidding deadline shall typically be fixed, and contractors shall be instructed to submit their bids in sealed envelopes under the supervision of an authorized representative of the developer. On the designated date, the sealed envelopes shall be opened in the presence of the contractors, and a comparative analysis shall be conducted to determine the lowest bid. Further discussions shall be held with the shortlisted contractors, during which the developers ascertain their work experience, capabilities, previous project records, and the availability of essential resources. Upon satisfaction with these aspects, the final terms and conditions of the agreement shall be rediscussed and finalized. Lastly, the negotiation on the price and costs shall be carried out. The terms of payment shall also be agreed upon and documented while placing the work order. In preparation for the engagement of contractors, a set of construction documents shall be created, encompassing general and supplementary conditions,

5.4 Selection of the Vendors for Materials Supply

153

specific requirements of the developers, detailed drawings, specifications, change orders, and other documents provided by the designer or consultants. These documents shall outline the scope, type, and quality of materials, equipment, systems, and other elements necessary for the project, to be acknowledged and accepted by the developers. Given the need to engage different contractors for various activities, a separate set of construction documents shall be prepared for each activity or contractor. For a more comprehensive understanding of the construction documents and contract awarding process, please consult Chap. 4 (Contract Documents) of this book. Following the finalization of the contractors, an advance for mobilization shall be disbursed to them, along with instructions to initiate their teams. Additionally, the contractors are required to submit material samples for the developer’s evaluation, with these samples being retained for comparison with the actual materials used during the construction phase.

5.4 Selection of the Vendors for Materials Supply See Table 5.4. During the construction of any building, a variety of materials are essential, including but not limited to cement, steel, sand, conduits, hardware, sanitary wares, cables, panels, electrical fittings, etc. To ensure the unobstructed progress of the project, it is advisable to procure these materials well in advance and adequate quantities. When awarding contracts for the construction and finishing of a building, three scenarios may arise. Firstly, the promoter may supply the materials, and the contractors are solely responsible for the labour aspect. Secondly, the contract may encompass both the materials and the labour. Lastly, it may involve a combination of both, where some tasks involve materials supplied by the promoter, and others solely entail labour. Irrespective of the scenario, timely procurement of materials is imperative. If the promoter supplies the materials, they need to request the designers and architects to prepare a Bill Of Quantity (BOQ) encompassing all the necessary items. This comprehensive list, including technical specifications and make and model details of the materials, shall be prepared well in advance. As soon as the BOQ is ready, an advertisement shall be released for the vendors to apply. After receiving the applications, the vendors shall be shortlisted in the pre-­ bidding qualification round. In this round, the vendors shall be evaluated based on the initial interview to judge the capacity of the vendor, checking the reference and quality of the earlier supplies, the general reputation of the vendor, etc. During shortlisting the vendors, preference shall be given to such vendors, who are either the direct manufacturers or otherwise who are the distributors of registered agents

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Table 5.4  Selection of the vendors for material supply

Activity Advertisement for the supply of building materials for items like  Steel  Cement  Bricks  Shuttering  Waterproofing  Compound  Generator  Pre-mix mortar  Electrical material like boxes, conduits, switches, wires and cables, MCB, etc.  Distribution boards, distribution panel  LT cables/rising main/bus ducts  Earthing and lightning  Protection  Electrical fittings like  fans, lights, exhaust  Electrical panels LT and HT  Transformer  Nurse call system  Aluminium doors/ windows  Wooden doors and windows  Hardware items  Paints  Sanitary fittings  Sanitary items like pipes, traps, main holes, water tanks, etc.  CP and other fittings for toilets

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

::::::::-

:::-

:-

:::::::::-

:-

5.4 Selection of the Vendors for Materials Supply

155

Table 5.4 (continued)

Activity  Plaster of Paris  Floor tiles  Wall tiles  False ceiling  Firefighting material  Lift  Central gas pipeline material  CCTV cameras  Modular furniture  Wood, plyboard, laminates, glass, boards, and hardware for the almirah, furniture  Air conditioning items  Borewell material  Geysers, coolers, etc.  Plantation material  Interior decorative material like pictures, murals, etc.  SS materials like handrails etc.

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::::::::::-

:::::-

:-

of the manufacturers. This will help the promoter to procure the original material at a cheaper price and will rule out the chances of any duplicate material. Once the vendors are shortlisted, the set of BOQ shall be given to the vendors who qualify during the pre-bidding qualifications. Generally, the last date for bidding shall be fixed, and the vendors are advised to submit the bid on or before the last date. The vendors shall submit the bid in a sealed envelope under receipt from the authorized person of the promoter. On the pre-decided date, the envelopes are opened in front of the vendors. The comparative sheet shall be prepared to work out the lowest vendor, and rounds of discussions shall be carried out with the vendors. Promoters shall satisfy themselves with the work experience, the capability of the vendors to supply the material, the vendor’s earlier experience, the availability of the required material with the vendor, etc.

156

5  Civil Construction Works of the Hospital Building

Upon the promoter’s satisfaction with the vendors, the final terms and conditions of the agreement shall be deliberated and concluded, followed by negotiations on pricing and costs. The agreed-upon terms shall be documented in the purchase order, including item details, technical specifications, applicable taxes, warranty conditions, payment terms, delivery details, warranty, spare parts availability, aftersales service, installation, commissioning and testing provisions, annual maintenance contracts, and dispute resolution clauses. To avoid overstocking or understocking, careful consideration shall be given to the delivery time of the materials. Overstocking may lead to material pilferage or expiry, while understocking may cause construction delays. Upon finalizing the vendors, an advance payment shall be made in accordance with the conditions specified in the purchase order. Additionally, the vendors are required to provide samples of the materials outlined in the purchase order, which are retained by the promoter for comparison with the actual materials supplied. In the case of contractors working with materials, the agreement shall clearly define the items, technical specifications, make, and model. Similar to the vendors, the contractors shall also be requested to submit samples of construction materials, which shall be retained for comparison with the materials actually used during the construction process.

5.5 Starting Preparing for Construction See Table 5.5. With the contractors appointed and the material orders issued, the focus now shifts to the preparations for initiating the construction work. To begin with, the ceremonial laying of the foundation stone shall be arranged according to the preferences of the promoters. The promoters may even plan a ceremony for the foundation stone laying. Arrangements for the storage of construction materials shall be made on-site, necessitating the construction of a temporary site store. This site store serves as the storage facility for materials, which are then issued to the contractors. It is advisable to employ a dedicated storekeeper responsible for overseeing and managing the inventory of materials received and issued. During the initial phase, key materials such as cement, steel, sand, bricks, and shuttering materials are typically in high demand. In the case of large project sites, using cement bags and mixing them with stone pebbles to produce Reinforced Concrete Cement (RCC) on-site might not be practical. Hence, arrangements shall be made for the supply of pre-mixed RCC materials, either from an external plant or by setting up an on-site pre-mix plant, if feasible. For administrative purposes, a temporary site office shall be constructed, and equipped with the necessary furniture such as tables, chairs, cupboards, and racks. Additionally, electrical points and communication ports shall be installed. If required, the office can be equipped with air conditioning.

5.5 Starting Preparing for Construction

157

Table 5.5  Starting preparing for construction

Activity Laying the foundation stone Arrangement of temporary electricity connection Arrangement of water for construction Arrangement of construction tools like cranes, excavators, lifting winches, carts, etc. A temporary portable light that can be moved to different places in the building Construction of site stores with a temporary structure Construction of site office with a temporary structure Construction of huts for labourers and providing them with services like electricity, water, and sewerage If the project is big, installation of a pre-mix plant at the site. Procure or arrange for the required safety equipment and tools like helmets, gloves, safety belts, shoes, etc. Start procuring materials like  Steel  Cement  Bricks  Sand  Stone pebbles of different sizes

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::-

::-

:-

:-

:-

:-

:-

:-

::::::-

158

5  Civil Construction Works of the Hospital Building

Considering the substantial manpower required for construction, contractors often request temporary housing facilities near the site for the accommodation of workers. Consequently, temporary huts with provisions for electricity, water, and sewerage shall be constructed. In addition to materials and housing, other necessary items and facilities shall be arranged on-site. These may include temporary electricity supply, temporary water supply, and portable lighting, among others. Depending on the regulations of the country, these arrangements can be made either through government supply agencies or through the promoter’s resources. Efficient construction necessitates the availability of various tools and equipment, such as cranes, lifters, winches, carts, and trucks. Depending on the terms outlined in the agreement with the contractors, these items shall be made available before the commencement of actual construction. Furthermore, in adherence to the terms of the contract, either the contractors or the promoters shall be responsible for arranging the necessary safety equipment, including safety belts, gloves, helmets, and shoes.

5.6 Layout and Excavation of Land See Table 5.6. Table 5.6  Layout and excavation of land

Activity Marking of the layout for excavation as per the approved drawing Start excavation from one point of the plot Removal of the excavated mud/sand from the pit Storage of the excavated mud/sand safely as it will be required later on for backfilling Adequate protection to be provided to avoid falling off the unexcavated mud Levelling of the excavated pit and preparing it for laying the foundation of the building

Status of works Start End Not Responsible date date Complete In-progress started person :-

::-

:-

:-

:-

Remarks

5.7 Building Construction

159

With all preparations in place to commence construction, the initial step involves obtaining excavation drawings and carrying out precise layout markings on the plot. These markings should be clearly visible to the workers. Proceed with the excavation of the land. Notably, if the building includes a basement, the excavation will naturally be deeper, necessitating the use of tools such as excavators. To remove the excavated mud, the material carrying belts can be used, as it will save a lot of manpower. In the absence of a basement, excavation is solely for the building’s foundation. The extent of excavation depends on the foundation type specified in the design. For a raft-type foundation design, the entire demarcated area shall be excavated. Conversely, if the design pertains to standalone columns, the excavation shall be confined to the designated space for the column footings. When excavating the entire area, the process should initiate from one point of the plot and systematically progress forward. It is crucial to simultaneously remove excavated mud or sand during the excavation process to prevent hindrances and avoid the soil becoming hardened, which may necessitate re-excavation. For deeper excavations, it is imperative to implement adequate measures to prevent unexcavated land from collapsing into the pit, as this could result in serious accidents. Following the advice of the designers and architects, precautionary measures shall be taken. It is advisable to securely store a portion of the excavated soil or sand, as it will be required for backfilling after the construction of basement walls or foundations. Insufficient storage may lead to additional procurement of soil at an extra cost to the promoters or contractors. Upon completion of the excavation, the surface of the excavated pit shall be appropriately levelled and prepared for laying the foundation. Incorporating level markers within the pit can facilitate the foundation-laying process.

5.7 Building Construction See Table 5.7. Given the significance of time in the construction process, it is crucial to expedite building construction as much as possible. Delays in construction beyond the estimated timeframe can potentially lead to increased construction costs owing to inflation, as well as postponement in the operational launch of the hospital, resulting in potential profit losses. Table 5.7  Building construction Status of works Activity Start construction in three shifts

Start date :-

End date

Not Responsible Complete In-progress started person

Remarks

160

5  Civil Construction Works of the Hospital Building

Conversely, timely completion of the building can lead to cost savings and facilitate the operational launch of the hospital. If the building is completed within or even before the designated time, it can serve as an added advantage for the promoters, enabling them to generate revenue earlier than anticipated. If financially viable, the promoters may even consider offering incentives to the contractors for the timely completion of the project. It is advisable to motivate the contractors to continue construction work in all three shifts, if feasible. Otherwise, construction shall at least progress in two shifts per day. This strategy helps ensure timely project completion, contributing to potential cost savings and early operationalization of the hospital.

5.8 Foundation of the Building See Table 5.8.

Table 5.8  Foundation of the building

Activity Compaction of the soil Rapid testing of the compacted soil Laying of PCC on the soil and compaction of the PCC layer Marking and layout of the footings/ column/raft Steel works for the foundation Shuttering of the footings/rafts Filling the check card for safety and civil works The casting of the foundation Curing of the foundation Providing shaft spaces for the elevators as per the size required by the elevator vendor

Status of works Start End Not Responsible date date complete In-progress Started person :::-

:-

:::-

:::-

Remarks

5.9 Works from the Basement Up to the Plinth Level

161

Upon completion of the excavation and levelling of the pit, the foundation work shall be initiated. To begin, ensure thorough compaction of the soil using appropriate heavy-duty tools, after moistening the soil with water. Random testing of the compacted soil shall be promptly conducted. Next, proceed with the laying of the layer of Plain Cement Concrete (PCC) according to the structural design specifications of the building. The thickness of the PCC layer shall comply with the designated requirements, followed by effective compaction. Once the PCC layer is in place, proceed to mark the layout of the column footings or the raft. Subsequently, carry out the binding of the steel for reinforcement and meticulously verify the levels and alignment of the steel structure. Take necessary precautions to ensure that the reinforced steel remains properly aligned during the process of shuttering for casting. Arrange appropriate shuttering for the footings or the raft, utilizing materials such as wooden planks, plyboard, or steel plates. Recheck the levels and alignment of the footings before commencing the casting of the foundation. During the casting process, ensure the use of vibrators for effective compaction of the RCC material. Following casting, initiate a rigorous curing process from the following day onward. Extensive curing promotes a stronger molecular binding between the cement and stone pebbles, thereby enhancing the strength of the RCC casting. During the casting process, ensure adequate provision of space for creating pits for the elevators in accordance with the specifications provided by the elevator manufacturers.

5.9 Works from the Basement Up to the Plinth Level See Table 5.9. After the completion of the foundation casting and ongoing curing process, the next step involves marking the layout of the columns on the foundation approximately a week after the casting. This is followed by the commencement of reinforcement steel works and the erection of the steel structure at the designated column locations. Ensure that the steel structure is securely fixed, levelled, and aligned, with proper support in place to maintain its stability. Proceed to install the shuttering for the columns, which can be made of wooden planks, plyboard, or preferably, the recommended steel box type shuttering. Prior to casting, verify and adjust the alignment and level of both the shuttering and the steel structure. During the casting of the columns, utilize pin-type vibrators to ensure thorough compaction of the RCC material, eliminating any potential air pockets. Limit the height of the column casting to 2000 mm in a single operation, maintaining the top

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5  Civil Construction Works of the Hospital Building

Table 5.9  Works from the basement up to the plinth level

Activity Layout for column Steelwork for columns Fixing shuttering of columns The casting of the columns Curing of columns Shuttering for RCC casting of the outer wall Steelwork for outer walls Casting all the outer walls of the basement with RCC Curing of outer walls of the basement Shuttering for RCC beams and slab for casting Steel reinforcement for beams and slab casting Casting all the beams and slabs with RCC Curing of beams and slab Opening the beams and slab shuttering Removing the shuttering material from the floor Internal brickwork Final plaster Door frame fixing and finishing Closure of holes in the walls Repair of conduit pipe fitting

Status of works Start End Not Responsible date date Complete In-progress started person ::::::-

::-

::-

:-

::::-

:::::-

Remarks

5.9 Works from the Basement Up to the Plinth Level

163

Table 5.9 (continued)

Activity Finishing of nicks and corners Waterproofing of the floor Waterproofing of the toilet floor Sunken pits for water collection and subsequent drainage Waterproofing of the outside RCC wall of the basement Fixing the Kota stone on the outside wall of the basement Backfilling of the soil Compaction of the soil with water and tools

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

::::-

:-

:-

::-

surface at a 45-degree angle to prevent the formation of straight joints between different castings. Initiate the curing process for the column castings, ensuring water seepage from the sides and top to facilitate thorough curing. After 2–3 days, remove the shuttering and reposition it for the casting of the remaining section of the column. Upon complete casting, allow the RCC to settle before removing the shuttering. The subsequent half of the column can then be cast, followed by another round of curing as recommended by the architects and structural engineers. Wrapping the column with gunny cloth and water application on the cloth can aid in improved curing. For the outer walls of the basements, which are also constructed using RCC, ensure completion of reinforcement steel works, shuttering, casting, and curing in accordance with the design specifications. Following a week after the casting of the outer walls, commence the shuttering work for the beams and slabs, noting that the slabs and beams are cast simultaneously. Upon completing the shuttering, adjust and level the beams and slab shuttering, and erect the reinforcement steel for the beams and slab as per the structural engineer’s specifications. Verify the alignment and level of the slab and beams after the steelworks, preparing them for the casting process.

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5  Civil Construction Works of the Hospital Building

Cast the beams and slab in a single operation to avoid potential leakage from joints. Initiate curing by ensuring water retention on the top of the slab. After the recommended curing time, remove the shuttering from the slab, beams, and column. Clean the floor by removing debris and preparing it for subsequent activities. Move the shuttering material to the next floor for reuse. Simultaneously, commence the internal brick/block work of the already cast basement while the structure work for the next upper basement or ground floor is in progress. Once internal brick/block work is completed, the conduiting activities, including MEP, shall be completed, and proceed with the plaster work. Ensure proper affixing, alignment, and levelling of door and window frames, providing adequate support before installation. Attend to any necessary repairs for the chase cutting performed for the conduits, closing any openings in the walls and finishing all edges and corners meticulously. Before beginning the flooring, apply the recommended waterproofing treatment, particularly for the floor and toilets. Pay special attention to the proper and effective waterproofing of the RCC outer walls of the basement. Apply a waterproof compound to the outer walls of the basement, followed by the fixing of Kota stone or any other non-porous hard stone. After completing the treatment of the outer wall, proceed with the backfilling of mud and sand, ensuring thorough compaction using appropriate tools and water. Note: These civil activities need to be separately conducted for all the basements of the building. At this stage, the work has been completed up to the plinth level. It is now time to construct the ground floor and subsequent upper floors.

5.10 Civil Works See Table 5.10. After a week of the casting of the slab of the lower floor, the layout of the columns shall be marked on the slab. Then, the reinforcement steel works shall be carried on. The steel structure of the column shall be fixed, levelled, and aligned. It is essential to provide adequate support to maintain the stability of the column steel structure. Install the shuttering for the column, choosing between wooden planks, plyboards, or the recommended steel box type shuttering. After the shuttering is in place, recheck and adjust the alignment and level of both the shuttering and the steel structure. Move on to the casting of the column, utilizing pin-type vibrators for effective compaction of the RCC material, leaving no air gaps in the process. It is crucial to limit the column casting to a maximum height of 2000 mm in a single operation. Additionally, maintain the top surface of the casting at a 45-degree angle to prevent the formation of straight joints between different castings during subsequent operations.

5.10 Civil Works

165

Table 5.10  Civil works Status of works Activity Layout for column Steel work for columns Fixing shuttering of columns The casting of the columns Curing of columns Opening the shuttering of columns Shuttering of the beams and slab Steelworks of beams and slab The casting of beams and slab Curing of beams and slab Opening the shuttering of beams and slab Removing the shuttering material from the floor Internal and external brickwork Final plaster Door frame fixing and finishing Closure of holes in the walls Repair of conduit pipe fitting Finishing of nicks and corners Waterproofing of the floor Waterproofing of the toilet floor

Start date ::::::-

:::::-

:-

::::::::-

End date

Not Responsible Complete In-progress started person

Remarks

166

5  Civil Construction Works of the Hospital Building

Now is the time to start curing the column castings, the water is poured from the sides and top so that the water seeps inside the shuttering and from the top. After 2 to 3 days, remove the shuttering and move it upwards for the next casting of the left-over column. Once the column is completely casted, let the RCC settle down. After settlement, remove the shuttering. The next half of the column is casted. Again, start curing. Curing shall be done for the duration as recommended by the architects and structure engineers. For better curing of the columns, it is advised to wrap the column with the gunny cloth and pour water on the gunny cloth. Following the week after the column casting, begin the shuttering process for the beams and slab, keeping in mind that the slab and beams are casted simultaneously. Once the shuttering is completed, ensure the levelness of the beams and slab shuttering. Erect the reinforcement steel for the beams and slab according to the design provided by the structural engineer. Recheck the levelness of the slab and beams after the steelworks and prepare them for the casting of the beams and slab. Cast the beams and slab in one go to prevent potential leaks from joints. Initiate curing with the help of water retention on the top of the slab. Once the recommended curing duration is over, open the shuttering of the slab, beams, and column. Clear the floor of debris and move the shuttering material to the next floor for reuse. Commence the structure work for the upper floor while simultaneously starting the external and internal brick/block work of the previously cast floor. Upon completing the external and internal brick/block work, begin and complete conduiting for other services before commencing plaster work. Refer to the appropriate section in this chapter for detailed information on the activities of other services. After completing all the conduiting activities, including MEP, proceed with the plaster work. Remember to install the door and window frames, ensuring their alignment and levelness and providing appropriate support. Repair any chase cutting done for the conduits, close all openings in the wall, and attend to any necessary repairs. Pay attention to finishing all edges and corners on the walls. Before flooring, apply the recommended waterproofing treatment for the floor, particularly focusing on effective waterproofing treatment for the toilets. Note: All these civil activities have to be separately carried out for all the floors of the building.

5.11 Flooring See Table 5.11. Regarding the flooring of the hospital building, the choice of materials, including marble, ceramic tiles, or granite stone, depends on the preference of the promoters and designers. Regardless of the flooring type, the installation process remains relatively the same.

5.11 Flooring

167

Table 5.11 Flooring

Activity Marking the levels of the floor Put the level markers Fixing the flooring of the rooms with tiles/marble/granite, etc. including skirting Grouting of the floor tiles of rooms Testing of the floor tiles/marble/granite of the rooms Laying the plastic sheet and POP on the flooring for the safety of the floor Fixing the floor tiles/ marble in the toilets Fixing of wall tiles in the toilets Grouting of the wall tiles of toilets Testing of the wall tiles of toilets Fixing of wall tiles on top of working counters Grouting of the wall tiles of counters Testing of the wall tiles of the counter Fixing of granite/ marble on the working tops Grouting of the granite/marble of the working top Testing of the wall tiles granite/marble of working top Fixing of granite/ marble on the staircases

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:::-

::-

:-

:::::-

:::-

:-

:-

:-

(continued)

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Table 5.11 (continued)

Activity Grouting of the granite/marble of staircases Testing of the granite/marble staircases Fixing rough tiles on the ramp Grouting of the tiles of the ramp Testing of the tiles of the ramp

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

:-

:::-

Begin by checking and confirming the floor levels. Thereafter, the level markers shall be provided on the floor. Subsequently, affix the tiles, marble, or granite flooring using cement. In case the tiles are used and the base floor is in level, the fixing compounds can also be used. However, cement is preferred on the raw surface to ensure more accurate and levelled fixing. Allow the floor to dry for approximately 2 days and inspect for any air gaps beneath the flooring. If any gaps are identified, it is advisable to remove the affected piece and reinstall it with a new one. Fill the gaps between the tiles or granite with cement or the compound recommended by the architect. When using marble stone, initiate the grinding process as per the recommended guidelines once the floor is set. However, if ceramic tiles or granite are employed, no grinding is necessary. Protect the finished flooring with a plastic sheet and apply liquid Plaster of Paris (POP) to the sheet to prevent breakage or scratches. Remove the sheet only when the building is entirely furnished and ready for operations. Similarly, affix wall tiles in the toilets and install toilet flooring, ensuring the gaps are grouted and the tiles are thoroughly checked for any remaining air spaces, as done during the installation of room flooring. For staircases, it is common to use granite or marble for flooring, following the same installation process as general flooring. Regarding ramps, special attention must be paid to using rough tiles to prevent slips and accidents. The process of fixing the ramp flooring remains the same.

5.12 False Ceiling See Table 5.12. In hospital buildings, the false ceiling is essentially required as most of the service line runs over the false ceiling and below the slab. These service lines typically

5.12 False Ceiling

169

Table 5.12  False ceiling Status of works Activity Level of ceiling Fixing the perimeter Fixing of hangers Fixing and levelling of the ceiling frame Laying of the POP/ gypsum board/ tiles/PVC Taping of the board joints if required Making cut-outs for lights, grills, and diffusers Making trap doors for AHUs Making cut-outs for sprinklers/ smoke detectors

Start date

End date

Not Responsible Complete In-progress started person

Remarks

::::-

:-

::-

::-

include electricity, air-conditioning, fire safety, medical gases, CCTV, IT networks, nurse call systems, and power lines. Hence, it becomes necessary to provide false ceilings. The false ceiling can be installed using various materials such as Plaster of Paris (POP), gypsum board, tiles, or PVC panels. Regardless of the material chosen, the installation process remains largely similar. Before commencing the installation of the false ceiling, detailed drawings and designs of the false ceiling shall be prepared well in advance. Begin by checking the level of the ceiling and marking out the levels to ensure a consistent false ceiling height. Subsequently, fix the perimeter on the wall, which serves as the support for the ceiling frame. After the perimeter, the hangers shall be installed on the ceiling with the Fowler bolts to support the false ceiling frame. Thereafter, proceed with the erection of the ceiling frame. Double-check the levels of the ceiling frame before securing the false ceiling. Initiate the installation of the false ceiling using the predetermined material, such as Plaster of Paris (POP), gypsum board, tiles, or PVC panels, following the predetermined design. If using the gypsum boards, ensure that taping is done between the joints of the two boards.

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Make necessary cut-outs for lights, fans, grilles, and diffusers. Construct trap doors below the Air Handling Units (AHUs) and provide cut-outs for accessories like sprinklers and smoke detectors.

5.13 Woodwork See Table 5.13. After completing the room painting, the subsequent step involves the installation of doors and windows before the final room finishing. Table 5.13 Woodwork

Activity Fixing the flush doors Fixing of locks, hinges, and handles on doors Fixing of door closers, stoppers, guards, etc. Fixing of margin of the door frame Fixing window frames Fixing the windowpanes Fixing of hinges and handles of windowpanes Fixing window stoppers Fixing of window glass on one of the windowpanes Fixing of wire mesh on one of the windowpanes (if required) Fixing of margin of the window frame Fixing MS/SS/ aluminium grills on the windows (if required)

Status of works Start End Not Responsible date date Complete In-progress started person ::-

:-

::::-

::-

:-

::-

Remarks

5.14 Aluminium Work

171

To begin, attach the doors to the pre-installed door frames using hinges. Install door accessories such as locks, handles, stoppers, and door closers. Set the margin on the door frame at the joint of the door frame and wall to ensure proper alignment. Next, proceed with the window installation. Start by securing the window frame in the designated space for the windows. Then, fix the windowpanes onto the window frames. Attach accessories like handles, bolts, and stoppers to the windowpanes and fix the glass securely in place. If the building is centrally air-conditioned and has fixed windows as per the design, the windowpanes are not affixed, and the glass is directly mounted onto the window frame. Establish the margin on the window frame at the joint of the window frame and wall for accurate fitting. Install wire mesh either on the windowpanes or on the window frame, depending on the window type (single or double). If included in the design, fix the security grills made of aluminium, mild steel (MS), or stainless steel (SS) for added safety.

5.14 Aluminium Work See Table 5.14. If the design calls for aluminium doors and windows rather than wood, the subsequent step involves the installation of the doors and windows before the final room finishing. To begin, securely attach the door frame to the wall using proper screws. Proceed to mount the doors with hinges onto the pre-installed door frames. For double doors operating with floor machines, install the door machines by cutting out the floor to accommodate them. These doors, constructed from extruded aluminium sections and filled with board and/or glass, should have their accessories, including locks, handles, stoppers, and door closers, properly affixed. Following the door installation, move on to the window fixtures. Start by fixing the window frame within the allocated window space. Attach the windowpanes onto the window frames and install accessories like handles, bolts, and stoppers as necessary. Secure the glass onto the windowpanes. In instances where the building is centrally air-conditioned and has fixed windows according to the design, there is no requirement for separate windowpanes, as the glass can be directly installed onto the window frame. Fix wire mesh either onto the windowpanes or directly onto the window frame, depending on the type of window (single or double). If specified in the design, attach security grills made of aluminium to ensure enhanced security. Additionally, certain areas within the hospital might necessitate the installation of aluminium partitions. If so, the partitions shall be made out of extruded

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Table 5.14  Aluminium work

Activity Fixing of door frames Fixing of floor machines Fixing of the doors containing glass/ board Fixing of locks, hinges, and handles on doors Fixing of door closers, stoppers, guard Fixing window frames Fixing the windowpanes Fixing of hinges and handles of windowpanes Fixing window stoppers Fixing of window glass on one of the windowpanes Fixing of wire mesh on second windowpanes Fixing MS/SS/ aluminium grills on the windows if required Assembling of aluminium partition Fixing of partitions Fixing of glass and board in the partition

Status of works Start End Not Responsible date date Complete In-Progress Started person

Remarks

:::-

:-

:-

:::-

::-

:-

:-

:::-

aluminium sections. These partitions shall then be erected at the required places and filled out with board and/or glass. If required, the door can be provided in these partitions.

5.16 Curtain Track, IV Rods, and Corner Guards

173

Table 5.15  Wall guards

Activity Fixing of frames for wall guards made out of wood/ aluminium/ABS Fixing the wall guards

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

:-

5.15 Wall Guards See Table 5.15. Wall guards are fixed on the walls in the corridors and are used to prevent damage to the walls while the movement of stretcher trollies or other movable items. Usually, while the movement of the materials in the corridors, the trollies strike the wall, hence damaging the wall. Wall guards are generally made up of aluminium, stainless steel, wood, or mild steel. The wall guards are generally installed at a height of about 1000 mm from the floors. Another advantage of the wall guards is that it gives support to elderly people and physically compromised persons. These guards are fixed on the wall with the help of screws or fasteners.

5.16 Curtain Track, IV Rods, and Corner Guards See Table 5.16. Usually, curtains are provided on all the patient beds in the hospital to provide privacy to the patient. For providing the curtains on the bed, firstly the hangers need to be fixed above the bed. To fix the hangers, the rods are suspended from the ceiling wherein the lower end of the rods shall be at a height of about 2100 mm from the floor. On the lower end of the rod, the curtain track is screwed. Other accessories like stoppers and curtain roller rings are installed. Once the painting and finishing are complete, the curtains are hung in these curtain roller rings. Similarly, the IV rods are also fixed by suspending them from the ceiling. Corner guards are fixed on the corners of the walls and are used to prevent damage to the corners. Corner guards are generally made up of aluminium, stainless steel, wood, or mild steel. The corner guards are generally 1000 mm in height. These guards are fixed on the corners of the wall with the help of screws or fasteners.

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Table 5.16  Curtain track, IV rods, and corner guards

Activity Fixing of hangers for curtain partition and IV rod Fixing of curtain tracks with curtain roller Fixing of track for IV rod Hanging of curtains Fixing of IV rods Fixing corner guards on all the corners where the trollies have to move like corridors, etc.

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

:-

::::-

Table 5.17  Painting of walls and ceiling Status of works Activity Cleaning the surface to be painted Applying putty on walls and ceiling After drying, rubbing the putty Second coat of putty if required Rubbing of the walls and ceiling Applying primer coat Painting up to the final finish from one to three coats

Start date

End date

Not Responsible Complete In-progress started person

Remarks

:-

::::::-

5.17 Painting Walls and Ceiling See Table 5.17. This is the stage to move forward towards finishing of the building. The last step towards finishing is painting the walls and ceiling.

5.18 Painting Wooden Doors and Windows

175

To commence, ensure that the surface selected for painting is thoroughly cleaned to eliminate any dust or debris. Proceed to apply putty onto the walls and ceiling. After the putty has dried, utilize sandpaper to smooth out the surface. Apply a second coat of putty, and once it has dried, repeat the sanding process. Subsequently, apply a layer of primer onto the walls and ceiling. Upon the primer coat’s complete drying, apply three coats of paint sequentially. Allow each coat to dry completely before applying the subsequent layer.

5.18 Painting Wooden Doors and Windows See Table 5.18. Now move on to the painting of the wooden doors and windows. Process wise, it is the same as in the case of walls and ceilings. To start, the wooden surface which has to be painted shall be cleaned properly to remove any dust or debris on the surface. Apply putty on the wooden surfaces. Once the putty is dried out, rubbing shall be done with the sandpaper. Apply the second coat of putty. Again, rub with the sandpaper when it is dry. Next is to apply a coat of primer on the wooden surfaces. Once the primer coat is dry, apply three coats of paint one after the other. After each coat, let the paint surface dry out before applying the next coat. Table 5.18  Painting of wooden doors and windows Status of works Activity Cleaning the surface to be painted Applying putty on doors and windows After drying, rubbing the putty Second coat of putty if required Rubbing of the surfaces Applying primer coat Painting/polishing up to final finish from one to three coats

Start date :-

::::::-

End date

Not Responsible Complete In-progress started person

Remarks

176

5  Civil Construction Works of the Hospital Building

If the wooden surfaces are to be polished instead of painting, the process remains the same.

5.19 Painting MS Iron Surfaces See Table 5.19. Next is the painting of mild steel iron surfaces. Process wise, it is the same as in the case of walls and ceilings. To start, the iron surface which has to be painted shall be cleaned properly and made free from any dust or debris. Apply metal putty on the iron surfaces. Once the putty is dried out, rubbing shall be done with the sandpaper. Apply the second coat of putty. Again, rub with the sandpaper when it is dry. Next is to apply a coat of red oxide primer on the iron surfaces. Once the red oxide primer coat is dried, apply three coats of paint one after the other. Before applying the next coat of paint, ensure that the previous coat is completely dry. If the iron surfaces are to be polished instead of painting, the process remains the same. Note: Please note that all the above activities of various services have to be carried out for all the floors of the building Table 5.19  Painting MS iron surfaces Status of works Activity Cleaning the surface to be painted Applying putty on the surface After drying, rubbing the putty Second coat of putty if required Rubbing of the surfaces Applying primer coat with red oxide Painting/polishing up to final finish from one to three coats

Start date :-

::::::-

End date

Not Responsible Complete In-progress started person

Remarks

5.20 Lifts/Elevators

177

5.20 Lifts/Elevators See Table 5.20. In a multi-story hospital, vertical lifts serve as a crucial means of efficient vertical transportation between different floors. This system plays a pivotal role in the movement of patients, medical equipment, support services, personnel, and visitors within the facility. Lifts also play a vital role in enabling evacuation protocols in the event of emergencies or accidents. The operation of lifts is typically regulated by national statutory regulations in the majority of countries. Hence, the lifts need to adhere to the stipulated requirements outlined by the relevant government authority. To initiate the installation process for the lift, the first step involves preparing the lift well. A lift well refers to the vertical shaft within which the lift operates. The construction of the lift well entails designing and preparing the necessary drawings based on the dimensions and specifications provided by the original lift manufacturer. The construction process involves erecting columns with beams on each floor, followed by the placement of brickwork between the columns and beams to shape Table 5.20  Lifts and elevators

Activity Plaster works of the lift well Painting of the lift well Providing lights in the lift well Waterproofing of the lift well pit Scaffolding in the lift well Prepare the machine room (if required) Providing required electrical points in the machine room Installation of the lift by the vendor Marble/granite on the wall of lift doors Commissioning of the lift Final testing of the lifts

Status of works Start End Not Responsible date date Complete In-progress started person :::::::-

::::-

Remarks

178

5  Civil Construction Works of the Hospital Building

the shaft. Subsequently, the interior and exterior of the lift well are plastered, and a coat of paint is applied to both sides. Using wall putty inside the well and ensuring a smooth surface can minimize the likelihood of spider webs forming within the well. The exterior painting can be coordinated with the building’s overall aesthetic. Considering the lack of natural light within the lift well, a lighting fixture shall be installed to facilitate maintenance work by ensuring clear visibility. At the bottom of the lift well, a pit is also provided, where the springs are installed, for the easy and jerk-free landing of the lift car. As this well is below ground level, it is necessary to waterproof the surfaces of the pit to avoid any seepage of the water. In the case of lifts that are not ‘Machine Room Less’ (MRL), a machine room must be built atop the lift well to house the lift’s machinery. However, MRL lifts are commonly installed nowadays. Once the lift well is ready, for installation of the lift, it is handed over to the vendor of the lifts for installation. The scaffolding shall then be erected in the entire well of the lift, to install the channels of the lift. In the meantime, the electrical supply shall be provided to operate the lift. The power shall be adequate to operate the lift and shall be given from the dedicated MCB. Upon the installation of the door frames by the vendor, the front facade of the lift, where the doors open, undergoes wall treatment. Typically, marble or granite stone shall be used to enhance the aesthetic appeal of the lift’s front side. Following this, the lift is handed over to the hospital authorities, who conduct a comprehensive assessment of the lift’s functionality and parameters. If everything is deemed satisfactory, the lift can be made available for regular use. Once the lift has been installed, the same has to be commissioned by the vendor by checking the operation and safety parameters of the lift. Subsequently, the lift shall be handed over to the hospital authorities, who in turn shall check the operation and all other parameters of the lift. If everything is found to be perfect, it can be approved for actual use.

Further Reading Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. India: Springer Singapore; 2022.

Chapter 6

Electrical Works of the Hospital Building

In any hospital project, it is crucial to evaluate the power needs for operating equipment, providing general electrical outlets, operating air conditioning systems, lighting and other essential functions. Additionally, it is equally important to identify specific areas that may require special power considerations such as magnetic resonance imaging (MRI), positron emission tomography–computed tomography (PET–CT), linear accelerators (LINACs) and other specialised equipment. The enclosed checklist provides the sequence of all such electrical works that have to be conducted inside the proposed building, and thus helps the site engineer plan the start and end days of each activity along with the present status of that particular activity.

6.1 Internal Electrical Works Inside a Hospital Building See Table 6.1. Electrical services are one of the most important components of a hospital building and are carried out both inside the building—i.e. on floors—and outside the building—like substations etc. Here, we highlight the works and activities that are to be carried out on the floors inside the building. The first step is laying conduits and fixing switch boxes. By cutting a chase in the wall, the conduits are laid and held in place with hooks. Similarly, switch boxes are also fixed to the wall after cutting a space in the wall. Once fixed, the walls are plastered to conceal them. Similarly, as per the drawings and designs, conduits may or may not be laid on the ceilings or floors. Once the conduiting of the rooms are completed, the main conduits are laid from the room to the main distribution box (DB) of the area. If required, cable trays are also laid either suspended from the ceiling or fixed to the wall. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_6

179

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6  Electrical Works of the Hospital Building

Table 6.1  Internal electrical works inside a hospital building

Activity Wall conducting and box fixing Providing required LT electrical outlets Conducting of ceilings All main and branch conduit connections Fixing the cable tray, if any Low Tension (LT) wiring of the room with copper cables with proper wire sizes Providing LT electrical points near the bed head panel Laying conduits for power points in the room Cabling for power points for equipment/air conditioning (AC) Fixing the distribution boxes (DBs) Fixing the switchboards Connection of cables to the switchboards Main line wiring from the rooms to the respective DBs Connection of the DB to the floor LT electrical panel Fixing of light fittings Electrical connection to the AHUs Laying conduits and wiring of UPS power supply from the LT floor panel to the room switchboard Points for emergency light Testing of the lights

Status of works Start End In Not Responsible date date Complete progress started person

:::::-

:-

:-

:-

::::-

:-

:::-

::-

Remarks

6.1 Internal Electrical Works Inside a Hospital Building

181

Table 6.1 (continued)

Activity Some of the LT panel cum DG panels that may be specifically required are:  Imaging department panel  Different floor panels  Heating, ventilation and air conditioning (HVAC) panel  Central laboratory panel  Cath lab panel  Operating theatre panel  LINAC panel  Lift panel  Plumbing panel  Utility panel Firefighting panel  External lighting panel

Status of works Start End In Not Responsible date date Complete progress started person

Remarks

:::-

:::::::::-

The next step is to lay electrical cables and wires. Cabling is done from the main DB to the concerned switchboard and then to the concerned electrical outlets. Separate cabling needs to be done for fans and electrical and power loads. In hospitals, usually, bed head panels are provided to supply medical gases. In these bed head panels, electrical outlets are also provided. Hence, separate cabling needs to be done for these bed head panels. Inside hospital rooms, electrical outlets are provided for fans, light appliances and power points. The switchboards are fixed to the walls of the rooms. Now comes the fixing of the distribution boards (DBs). DBs generally have miniature circuit breakers (MCBs), which control the supplies to the switchboards of the rooms. If an overload is noticed or there is any fault in the room lines, then the DB trips automatically. Individual wires are laid from the switchboard of the room to the respective DB. From DBs, cables are laid to be terminated at the floor’s low-tension (LT) panel. In turn, the LT panel is connected to the main panel of the building. Once painting of the rooms is done, electrical appliances like lights and fans are installed in the rooms, corridors, etc. In case the hospital building is centrally air conditioned, air handling units (AHU) need to be installed. Electrical supplies will be provided to these AHUs from a separate MCB in the respective DB.

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6  Electrical Works of the Hospital Building

As continuous power backup is essential in a hospital building, the provision will be made for either a centralised uninterruptible power supply (UPS) or separate UPSs for different areas. If a central UPS is designed, the cabling should be done separately for each area and should terminate at the different DBs. From the DB, the cabling should be laid, which should terminate at the respective UPS. Adequate arrangements for emergency lights in all the important areas of the hospital must be made. Hospitals provide several services, which require a heavy load of electricity. Apart from this, there are a few sophisticated and sensitive machines that may require good quality electricity. Hence, it is always advisable to install a separate electrical panel for these areas, so as to provide controlled and regulated electrical supply. These types of panels can be planned for heating, ventilation and air conditioning (HVAC), imaging departments, clinical laboratories, operating theatres, Cath lab, linear accelerators (LINACs), firefighting, elevators, etc. Note: Please note that all the above activities of various services have to be carried out for all the floors of the building.

6.2 Centralised Electrical Works See Table 6.2. Both central and control works for effective supply of electricity to the end users are required to be carried out in the hospital building well in time. Once the electrical internal works are completed, the works of the central and control works should be started. However, if time or progress allows, then these works can also be started simultaneously along with the internal electrical works. The central and control works of electricity supply include various modalities like an High Tension (HT) substation, a main Low Tension (LT) panel, a floor panel, distribution boxes, Moulded Case Circuit Breaker (MCCB) and Miniature Circuit Breaker (MCB), diesel generator sets, a UPS system, earthing, lightning arrestors and solar power system. Now, let us discuss all these modalities one by one.

6.2.1 HT Substation Works An HT substation of a hospital is usually required in case the connection to the hospital is released by the service provider through high-tension (HT) lines. In case the connection is supplied through low-tension (LT) lines, a complete substation is not required and only a meter room will suffice. If it is an HT line, then the cables have to be laid from the grid and terminated at the energy meter installed in the hospital meter room. However, if it is an LT line,

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Table 6.2  Centralised electrical works

Activity Substation works Laying the cable from grid lines till the energy meter Installing the energy meter Sealing the meter with a sealing certificate Laying the foundation for a VCB Installing a VCB Providing a 11-kV supply line from the metering room, which should terminate at the main HT VCB Laying the foundation of the transformer Installing the transformer Providing a 11-kV supply line from the VCB, which should terminate at the main transformer Preparing the cable tranches/trays Providing a servo stabiliser with a spike burster Connecting the transformer with a servo stabiliser through the busbar/cables Providing a bus coupler between the servo stabiliser and the LT panel LT panel room Installing the main LT panel cum DG panel Installing capacitor panels Connecting the main LT panel with the floor panel through the rising main Connecting the floor panel with the floor DBs Diesel generator sets Laying the foundation for the DG sets

Status of works Start End In Not Responsible date date Complete progress started person

Remarks

::::::-

:::-

:::-

:-

:::-

:-

:(continued)

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Table 6.2 (continued)

Activity Installing DG sets with accessories like the fuel tank, silencers, etc. Synchronising DG sets with a common bus bar Testing and commissioning DG sets Connecting DG sets with the main DG panel located in the panel room of the building and providing a bus coupler UPS system Installing all the uninterruptible power supply (UPSs) systems required for the hospital in the UPS room Connecting the UPS to the main LT panel in the panel room Earthing Earthing of the HT/LT distribution system Earthing of the medical equipment for which separate earthing is required Lightning arrestors Installing lightning arrestors Earthing of lightning arrestors Solar electrical system Constructing foundations for rooftop solar cell panels Fabricating and fixing the GI/MS structure for fixing solar cell panels Installing solar cell panels Connecting the solar cell panels with the inverter Connecting the invertor with the solar control panel in the main control panel room Metering of the solar power

Status of works Start End In Not Responsible date date Complete progress started person :-

:::-

:-

:-

::-

::-

::-

:::-

:-

Remarks

6.2 Centralised Electrical Works

185

then the cables need to be laid from the transformer of the service provider to the energy meter installed in the hospital meter room. In either case, the cost of laying the cable has to be worked out and clarified by the service provider as to who is going to bear this cost. In the case of the HT line, usually, the beneficiary has to pay the amount, whereas, in the case of the LT line, the service provider bears the cost of laying these cables. There is one more scenario, which is the independent feeder provided by the service provider. An independent feeder means that on this feeder, no other connection will be released to other users and the power will be supplied to only one beneficiary. In this case, the entire cost of cabling from the feeder to the energy meter in the hospital also has to be borne by the beneficiary. In either of the cases, the project engineer should ensure that the cable is laid properly and terminates in the meter room of the hospital. Next is the installation of the energy meter. It is the responsibility of the hospital to provide an energy meter room at a convenient place near the main gate of the hospital so that the meter can be read by the service provider without entering the hospital building. The size of the meter room should be approximately 3048 mm × 3048 mm. There should be proper ventilation in the room, and the door of the room should be about 915 mm wide. It has to be strictly ensured that there is no seepage in the room and that outside water or rain water cannot enter the room under any circumstances. The meter should be fixed on one of the walls of the room, and the cable connecting the grid should terminate at this meter. The meter should be sealed by the service provider in the presence of the hospital authorities, and the meter sealing report and certificate should be signed by both parties. One copy of this report cum certificate should be safely secured by the hospital authorities. In case the supply to the hospital is from the HT line, the power in the energy meter will also be on HT. This HT power needs to be stepped down to LT power through the transformer. As there is always the chance of any fault in the HT line, a protection device should be installed between the energy meter and the transformer. Hence, a vacuum circuit breaker (VCB) is provided just after the energy meter. To install a Vacuum Circuit Breaker (VCB), the foundation should be laid, preferably in a separate room (other than the meter room). The size of the foundation should be as per the specifications provided by the manufacturer of the VCB. It is advised that the VCB be installed in front of the wall, which is common to both the rooms i.e. the meter room and the VCB room. Sleeves should be installed on this common wall to cross the cables from the energy meter to the VCB. The size of the VCB room should be approximately 3048 mm × 3048 mm. The room should have proper ventilation, and the door of the room should be about 915 mm wide. As in the case of the meter room, it should be ensured that the VCB room also has no seepage and that outside water or rain water cannot enter the room under any circumstances. Once the foundation is ready, the VCB is installed by the vendor. Thereafter, the cable connecting the meter and the VCB is provided, and the VCB should be tested to ensure proper supply of power and working of the VCB.

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Next is the installation of the transformer. A transformer is required to step down the HT voltage to the LT voltage. A transformer should be installed outside the building and should be open so that it can be properly cooled by air. The size and load-bearing capacity of the foundation should be as per the specifications provided by the original manufacturer of the transformer. Although there are no specified norms, it is recommended that the height of the transformer not be less than 1000 mm from the ground level. While laying the foundation, all the norms of civil construction like the ratio of concrete, use of vibrator and curing should be adhered to. Once the foundation is ready, the transformer should be installed and properly connected to the VCB through the HT cable. The transformer should be commissioned and tested for proper output of the LT voltage. Then comes the stage where the output of energy from the transformer has to be transmitted to the hospital building. The first step is to provide the facility for laying cables or busbar from the transformer to the main LT panel of the hospital. The cable or busbar can be laid either in the trenches or in the overhead cable trays. As the substation is outside the main hospital building, it is recommended that the cable be laid in underground trenches. However, if cable trays are provided, then they can be also overhead. These connecting cables or the busbar should be connected to the output of the transformer and terminate in the main LT panel room. It is further recommended that the main power supply be routed through the servo stabiliser installed in the hospital before entering the LT main panel. There are always chances of voltage fluctuations and, at such a time, a pure sine wave may not be obtained as output. Sensitive electronic medical devices can be damaged due to such fluctuations and spikes. Hence, providing a servo stabiliser with a spike burster is recommended. If such a stabiliser is installed, then the main cable or busbar from the transformer should terminate at this stabiliser. The output of this stabiliser should be connected to the main LT panel of the hospital. In case of any fault in the transformer or the connecting cables/busbar and or precaution of the LT panel, a bus coupler should be provided between the transformer and the LT panel.

6.2.2 The LT Panel Room The LT power obtained from the output of the transformer or the servo stabiliser, as the case may be, should be connected to the main LT panel installed in the hospital. The main LT panel is usually installed in the main building or in an annexure building near the main building. The LT panel acts as the main control panel for controlling the electricity of the entire hospital building. From this LT panel, various circuits are drawn and connected to the individual floor panels of the hospital. The LT panel also facilitates connecting the power generated by the diesel generator (DG) set. The LT panel has a provision for incoming power from the main power supply and the power supply from the DG set. There is an automatic and

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manual bypass of the main power and the DG power. If the main supply is available, the the incoming from DG power will get disconnected, and vice versa. From the main LT panel, various circuits are drawn and connected to the rising main cables or rising main busbar, provided in the building for the supply of power to different parts of the building. For laying down the rising main cable/busbar, a dedicated service shaft should be provided near the main LT panel room. This shaft should travel through the entire floor of the hospital building. These cables or the busbar should be properly affixed to the wall of the shaft with the help of fasteners, and the open spaces of the shaft should be properly sealed so that in case of fire, the smoke from the cable/busbar shaft does not travel to the upper or lower floors. Along with the LT panel, a capacitor panel should be installed to control the power factor of the power. This panel is again connected to the main LT panel. The rising main cable/busbar should terminate individually at all the floor panels installed on the individual floors of the hospital. To facilitate this, a small panel room should be provided on each floor just one above the other. An individual floor panel should be installed in these panel rooms, and the rising main cable/busbar should be connected to these floor panels. From these floor panels, different circuits are formed and connected to the DBs at various locations on the floor.

6.2.3 Diesel Generator (DG) Sets In a hospital setup, there are always chances of power failure due to any reason what so ever. Power failure in hospitals is unacceptable. Hence, there should be provision for the supply of uninterrupted power in hospitals and, as such, a backup power system should be facilitated. Although there are other sources like solar power etc., the best source is a diesel generator set. What should be the capacity of a DG set? During the planning of the electrical load, the total load of the building is calculated. The rating of DG sets should be decided and calculated based on the power required at peak load and at normal non-­ peak load. Considering this load, the power required for non-essential services like air conditioning, heavy lighting, etc. is deducted and the load required from the DG set is calculated. About 20% extra is added to this load to avoid overloading on the DG set. This will provide the total capacity required for the DG set. Furthermore, it is recommended that instead of going in for one DG set of the calculated capacity, it is better to opt for two DG sets of less capacity so that in case of failure of either of the DG sets, the other is available as a backup. Once the order for the DG set is placed, the specification of the foundation from the manufacturer of the DG set in terms of the size of the foundation and its load-­ bearing capacity considering the vibration load of the DG set should be taken. Accordingly, the foundation of the DG set should be constructed. Ensuring the proper curing of the foundation is also essential.

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Now is the time for the installation of the DG set on the foundation. The DG set should be affixed with the help of fasteners. Proper vibration pads should be provided below the body of the DG set during installation. Other accessories like fuel tanks, silencers, etc. should be installed. The open end of a silencer should be at least 1524 mm higher than the height of the building. Provision for onsite storage of diesel for generator sets should be provided. The amount of diesel to be stored is determined by the estimated running hours of the DG set. If more than one DG set is installed, then it must be ensured that all such DG sets are of the same frequency so that they can be easily synchronised on a common busbar. Once all the DGs are installed, all these sets should be synchronised to a common busbar. These DG sets will provide power automatically in the absence of a primary power supply or when the supply voltage falls below a predetermined level. Hence, DG sets should have for the capacity to auto-start. DG sets should be commissioned and tested. Thereafter, the output from the busbar should be taken to the DG panel (if provided separately) or otherwise connected to the main LT panel provided in the hospital building, through the bus coupler. This connection will be one of the incomers for the main LT panel.

6.2.4 Uninterruptible Power Supply (UPS) Systems In any hospital, there are a number of medical devices like ventilators, CT scanners, operation theatre devices, etc., which require uninterrupted power supply. If power is switched off even for a second, then these machines will shut down, which can prove fatal to patients. Hence, the best option is to install uninterruptible power supply (UPS) devices. For calculating the capacity of a UPS, the electrical load of the medical devices should be worked out, about 20% should be added to this load (to avoid overloading on the UPS) and the required capacity of the UPS should be calculated. The next issue is the backup time. As a UPS works on a battery system, the more the backup time will be, the more the number of batteries that will be required. Usually, it is recommended that the backup be about 20–30 min. Critical care units such as intensive care unit (ICU), neonatal care unit (NICU), emergency and so on must each have a dedicated UPS system connected to the concerned unit. Few light points (not all are required) and approximately half of the electrical outlets should be connected to the UPS circuit. These outlets should be used to connect life-saving machines such as monitors, invasive and non-invasive ventilators and so on. It is recommended that a three-phase online UPS be installed in all the ICUs separately. The UPS rating should be designed to meet the requirements. For example, the UPS rating for a 10-bed ICU should be around 5–10 kVA on average. For emergency lighting in the hospital building, a single UPS or a floor UPS can be used. The UPS rating should be designed based on the load requirement.

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189

As far as the operating rooms (ORs) are concerned, each OR should have a dedicated UPS system. The plenum and peripheral lights should be connected through the UPS circuit. All the electrical outlets and sockets should also be connected to the UPS so that power can be supplied to the machines and equipment in the OR, in case of failure of the primary power. It is recommended that in ORs, a three-phase online UPS be provided. The rating of the UPS should be designed as per the requirement. Generally, the rating of the UPS for each OR should not be less than 10 kVA. A UPS should also be provided for the hospital server and the working nodes and distribution switches located throughout the hospital. One dedicated UPS should be provided for each server, and a small offline UPS should be installed for each working node and distribution switches. Otherwise, a dedicated UPS power supply line can be installed in the building to provide power backup to all information technology (IT) equipment such as computers, closed-circuit television (CCTV), wi-fi routers, fire panels, alarms and so on. The UPS rating should be designed to meet the requirements. For high-rated MRI, CT or LINAC machines, a dedicated UPS system for each should be provided. This UPS system for each machine should be placed near the concerned machine. The next step is installing the UPS. If all the UPSs are placed at a common location in the hospital, one room of adequate size should be constructed, which is generally not assessable. The size of the room should be determined based on the number of UPS systems to be installed in the room. Because battery life is heavily influenced by room temperature, the temperature in UPS rooms should be kept between 18 and 22 °C. Alarm systems should also be installed in the UPS room, for warning in case the temperature rises above the normal range. As batteries produce fumes, the room should also have adequate provision for exhaust. If individual UPS systems are to be provided at different locations in the hospital or for different machines separately, then there is no need to provide a separate room. Providing a separate enclosure for a UPS at the concerned location of the machine is sufficient. Once the UPS is placed in position, the battery bank should be connected to the UPS. It must be ensured that the batteries are properly positioned on the stands and that they are connected to each other and, finally, to the UPS. In case a common UPS is provided for the emergency lighting of the building, the UPS output should be connected to the main LT panel kept in the hospital building, with auto switchover provision.

6.2.5 Earthing For almost every electrical installation at the hospital, earthing should preferably be provided. Earthing should be provided for the entire HT/LT distribution system. This can be accomplished by establishing a local maintenance-free earth station and

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bonding the cables/equipment. Earthing should be accomplished using an insulated copper earthing wire that runs throughout the length of circuits, terminates at boxes or electrical fixtures and is bonded to the main earth. Separate chemical earthing should be carried out using copper electrodes for the entire UPS system units, electronic private automatic branch exchange (EPABX), servers, lifts and low-voltage systems. Most importantly, equipotential bonding for all hospital equipment is required. This is accomplished by connecting the metal bodies of the aforementioned equipment to the earth bonding bar (EBB), which is then connected to the chemical earthing. Critical units, such as ORs, should be earthed using a dedicated EBB that is located near the Operating Room (OR).  Other areas require Earth Bonding Bar (EBB) in the respective sub-electrical rooms where the final DBs are installed. Major machines, such as MRI machines, CT devices, LINACs, chillers and so on, should have supplementary earthing and bonding with a dedicated EBB. All electrical panels and sub-panels should be bonded and earthed separately with a separate EBB. It should be ensured that all the HT, LT and floor panels, including the DBs, are properly earthed. Similarly, for medical devices for which separate earthing is recommended by the manufacturer of the device, earthing should be provided as per the specification provided.

6.2.6 Lightning Arrestors A lightning arrestor is a device that is installed on the outside and top of a building to prevent structural damage caused by lightning and similar discharges. It also protects against secondary damage, such as strikes that cause branches of nearby trees to fall. Lightning arrestors also help protect a building’s vulnerable wires and cables. The project engineer should ensure that lightning arrestors are installed properly at the recommended height. The arrestors should be properly secured and supported by wires so that they do not fall by wind pressure. After installation, the arrestors should be properly earthed to the ground by the methods recommended by the manufacturers of the same.

6.2.7 The Solar Electrical System Solar electrical power is a renewable source of energy. If the roof top of the hospital allows for the installation of a solar power system, then the promotor should opt for same. If it is planned, then the first step should be calculation of the capacity of panels that can be installed considering the size of the solar panel, shading area and

6.3 The Street Lighting System

191

the direction of the sun. Once this exercise is done, the capacity and number of solar panels are finalised. Depending on the number of solar panels, the foundation should be prepared. It is recommended that the foundation not be directly placed on the final surface of the rooftop but on the slab, and it is preferrable that the reinforcement steel be screwed to the reinforced concrete cement (RCC) slab of the roof. Next is the casting of the foundation. Provisions for fixing the fastener of the solar panel structure on the foundation should be provided. The foundation should be properly cured. Once the foundation is ready, the prefabricated Galvanized Iron (GI) / Mild Steel (MS) structure of the solar panel should be fixed on the foundation. It is this structure on which the solar panel will be mounted. Now, the solar panel is mounted on the structure and screwed properly. The direction of the solar panel should be aligned. The cables coming out of the solar panels should be connected to the inverter provided near the solar panel. The output of the invertor should be connected to the solar panel kept near the main LT panel of the building. This solar panel should then be connected to the main LT panel as an incomer. Last is the metering of solar power generation. If the hospital is using the entire power generated by the solar system, then it should have a meter of its own just to keep track of the power generated from the solar power plant. If there is excess power or the hospital does not want to use solar power, then this unutilised power can be fed into the main electrical grid of the service provider through the meter. The charges from power fed into the grid are ultimately adjusted in the total bill of electricity supplied to the hospital by the service provider.

6.3 The Street Lighting System See Table 6.3. Hospitals typically require higher-quality lighting as many of the users and visitors will have poorer mobility, eyesight and general awareness, often due to illness or old age. This often translates into higher average lux levels, higher uniformity, fewer shadows and less clutter and should be aesthetically pleasing and provide scalable lighting. Hospital outdoor lighting is required for all hospital entrances, hospital roads, parking lots, rest gardens and building exteriors, among other things. Bright, welcoming, exterior lighting not only provides a sense of security for patients who arrive at the hospital late at night but also delight patients, already admitted, who are sick or are suffering from pain. For lighting of the internal roads, GI electrical poles should be provided alongside the roads. Cabling should be done for all electrical poles. The pole-spacing configuration should be such that it can improve illumination uniformity. The height of the pole should be at least 7 m.

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Table 6.3  The street lighting system

Activity Providing the electrical poles Providing low-height garden lights Providing building highlighter lights Providing light fittings on the boundary wall Providing light fittings on the columns of the main gate Providing bulbs and light-emitting diodes (LEDs) for the lights Laying wiring/cables for external lighting Connecting the lights with the main switches If solar lights are used, then providing a battery box on the poles If automation for auto on/off is required, then connecting the lights with the automation control unit Commissioning and testing of the lights

Status of works Start End In Not Responsible date date Complete progress started person Remarks :::::-

:-

:::-

:-

:-

Inpatient rest gardens and lawns are primarily used to beautify the environment and provide patients with outdoor rest and walking space. Such spaces should be warmly lit, but not too brightly, using low-height garden lights. The inter-distance of these lights should be sufficient enough to adequately illuminate the entire area. Special attention should be paid to provide lighting to all the nooks and corners of the premises. To highlight the building, high-lumen building highlighters should be used. These highlighter fittings should be fixed on the ground outside the building, with the beam angled in such a manner as to cover the entire building elevation. For better security of the hospital premises, it is also advised to provide lights on the top of the boundary wall of the hospital. For lighting of the boundary wall, boundary lights can be used or, otherwise, a small pole with an electrical fitting on top can be used. In some cases, instead of fixing the lights on the top of the

Further Reading

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boundary, GI poles (as provided for roads) can be installed alongside the boundary for lighting. Similarly, on top of the columns of the main gates, lights should be provided. Here, any fancy electric pillar lamps can be used. Once all the poles and light fittings are installed, the next is to fit bulbs. It is advised to use Light Emitting Diode (LED) bulbs instead of any other conventional ones as the power consumption of LED bulbs is much less as compared to those of others. Cables and electrical wires should be laid, and main switches at any convenient place, preferably near the main security post, should be provided. However, it is better if external lighting is provided with a timer controller for switching ON/OFF as per schedule. In case solar lights have to be used for street lighting, the GI pole should have a provision for fixing photoelectric cells on top of the pole and a battery box should be provided in the middle of the pole to place the rechargeable battery.

Further Reading Farooq A, Alhalabi W. Smart electrical Design of Medical Center to vary field parameters: sensor network in improving health care. J Eng Appl Sci. 2019:14. Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. India: Springer Singapore; 2022. p. 425–32. Chapter 39, Electrical Works Group TM.  Hospital-Grade Standards for Power Cords and Other Power System Components for Global Markets [Internet]. [cited 2021 Jul 12]. https://www.medicaldesignbriefs.com/ component/content/article/mdb/features/technology-­leaders/21330 Owen S.  NFPA 99 and the NEC: the basis for a healthy electrical system [internet]. EC&M 2004 [cited 2021 Jul 12]. https://www.ecmweb.com/content/article/20891697/ nfpa-­99-­and-­the-­nec-­the-­basis-­for-­a-­healthy-­electrical-­system Reiling J, Hughes RG, Murphy MR. The impact of facility design on patient safety. In: Hughes RG, editor. Patient safety and quality: an evidence-based handbook for nurses [internet]. Rockville, MD: Agency for Healthcare Research and Quality (US); 2008. [cited 2021 Jul 12]. (Advances in Patient Safety). http://www.ncbi.nlm.nih.gov/books/NBK2633/. Saving money in hospital electrical distribution systems [Internet]. Healthcare Facilities Today. [cited 2021 Jul 12]. https://www.healthcarefacilitiestoday.com/posts/ Saving-­money-­in-­hospital-­electrical-­distribution-­systems%2D%2D2607 The Electrical Distribution Systems for Hospitals [Internet]. [cited 2021 Jul 12]. http://www. electrical-­knowhow.com/2012/02/electrical-­distribution-­systems-­for.html

Chapter 7

Water Supply and Drainage Works of the Hospital Building

Water is an essential element for sustaining life, and a reliable water supply and efficient drainage system is vital for human survival. Their importance is particularly heightened in hospitals, where the well-being of ill and critical patients is at stake. In such healthcare facilities, it is imperative to have an excellent water supply and drainage system that guarantees clean, hygienic and high-quality water. The quality of water supply and the effectiveness of the drainage system both have a significant impact on critical factors such as infection control, the lifespan of medical equipment and the hygiene of staff and patients. Many systems and procedures within hospitals rely either partially or entirely on the availability of clean and treated water for the well-being of both patients and staff. Moreover, the performance of certain medical equipment is directly influenced by the quality of water they receive. Equally important is the proper drainage and treatment of wastewater. Ensuring the reliability of the water supply system is of utmost importance. It is crucial to have uninterrupted access to water at all times within the hospital building. However, it is also essential to regulate the volume of water to avoid unnecessary wastage and prevent water stagnation in storage tanks. The enclosed checklist provides the sequence of works related to water supply and drainage, which has to be carried out for the building, and helps the site engineer plan the start and end days of each activity along with the present status of that particular activity.

7.1 Sanitary Works Inside a Hospital Building See Table 7.1. First is the laying of the pipelines for the supply of water and drainage. For supply lines, the water supply pipes should be laid on the walls or floors (as per the design and drawings) by cutting a chase on the wall. The pipes are held in place by © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_7

195

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Table 7.1  Sanitary works inside a hospital building

Activity Core cutting for drain pipes if the sunken portion of the toilets is not provided Waterproofing and sealing of the cutting after fixing the drain pipes Providing an individual toilet supply line conduiting for both hot and cold water Providing a supply line for drinking water from the RO plant to the floor Providing an individual toilet drain piping Providing an individual toilet floor trap fixing Fixing traps for Water Closet (WC) Connecting the supply line with the main supply line Connecting the drain with the main drain line Fixing the angle valves Fixing the brackets and angles Fixing the mixtures Fixing the flush valves Testing all supply lines Testing all drain lines Fixing wash basins and WC Fixing taps and other fittings Providing a settlement tank for radiation waste Final testing of toilets

Status of works Start End In Not Responsible date date Complete progress started person

Remarks

:-

:-

:-

:-

::::-

:::::::::::-

fixing hooks. These pipes are then covered by plastering the wall. If the pipes are laid on the floor, then these would be covered at the time of flooring. As far as the drain pipes are concerned, in case the sunken portion of the toilets are provided, the pipes are laid from the outlet of the drain traps and are routed

7.2 Central Works of Water Supply and the Drainage System

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through the service shaft of the building, terminating at the main hole on the ground floor, which is generally provided outside the building. In case the sunken portions are not provided for toilets, fine-core cutting of the slab is carried out, pipes are fixed and effective sealing and waterproofing are carried out around the core cutting. For the supply of hot water, separate insulated pipelines need to be laid from the hot water generation source till the utility end. Similarly, separate pipelines should be laid for drinking water right from the reverse osmosis (RO) water supply source till the last user end. Then, all the floor traps should be securely fixed and sealed to avoid water leakage. Ensuring proper connection of the drain pipes from the traps to the drain lines, which terminate at the main holes, is a must. Once the toilets and rooms are painted and finished, bathroom and sanitary fittings, such as required taps, angle valves, flush valves, faucets, brackets, soap dishes, towel hangers, mirrors, wash basins, commodes, etc., should be installed. In case a nuclear medicine testing facility is provided in the hospital, a separate settlement tank for radiation waste should be installed before connecting it to the main disposal line. The toilets to be used for these patients should be connected to the settlement tank. All the pipelines, drains and bathroom fittings should be tested to ensure their proper working. Note: Please note that all the above activities of various services have to be carried out for all the floors of the building. To supply water in and outside the hospital building, some external works are also required, such as water supply, hot water supply, drainage, rainwater harvesting, irrigation water supply, sewage treatment plant/effluent treatment plant (STP/ ETP), pump rooms, RO water supply, etc.

7.2 Central Works of Water Supply and the Drainage System See Table 7.2.

7.2.1 The Water Supply System A hospital has various sources of water supply. These can include water supply from a water network supplier by connecting to their distribution network (which could be government-owned or private), self-owned boreholes, underground water wells and connections for portable water trucks, among others. If the water source is from a self-owned borewell, then a borewell needs to be dug. Before digging the borewell, the designer should assess the quantity of water that will be required at the hospital. While assessing the quantity, the designer should consider factors like weather (as summers may require more water as compared to winters), the peak flow requirement of water (morning hours may require

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7  Water Supply and Drainage Works of the Hospital Building

Table 7.2  Water supply and the drainage system

Activity Water supply system Assessing the water requirement Digging a borewell, if required Installing the casing and filters in the borewell Preparing a submersible pump to be installed in the borewell Installing a submersible pump in the borewell Electrical connection of the submersible pump Installing the rooftop/ overhead tanks Water outlet connection of the borewell to the rooftop water storage tank Automation of tank filling using cut-off devices Connecting the outlets of the rooftop/overhead tank with the down-­ coming main supply line If the source supply is from the water service provider of the area, then the connection of the water supply Installing a water meter Sealing the water meter with s sealing certificate Connecting the water supply from the water meter to the underground water storage tank If an underground water tank is provided, then installing a pump to fill up the overhead tanks

Status of works Start End In Not Responsible date date Complete progress started person Remarks ::::-

::::-

:-

:-

:-

:::-

:-

7.2 Central Works of Water Supply and the Drainage System

199

Table 7.2 (continued)

Activity Connecting the underground water tank to the overhead tanks Electrical connections of the pumps Laying the main down-coming water supply lines and connection to the floor supply line Providing a water pressurisation system for water supply to the floors Hot water supply system Laying the main header for hot water supply Connecting the main header for hot water to the floor lines Installing a hot water generator, a heat exchanger system or a solar hot water generator Insulating the hot water lines Electrical connections of the hot water system through the electrical panel Providing a thermostat on the hot water generator for auto cut-off and start according to the temperature of the water in the tank Drainage system Laying the main downcomer for drain Connecting the floor sewerage line to the main down-coming sewerage pipelines

Status of works Start End In Not Responsible date date Complete progress started person Remarks :-

::-

:-

::-

:-

::-

:-

::-

(continued)

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Table 7.2 (continued)

Activity Preparing the main holes and gully traps as per drawings Laying the outside main sewer line Providing vent pipes as per the drawings Connecting the main hole to the main sewerage line If the septic tank is provided, then preparing the septic tank Connecting the septic tank to the main drainage lines Providing a holding tank for radiation waste Providing a grease interceptor for kitchen waste Rainwater harvesting Laying rainwater lines in shafts Providing a rainwater harvesting pit Irrigation water supply Providing a source of irrigation water (treated water/fresh water) Providing a storage tank for irrigation water Laying pipelines for irrigation throughout the green area Providing taps at outlets at required places for irrigation Sewerage Treatment Plant (STP)/Effluent Treatment Plant (ETP) Preparing an STP tank Preparing an ETP tank Drinking water supply system

Status of works Start End In Not Responsible date date Complete progress started person Remarks :-

:::-

:-

:-

::-

::-

:-

::-

:-

::-

7.2 Central Works of Water Supply and the Drainage System

201

Table 7.2 (continued)

Activity Installing the RO plant for drinking water Providing a tank for storage of RO water Laying the drinking water supply line from the RO water storage tank to the drinking water outlets

Status of works Start End In Not Responsible date date Complete progress started person Remarks :::-

more water), the number of toilets in the hospital, expected foot fall and the number of human beings expected to be housed in the hospital building and the quantity of water required to operate and run equipment. To this figure, at least 25% spare water capacity to the system should be added. Moreover, the expansion plan of the hospital that may occur in future should also be considered. Once the quantity of water required is determined, an assessment should be conducted to ascertain how many borewells will be needed to fulfil the water requirement. It is recommended that the number of the borewells should be more than one, to maintain the backup, in case one fails. The next step is to calculate the working hours of the borewell and the total quantity of water required per minute. Now, considering the water required per minute and the head (height to which water has to be carried to fill up the tanks), the capacity and size of the water pump should be determined. If using a submersible pump (which is more common these days), then the diameter of the pump should be ascertained. Accordingly, the diameter of the borewell should be finalised, which should be 25% more than the diameter of the pump. The borewell can now be dug. While digging the borewell, it must be ensured that the loose mud or sand does not fall back into the borewell. Both casing and a filter pipe should be installed in the borewell. Care should be taken that when the work of digging the borewell is not in progress, the borewell is covered and guarded, to avoid any accidents. Once the borewell is ready, the submersible to be installed in the borewell should be readied. The pump should be connected to the delivery water pipeline. Once ready, the submersible pump should be carefully lowered down into the borewell to install it. Caution must be exercised when holding the pump and delivery pipe securely, as there are chances that the pump may fall into the borewell. If this happens, then there are no means to take the pump out. If there are any means, the cost of taking the pump out can be tremendous. Once the pump is installed, an electrical connection should be provided to the pump for its operation from a dedicated distribution box with miniature circuit breakers (MCBs) of appropriate rating.

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After supplying electricity to the pump, it must be operated to check its functionality and the quality of water checked. The pump should be allowed to run for a few hours and the initial stream of water should be discarded, as it contains mud, sand and impurities from the new borewell. This needs to be done till the submersible supplies clean water. In the meantime, water storage tanks should be installed on the roof of the hospital building. It is preferred that a separate storage tank be provided for every main supply line. It is recommended that if rooftop tanks are planned, then the number of such tanks should be more than one. It means that a cluster of toilets, or other locations where water supply is needed, should be clubbed and dedicated tanks should be provided for that cluster. In case an overhead tank is planned, then this tank should be a stand-alone and also be able to provide water to larger areas, such as the whole of the hospital campus. This tank resembles the one built by the municipality to supply water to an entire colony. Whatever the case may be, in both the scenarios, the output from the water source, should be connected to the incoming line of the tank. With this connection, the tank will start filling up as soon as the submersible is switched on. The tank also has an outlet through which water is supplied to the building. The outlet of the tank should then be connected to the main supply line of the building. These days, filling of the water in the tank is generally automated, and this helps avoid water wastage caused by tank water overflow. This device is fixed in the tank, and as soon as the water level in the tank falls below the indicated mark, the device will energise the submersible and, as a result, the submersible will switch on and the tank will start filling up. When the tank fills up to the indicated level, the device will stop the pump immediately. The next source of water supply can be the supply from a governmental or non-­ governmental water network supplier by connecting to their distribution network. In this case, the connection should be sanctioned by the water supply agency. Once this is done, the hospital’s water line will be connected to the water supply line of the agency. At the point of connection, the water meter is installed, to take a reading of the water utilised by the hospital and, based on this, the agency bills the hospital for water consumption. Once a meter is installed, it will be sealed by the agency in front of the hospital authorities. The sealing certificate should be signed by both parties. One copy of the same should be retained by the hospital. Next, a water line should be installed to fill up the hospital storage tank. Usually, an underground water storage tank is constructed by the hospital to store the water provided by the water supply agency. The reason for installing an underground water tank is that the supply from the agency is usually at an extremely low pressure and the rooftop tank or the overhead tank cannot be filled up with this pressure. In any case, it has to be pumped up again. Therefore, the underground tank should be installed to store water and subsequently to pumped it to the tanks. A connection will then be established from the underground tank to the rooftop tank or the overhead tank. Once this is done, the next step is to install a pump for filling up the tanks from the underground tank. The rating of the pump is determined

7.2 Central Works of Water Supply and the Drainage System

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considering the water flow and the head (height of the building). Once the pump is installed, the electrical connections are completed and the pump is ready to lift water to the tanks. The automation process for controlling pumps, as explained earlier, can also be considered for this pump. When all these installations are in progress, side by side, the main supply downcomer for water supply to the building should also be erected. This downcomer should be used for supplying water from the tank to the individual floors. This downcomer is then connected on each floor to the floor supply line, which in turn carries the water to the individual water outlet. (Usually, the problem faced on some floors is that the water pressure is low at the outlet. This is due to the pressure difference in the main supply downcomer line. A high flow of water is required in hospitals for hygienic hand washing and cleaning. As a result, a hospital should have a system of constant and high-flow water pressure to ensure a sanitary and infection-free environment. A booster pump may be installed to ensure that adequate water pressure is available throughout the hospital. Instead of single-stage pumps, it is recommended that a multi-stage booster pump be used. This is also known as a water pressurisation system. To ensure the uninterrupted working of the booster pumps or say the pressurisation system, it should be connected to an emergency power supply like uninterruptible power supply (UPS).

7.2.2 The Hot Water Supply System Hot water is required in a hospital at several locations, including scrub sinks, hand wash basins, patient bathrooms, kitchen, Central Sterile Supply Department (CSSD), maintenance areas and the area where instruments are washed. The hot water systems generally provided in hospitals include electrical hot water generation, hot water generation from boiler/steam by burning fuel, solar hot water generation and stand-alone hot water geysers. Out of all, the most commonly used are electric hot water generators and solar hot water generators. As the first step, the designer should assess the quantity of hot water that will be required at the hospital. While assessing the quantity, the designer should consider factors like weather (as winters may require more hot water as compared to summers), the peak flow requirement of the hot water (morning hours may require more water), the number of hand scrub stations and wash basins in the hospital, expected footfall and the number of human beings expected to be housed in the hospital building and the quantity of hot water required to operate and run equipment and clean instruments. To this figure, at least 25% spare water capacity to the system should be added. Moreover, the expansion plan of the hospital that may occur in future should also be considered. Now comes the installation of the hot water system. First, the main header line for supply from the generation point to the floor hot water supply line is laid. This main header should be connected from the hot water generator to the floor supply

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lines on all the floors. The laying of the floor supply lines has been discussed in the previous chapter. Once the pipelines are laid, they should be insulated with moulded insulation, which should be flame-proof with a jacket suitable to control the temperature. Now is the time to install a hot water generator for heating water. In case the hospital opts for electrical hot water generation, the same should be installed somewhere on the top of the hospital building, preferrable on the roof. A hot water generator is primarily a cylindrical tank made of stainless steel, which has been insulated to prevent thermal losses. High-quality heating elements are installed at the tank’s bottom, where they heat the water. A thermostat, which monitors the temperature of the water, controls these elements. When the water temperature falls below the set temperature, the elements turn on, and, when the water temperature rises to the set temperature, they turn off. This tank is then connected to the main header of hot water. In between the tank and the main header, a gate valve is provided for safety purposes. Once the hot water generator is installed, an electrical connection should be provided to the hot water generator for its operation from a dedicated distribution box with miniature circuit breakers (MCBs) of appropriate rating. If the hospital opts for a solar hot water generation system, then the first step is to install a solar hot water plant on the roof of the hospital. Solar cells with conductive copper pipe capillary lines are installed on the rooftop where they are exposed to sunrays. Water flows through these copper tubes within the solar cells and heats up. This water is then stored in an insulated water tank, from which it is distributed to various locations. The tank should then be connected to the main header of hot water. In between the tank and the main header, a gate valve should be provided for safety purposes. Individual stand-alone geysers are used to provide hot water in tiny hospitals because it is not feasible to establish a central hot water system. The input and exit pipelines must be laid because these geysers are situated at various sites. The necessary power switch or socket should be present near the geysers.

7.2.3 The Drainage System To safely dispose of sewage and prevent water stagnation, hospitals should design effective drainage and sewage systems. The general effluent drainage system should be gravity-driven. Contrarily, a pressure drainage system uses a sump and pump connection to drain wastewater from places like basements. Hospital drainage systems of different types should be kept apart from one another. This is essential for both infection control and drainage system efficiency. In hospitals, drainage has to be provided for wastewater drainage that comes from basins, sinks, scrub stations and floor drains and only has contaminated water in it; soil water drainage from restrooms and dirty linen, urinals and toilets that typically have human faeces in them; storm water drainage gathered from sprinklers or rain;

7.2 Central Works of Water Supply and the Drainage System

205

chemical drainage produced by laboratories where the waste must be neutralised before being discharged to the main system and radiation drainage produced by hot labs, settlement toilets, etc. The first step for the drainage system is to lay the main downcomer pipes for the draining, which should be installed in the shafts provided outside the building. The main downcomer should be securely fixed to the wall. If the downcomer is laid in the closed shafts, then it should be ensured that a suitable window is provided on all the floors for easy maintenance of the downcomer pipe. The main downcomer should subsequently be connected to the floor sewerage lines. While connecting the floor lines with the main downcomer, it should be ensured that the joints are properly secured to prevent any type of leakage from the joints. The main drain downcomer terminates at the main holes provided on the ground floor. Hence, main holes and gully traps should be constructed as per the drawings provided by the mechanical, electrical and plumbing (MEP) engineers. As far as the main header from the basement is concerned, the same will also be laid upwards and will terminate at the main hole. The waste will be pumped from the basement through the header to the main hole. For each main downcomer, a separate main hole should be provided around the hospital building. Once all the main holes are ready, they have to be connected to each other to create the sewerage line. This line is the main sewerage line. All the main holes should be connected to this main line. Ensuring that a proper slope is provided in the main sewerage line so that the water flows by gravity is a must. The next step is to provide vent pipes in the entire drainage system, to avoid the foul smell of the effluents coming out of the drainage. Preferably, separate floor drain lines and a main downcomer drain should be provided for soil water drainage generated from toilets (WCs), urinals and dirty utilities. Similarly, the main sewerage line laid on the ground floor should be separate for this type of waste and terminate at the water treatment plant. In hospitals, where biohazardous materials with suspended living organisms are generated from areas like isolation rooms etc., a holding tank, called a ‘kill tank’, should be provided. The waste from all the areas should be deposited in this kill tank. After treatment of the waste with the help of chemicals, the waste should be discharged to the main sewerage line. In hospital setups, where a municipality sewerage disposal system is not available, a septic tank should be provided for waste disposal. Hence, the construction of a septic tank should be carried out as per the design provided by the engineer. All the sewerage lines of the hospital should then be connected to this septic tank for further management. For radiation waste, a settlement/holding tank should be provided near a toilet at a location where it remains harmless even after being subjected to radiation. Once the radiation effects are settled, the water should be pumped to the main sewerage line. For greasy waste from the kitchen, a drainage system should be provided with a grease interceptor before discharging the effluents to the external drainage network.

206

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In the meantime, the sewerage water treatment plant should be constructed. All the main sewerage lines should terminate at the sewerage treatment plant, where the waste will be processed and the treated water will be stored to be used for irrigation purposes. Once the drainage system is complete and is connected to the main holes of the buildings, the drain water should be treated before it is finally drained into the main sewerage network provided by the municipality or is discharged in soak pits.

7.2.4 Rainwater Harvesting For collecting and harvesting rainwater from the roof of the hospital, first of all, horizontal pipes should be provided on the roof. The main precaution to be taken is that the slope of the roof should be such that the water automatically flows towards these horizontal pipes. These horizontal pipes are, in turn, connected to the vertical pipes provided alongside the building wall or in the shaft. These vertical pipes are then connected to either the holding tanks or the soak pits installed on the ground floor. As far as other open areas of the hospital are concerned like roads and open grounds, for collection of the rainwater, a network of underground pipelines should be provided. The rainwater flows in these pipelines and the same is carried to the holding tanks or soak pits for further disposal. The water collected in the holding tanks or soak pits penetrates into the earth and increases the underground water level.

7.2.5 Irrigation Water Supply For offsetting up an irrigation water supply system, the first task is to identify the source from where the water for irrigation should be taken. It is not always necessary that fresh underground borewell water is used for irrigation. The best option is to use the wastewater that has already been treated by the water sewerage plant. This irrigation water can be used for either external or internal landscaping. In that case, a dedicated storage tank should be provided where the treated water is to be stored. It should be ensured that the treated irrigation water does not get mixed up with any other water supply line. Preferably, this tank should be underground. The next step is to lay a network of pipelines throughout the green area of the hospital to supply irrigation water. Thereafter, taps and outlets should be provided at the required locations from where the hoses have to be connected for irrigation.

7.2 Central Works of Water Supply and the Drainage System

207

7.2.6 Sewerage Treatment Plant/Effluent Treatment Plant Before being disposed of, hospital wastewater needs to be appropriately treated to prevent major environmental harm and the spread of infectious diseases to humans. Hospitals therefore should have an effluent treatment plant. Wastewater generated from hospitals, generally, contains chemicals and biological waste, including radioactive isotopes, heavy metals, dangerous bacteria and viruses, medications, hazardous compounds, etc. Wastewater is continuously produced by a hospital’s different departments, including pathology, emergency, operating rooms (ORs), intensive care unit (ICU), hot lab, radiology, laundry and kitchen, among others. Before water is utilised again in a hospital or released into the environment, organic matter and suspended solids are removed from it using an effluent treatment plant (ETP/STP). The first step is to provide a prefabricated STP/ETP plant. If not, an STP/ETP plant needs to be constructed as per the drawings and specifications provided by the engineer and the designer.

7.2.7 The Drinking Water Supply System Generally, hospitals provide a separate water supply line for drinking water, fitted with taps and fountains. This drinking water should be free from any impurities and should have low parts per million (PPM) and total dissolved solids (TDS). Hence, in hospitals, the best method is to treat water through reverse osmosis (RO) technology. The maximum number of contaminants are removed using this technology by passing water under pressure through a semi-permeable membrane. RO equipment include filters such as a pre-filter, sand filters, charcoal filters, reverse osmosis and ultraviolet (UV) filtration. The first step is to install an RO plant of adequate capacity. The raw water taken directly from the borewell or the storage tank should be supplied to the RO plant at its input point. Hence, the input of the RO should be connected to the source of the water supply. Once the RO plant has been installed, an electrical connection should be provided to the RO plant for its operation from a dedicated distribution box with miniature circuit breakers (MCBs) of appropriate rating. The plant should be commissioned and the output water tested for its chemical analysis and properties. The water duly treated by the RO plant should be stored in a tank provided for this purpose. Ensuring that the tank is properly covered from all sides, to avoid any contamination, is a must.

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From this storage tank, a separate pipeline should be laid to carry the water to the desired location where the drinking water outlet is provided.

7.3 The Steam Supply System See Table 7.3. In a hospital, there are various locations where steam may be required like laundry, food and beverages, laboratories, sterile store, CSSD, etc. As the usage of different units is different, the quality of steam to be supplied to a unit will depend on the application for which it will be used e.g. areas like laundry or food and beverages may require ordinary plant steam, CSSD and critical areas will be provided with clean steam and sensitive areas like laboratories or pharmaceutical preparation may require pure and filtered steam. To prepare for steam supply, the first step is to provide the infrastructure for the production of steam. For this, a boiler should be provided. This boiler can be electrically operated, which is also called an electrical steam generator. However, boilers with other means of fuel like diesel, wood, coal, gas or biogas are also available. Depending on the quantity and quality of the steam required, the boiler is planned and procured. Central steam generation vs. local steam generation: For steam generation, hospitals have the option of establishing a central plant or localised plants at different locations. Although setting up a central plant is more economical, it is not that

Table 7.3  The steam supply system

Activity Providing a boiler for steam (electric/diesel/ gas/wood/coal-based) Providing fuel storage space Laying the pipeline up to the user point Connecting the pipeline from the boiler to the user point Insulating the pipeline Providing an exhaust for the boiler as per the rules Testing the boiler and steam generation

Start date :-

:::-

::-

:-

End date

Status of works In Not Responsible Complete progress started person

Remarks

7.4 Other Miscellaneous Works of Drainage Outside the Building

209

efficient. Second, if steam consumption is too low, then the operational cost of the central plant will be high. The next factor is the distance between the generation site and the user site. If the distance is more, then the cost of laying and maintaining the pipeline will be more. Another advantage with localised plants is that in case any one of the plants fails, the other systems will work to provide backup. However, some hospitals prefer to operate using a combination of both systems. If the boiler is electrically operated, the power should be provided near the boiler through a separate panel and MCB. If fuels like diesel, wood, coal, etc. are used, then fuel storage space and tanks (if required) have to be provided. A proper exhaust chimney should be provided along with the boiler to exhaust the smoke. The exhaust pipe should be placed in accordance with the strict rules, regulations and norms prescribed by the authorised agency of the government. The boiler should be connected with the water input line, to fill up the water tank of the boiler. The steam outlet of the boiler should be connected with the main steam supply line that will carry the steam to the desired location. Piping must be made out of stainless steel as it is a hard and non-reactive metal and can resist corrosion as well. The steam supply line should be adequately insulated to maintain the temperature in the pipeline. If the temperature of the steam falls, then it may be converted back to liquid.

7.4 Other Miscellaneous Works of Drainage Outside the Building See Table 7.4. Apart from all the above jobs, care should be taken to cover all the main holes with proper main hole covers to avoid any type of accident. Similarly, all the openings of the STP and ETP tanks should be covered. A proper exhaust for easy disposal of the fumes and smell from the main holes should be provided.

Table 7.4  Other miscellaneous works of drainage outside the building

Activity Covering all the main :holes with proper main hole covers Covering all the :openings of STP/ETP tanks with proper covers

Start date

End date

Status of works In Not Responsible Complete progress started person

Remarks

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Further Reading Altin A, Altin S. Sustainable water and wastewater management in hospitals. Turk J Occup Environ Med Saf. 2017;2:1–7. Balwani KS, Nagarnaik DPB. Water and waste water management of a hospital- a review. Int J Sci Res. 2015;6(4):4. Emergency Water Supply Planning Guide for Hospitals and Healthcare Facilities | Water, Sanitation, and Hygiene-related Emergencies and and Outbreaks | Healthy Water | CDC [Internet]. 2020 [cited 2021 Jul 14]. https://www.cdc.gov/healthywater/emergency/ewsp.html Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. Chapter 42, Water Supply and Drainage System. India: Springer Singapore; 2022. p. 451–8. Hospital Plumbing Systems [Internet]. [cited 2021 Jul 14]. https://www.hfmmagazine.com/ articles/2260-­hospital-­plumbing-­systems Paleologos EK, O’Kelly BC, Tang C-S, Cornell K, Rodríguez-Chueca J, Abuel-Naga H, et al. Post Covid-19 water and waste water management to protect public health and geoenvironment. Environ Geotech. 2020;18(3):193–207.

Chapter 8

HVAC (Air Conditioning) Works of the Hospital Building

The HVAC (heating, ventilation, and air conditioning) system in a hospital is notably more intricate compared to those in other commercial buildings. Its functionality goes beyond providing thermal comfort and encompasses various crucial aspects unique to the hospital environment. In hospitals, the HVAC system plays a vital role in maintaining comfortable climatic conditions for patients and employees while also ensuring a germ-free and clean environment to prevent the spread of diseases. The sensitivity of medical equipment further emphasises the need for precise air control to ensure optimal performance. Consequently, designers must give special attention to these considerations when designing HVAC systems for hospitals. The complexity of HVAC system design in hospitals is compounded by the fact that different rooms serve different purposes. Clear definition and classification of zones and spaces are necessary. For instance, isolation rooms may be required to separate patients with contagious diseases, while other rooms cater to immune-­ compromised patients. Hospitals inherently harbour a higher concentration of microorganisms and pathogens compared to commercial buildings, and some of these contaminants can travel through the air. Spaces such as ICU units, neonatal units, and operating rooms require effective measures to limit the arrival and growth of pathogens. Therefore, the air conditioning system must be highly sensitive to filter and eliminate such contaminants, safeguarding patients, staff, and visitors. Furthermore, the HVAC system should include comprehensive air filtration, particularly for the supply of external air, which is introduced to the system for fresh air circulation and exchanges. This practice helps prevent the growth, spread, and accumulation of micro-particles and pathogens, enhancing overall air quality within the hospital. The enclosed checklist provides the sequence of such works related to HVAC (air conditioning) that has to be done inside the building and helps the site engineer to plan the start and end day of each activity along with the present status of that particular activity. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_8

211

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8  HVAC (Air Conditioning) Works of the Hospital Building

8.1 Air Conditioning (HVAC) Works Inside the Hospital Building See Table 8.1. For air conditioning the spaces of the hospital building, if central water chilled system is planned, first of all, the locations of the air handling units (AHUs) shall be decided as per the drawings and the designs. Table 8.1  Air conditioning (HVAC) inside the hospital building

Activity Water supply line with required valves till AHU/fan coil unit from the central plant Water return line with required valves from AHU/fan coil unit till the central plant Room wise ducting AHU/fan coil unit-wise drain pipe till drain line Fixing of AHU/fan coil unit Providing electrical power point near AHU/fan coil unit Preparing and installation of the air ducts Connection of AHU and duct Conduiting form AHU//fan coil unit for connecting remote control Fixing of remote control if the same is wired Cut-out in duct for fixing grill and diffusor Fixing of grill and diffusers

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

::-

::-

:-

::-

:-

:-

:-

8.1 Air Conditioning (HVAC) Works Inside the Hospital Building

213

Table 8.1 (continued)

Activity Providing wall cut-outs for fresh air intake Providing wall cut-outs for exhaust of air If a VRV system is adopted, laying of the copper line from the outdoor unit to the indoor unit (duly insulated) For VRV install an indoor unit If split air conditioners are to be used, provide pair of copper pipes to connect the indoor and outdoor unit For VRV/split units, providing electrical power points near the indoor unit

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:-

::-

:-

First of all, the room works shall be completed. The required air supply ducts shall be fabricated and installed at the respective place. The cut-out in the wall shall be made for fixing the supply grills or in case of false ceiling spaces shall be provided for diffusers. The supply ducts installed for the rooms shall be installed in such a fashion that they can be easily terminated and connected to the concerned AHU. Now, an insulated chilled water supply and water return lines shall be laid down which shall connect the chilled water supply source and shall terminate near the concerned AHU from where it can be easily connected to the concerned AHU. Install the AHU at the designed place. Connect the chilled water supply and water return line with the AHU as per the design. Provide drain pipes to drain out the water from the AHU and terminate it at the nearest drain point. Provide electrical supply to the AHU through the main switch or MCB. If the AHU is provided with the remote control, arrange for connecting the remote control to the AHU. Connect the supply air duct to the AHU by providing the canvas collar. Place the filters inside the AHU after cleaning.

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8  HVAC (Air Conditioning) Works of the Hospital Building

In case the room-wise fan coil units (FCUs) are used instead of AHUs, the individual fan coil units of the rooms shall be installed. Chilled water supply and return lines shall be connected to each fan coil unit. Provide drain pipes to each FCU. Provide electricity supply to the FCU. Thereafter, flush the chilled water supply lines thoroughly and make them ready for use. Fix all the required grills and diffusers. And test the system and keep it ready for use. In case the split air conditioners are used, the copper pipe lines shall be laid down in the room to connect the indoor and outdoor units of the air conditioners. Fix the indoor units on the wall and provide electricity. Install the outdoor unit and connect the indoor and outdoor units and test the unit before use. In case the Variable Refrigerant Volume (VRV) system is adopted for air conditioning, first of all, the concealed copper tubing shall be laid down which shall connect the outdoor central VRV unit with the indoor unit of the system. Supply power to the indoor and outdoor unit, and test the system before use. Note: Please note that all the above activities of various services have to be carried out for all the floors of the building

8.2 Central Control Works of Air Conditioning (HVAC) System See Table 8.2. There are various systems that can be adopted for the air conditioning of the hospital. These are central water chilled plant where the central chillers chill the water, which then travels to the pipelines and air handling units; DX (direct expansion) chilling, where instead of chilled water, the refrigerant (gas) circulates in the pipelines; and split air conditioning. Out of all, the first one, i.e., central water chilled plant, is used most of the time. However, if the hospital project is very small, other systems may be thought of. Therefore, in this chapter, we will be discussing about the set of the central water chilled plant only. In this kind of system, central chillers chill water, which is subsequently transported via insulated pipelines to the coils of air handling units (AHUs). Fans positioned behind the coils of an AHU blow air into the space. The air that is blown is cooled, and it travels through ducts to its destination before being distributed throughout the spaces using diffusers. Calculating the plant’s necessary capacity is the first stage in designing an air conditioning system. This calculation should be done based on the size of the spaces and the area’s specific air conditioning needs. Not just the total of the separate system loads, but also the simultaneous peak load, shall be taken into consideration by the designer. The capacity of the central cooling plant shall also take into account a

8.2 Central Control Works of Air Conditioning (HVAC) System

215

Table 8.2  Central control works of air conditioning (HVAC) system

Activity HVAC plant room Construction of foundations for chillers; pumps and LT panels in the HVAC plant room Installation of chillers Connecting the chillers to the chilled water supply line both supply and return through pumps Electrical connections to the chillers Commissioning and testing of chillers Installation of chilled water pumps Cooling towers Construction of foundations for cooling towers Laying of the main header for supply and return Installation of cooling tower pumps Connecting cooling tower pumps with the cooling tower supply line Electrical connection to the pumps Commissioning and testing of pumps Erection of the cooling tower Connecting supply and return lines of the cooling tower to the chillers

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

::-

:::-

:-

:-

::-

::::-

(continued)

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Table 8.2 (continued)

Activity Installation of the water make-up storage tank Electrical connection to the cooling tower Air handling units/ fan coil units Install the AHU at the identified place in the room or suspend it from the ceiling Connect the AHU to the duct by providing a collar between the duct and the AHU Connect the AHU with the return air duct or return air vent Provide an opening in the wall for extracting the fresh air or provide a duct for fresh air intake Clean and install the filters in the AHU If required install the UV light in the AHU Electrical connection to the AHU Commissioning and testing of AHU Ducting Fabricate the ducts as per the drawings Insulate the ducts Fix the screw rods and channels for hanging the ducts Hang the ducts from the ceiling

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:-

:-

:-

:-

::::-

:::-

:-

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217

Table 8.2 (continued)

Activity Provide the cut-outs and prepare the collars for fixing the grills/ dampers/diffusers Connect the duct to the AHUs Operate the AHU and blow air in the duct to clean the duct and remove any foreign particle Grills, diffusers, and registers Get the grills, diffusers, and registers manufactured as per the drawings Fix the grills, diffusers, and registers on the collars provided at the cut-out of the duct Securely screw the grills, diffusers, and registers to the collars of the duct Electrical control Installation of LT panel Commissioning and testing of LT panels Testing and commissioning Pressure testing of supply and return pipeline Testing of the entire HVAC system Commissioning of the HVAC plant Test run the plant for at least 24 h to clean the system

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

::-

:-

:-

:-

::-

:-

:::-

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variety of variables, including the heat load of the machinery in the spaces, the number of people in the spaces, the heat load of the lighting, thermal loss from sunlight in the room, etc.

8.2.1 HVAC Plant Room The first step for the setup of the HVAC system is to construct the space where the plant of HVAC has to be installed. The chillers, pumps, valves, pipelines, and electric panels are the items that shall be installed in the plant room. The plant room shall be of adequate size to accommodate all the machinery items. Furthermore, the provision for further expansion of the plant room shall also be considered while designing the space. The plant room should ideally be located away from the patient or clinical areas. For this, the building’s basements, roof, or outside space (in the main or annexure structure) can be taken into consideration. It must be confirmed that the building’s structure can support the load of the HVAC equipment before deciding on the chiller’s location, weight, and other related equipment. A minimum of two chillers shall always be provided so that they can alternately operate. If one chiller fails, the other can serve as a buffer as well. Typically, two chillers shall be placed during the initial phase; however, places shall be made available for future installation of more chillers at the same location in consideration of the expansion of air conditioning facilities. Once the capacity has been designed, the spaces in the plant room shall be organised appropriately because the size of the chiller varies with its capacity. Places for supply pumps and chiller pumps shall be designated in the plant room next to the chiller. Similar to this, space shall be set aside for the pipelines carrying chilled water to AHUs and the water supply for chillers. In addition, there shall be enough room for equipment removal and maintenance. If air-cooled chillers are planned, there shall be enough space for fresh air to circulate around the chillers. If the design provides for heating of the building, space shall be set aside in the plant room for the installation of a hot water generator that produces warm water to be circulated to the AHU for heating the air. The make-up tank of water, which makes up the level of water to be used for cooling the chillers as well as chilling the water, shall also be installed in the plant room. The electrical panel and major switches that deliver electricity to the system must also have space. Once the spaces have been identified for installation of the machinery in the plant room, the next step is to prepare the foundations for the chillers, pumps, electric panels, etc. The foundations shall preferably be separate for each machine. Before designing the foundations, the details and drawings of the foundations shall be taken from the original manufacturer of the machines. The foundation bolts shall be

8.2 Central Control Works of Air Conditioning (HVAC) System

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properly provided in the foundation to securely fasten the machines on the foundations. Now is the time to install the chillers, pumps, and electric panels on the foundations. Depending on the design and recommendations of the manufacturers of the machines, the machines shall be mounted on a base plate only with desired mounting anchor fasteners. As the vibration of the machines such as chillers is tremendous, it is recommended that vibration pads shall be used. Once the chillers are installed, the chilled water supply line and the chilled water return line shall be connected to the chiller. These lines are to carry and return the chilled water into the chiller. Apart from this, the incoming and outgoing water lines shall be connected between the cooling tower and the chiller. These pipe lines are for cooling the chillers. All the pipelines connected to the chillers shall be routed through the deliver pumps. For each line, two pumps are provided: one as a working pump and the other as a standby pump. The isolation valves and other pipe fittings are also installed as per the drawings and specifications. The chilled water lines are then insulated as specified to maintain the temperature of the water inside the pipelines. Proper raw water supply pipelines shall be provided to connect the raw water supply line to chillers, make-up tank, and cooling towers. In case the raw water, that has to be supplied to the plant, is hard, plan for providing the water softening plant. The raw water shall be treated with this plant before supply to the chillers, cooling towers, and the make-up tank. This will increase the life of the HVAC plant. Then is the time to connect the chillers and the pumps to the electric supply. For the HVAC plant room, a separate electric panel shall be designed. For every machine, separate MCBs and switches of adequate capacity shall be provided. The pumps and chillers shall then be connected to the panel and are energised to be operated. As soon as the plant room is ready to operate, switch on the chillers and pumps and test the performance of the plant. Now leave the plant till the entire HVAC system is in place.

8.2.2 Cooling Towers When the chillers are turned on, they generate a lot of heat, and as a result, the chillers’ body also heats up. To keep the body of the chiller cold, the chillers are provided with a jacket wherein the water circulates. As the water circulates, the water also gets heated. Hence, the water is required to be cooled before being recirculated in the body of the chillers. This task is accomplished through the use of cooling towers. The cooling towers are factory-fabricated and tested, and they shall be induced draft type with counter-flow. The cooling tower’s structure and basin shall be made of stainless steel 304 grade, with FRP removable louvres. The cooling towers shall include a basin cleaning system.

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For the installation of a pair of cooling towers, open space shall be allotted either on the rooftop or in an area open to the sky. In the identified area, the foundations for the cooling tower shall be constructed according to the design and specifications received from the original manufacturer of the cooling tower. Once the foundations are ready, cooling towers shall be assembled and installed. In the mean construct the foundations for installation of the tower pumps. Now install the tower pumps that will supply the water to the cooling tower. The tower pumps shall now be connected to the cooling tower. For receiving and supplying water to the chillers, the tower pumps shall be connected to the water pipelines. Also, to draw water from the make-up tank, for the cooling tower, a water pipeline shall be provided between the cooling tower and the make-up tank. Once all the installations of the cooling tower and the pumps are over, connect the tower pumps and the cooling tower to the power supply to energise them. For every pump and cooling tower, separate MCBs and switches of adequate capacity shall be provided. Start and test the working and performance of the cooling tower and the tower pumps.

8.2.3 Air Handling Units/Fan Coil Units The air handling unit (AHU) or fan coil unit (FCU) is a box-like structure that takes in air, cools/warms it to the desired temperature, and sends it to the diffuser for distribution in the designated spaces. The AHU shall have provisions for drawing fresh air from the surrounding environment. The amount of air to be taken can be controlled by the damper installed in the AHU. In terms of fan coil units, these are typically installed in smaller rooms and serve as the AHU for that room only. The AHU shall be installed closer to the area where cool air is required. A separate room, preferably, shall be provided for the installation of the AHUs, with openings for installing the air ducts and an opening for taking fresh air from the atmosphere. Alternatively, if the floor height permits and the ceiling have sufficient load-bearing capacity, ceiling-suspended AHUs shall be installed, which are suspended from the ceiling using screw rods and fasteners. Fan coil units are suspended from the ceiling at any convenient location in the room, preferably at the room’s entrance. Each AHU shall be installed as a stand-alone unit with no interface to another AHU. AHUs shall not be stacked vertically. Service access doors of the AHUs shall always open inside the AHU, i.e., on the door’s positive side. Internal parts of the AHU shall not obstruct the opening, and these doors shall be equipped with micro switches or safety switch interlocks to protect maintenance personnel from potential injuries.

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Once the AHU has been installed, the same shall be connected to the air supply duct. The duct and AHU are connected to each other by providing the collar made out of the canvas sheet. Clean and install all the recommended and designed filters in AHUs. All AHUs must have a first-stage filtration rating of at least MERV 8/ePM10 60%. Similarly, a final filter with a MERV 14/ePM1 70% rating shall be installed downstream of all wet air cooling coils and supply fans. Filters such as pre-filters, sand filters, micro V filters, and HEPA filters shall be used in the HVAC system where the design calls for it. On the back end of the AHU is an opening for the intake of the return air shall be provided. This return air is again cooled in the AHU and after filtration is blown off in the space duly mixed up with the fresh air component. The AHU shall also be linked to the return air duct, or a return air vent shall be installed in the AHU to collect returning air from the spaces. For the intake of fresh air through the damper provided in the AHU, provide an opening in the wall from where the fresh air is taken by the AHU. In case the outer wall is not available near the AHU, provide the duct connecting the AHU and the opening on the outside wall. Please remember to provide the recommended filter between the AHU and the opening for fresh air so that fresh air can be filtered before entering the AHU. AHU also has filters, such as pre-filters and micro V filters, installed in the air return pathway to filter the air before it is sent out. If necessary, ultraviolet (UV-C) disinfection shall be used to inactivate the microorganisms. To avoid fungal amplification, UV-C is recommended for cooling coil surfaces. To reduce virus spread, upper air UV for patient rooms in critical care or isolation rooms shall be provided. Connect the AHU/FCU to the necessary electrical power supply points to power it up. The use of variable frequency drives (VFDs) for AHUs is encouraged. VFDs shall be designed and configured in such a way that if one fails, it does not disable the entire unit. A bypass switch can also be used for this. Once everything is in place, switch on the AHU/FCU and check the working and performance.

8.2.4 Ducting Cool air must be transported to the terminal point via ducts. The ducts are also sometimes utilised for sending the return air to the AHUs. Depending on the layout and availability of the spaces above the false ceiling, the duct shall be provided which can be rectangular, square, or round in shape. Most ducts are constructed of galvanised steel. The duct is manufactured from aluminium for particular specific areas, such as operating rooms. The anti-microbial coating must be applied to the interior surface of the ducts once they are ready. The exterior of the duct must be insulated, preferably with an adhesive-applied nitrile sheet.

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Once the ducts are ready to be installed, the marking on the ceiling shall be done. Now fix the screw rods and the hangers to suspend the duct from the ceiling. Place the duct on the hangers. Connect the ducts to each other. The supply duct is connected to the AHU on one side and terminates at the VAV or the grills/dampers/diffusers on the other. The return duct is similarly connected to the grills and terminates by connecting to the AHU. Provide the cut-outs in the duct, as per the drawings, and make the collar at the cut-out. Fix the grills, dampers, and diffusers as per the drawings. Once the duct is in place and is connected to the AHU, switch on the AHU to blow air into the duct. This is required to clean the duct and make it free from any dust, insects, foreign particles, etc.

8.2.5 Grills, Diffusers, and Registers Grills: The grill’s main purpose is to provide cover on the duct’s cut-out and allow air to enter and exit the room via it. Grills often do not have any moving parts or dampers, making them one of the simplest devices to maintain. However, it will not work if the airflow direction or the volume of air coming in and going out needs to be changed. Registers: A grill-like device known as an air register has adjustable dampers inside of it. A register simply releases air, as opposed to grills, which are utilised for both air intake and air exhaust in a space. The dampers aid in directing airflow or stopping it altogether. Diffusers: The airflow direction variability is different with a diffuser. Instead of the single air direction of a register, a diffuser and its dampers are constructed facing all directions. The grills, diffusers, and registers are generally tailor-made as per the drawings and the specifications. The sizes depend on the cut-outs provided in the duct. So, the first step is to get the grills, diffusers, and registers fabricated. Once ready, the grills, diffusers, and registers shall be placed at the specific cut-­ out of the duct. Screw it properly so that it does not fall or vibrate due to the high velocity of the air coming out of the grills, diffusers, and registers.

8.2.6 Electrical Control The whole of the HVAC system is highly dependent on the electric supply. Hence, a proper set is required to be provided for the supply of good quality and uninterrupted power to the HVAC system. Hence, a separate LT panel shall be designed for the HVAC system. The connections to this HVAC panel from the main hospital panel shall be done with the help of LT Armored XLPE, aluminium cables, or a Rising Main Bus-bar.

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The power supply from the HVAC panel shall be terminated at the lighting distribution board (LDB)/power distribution boards (PDB) installed at various locations throughout the HVAC plant room. It shall have both incoming MCBs and outgoing MCBs. The MCB rating shall be designed in accordance with the load factor on a specific MCB. The underground LT copper cable distributes power from the MCBs to various machines in the HVAC system. If necessary, cable trays can be used instead of going underground. As far as the power connections of the AHUs are concerned, the same can be supplied from the individual floor electric panel. However, the supply to the AHU shall be from a dedicated MCB that shall be nearer to the location of the AHU. Energise the HVAC panel and commission the panel. Test run all the machines of the HVAC plant.

8.2.7 Testing and Commissioning Now as we are ready with the erection and installation of the HVAC plant, it is time to test and commission the plant. As the first step, thoroughly test all the pipelines at high pressure. This testing is required to trace out leakages in the system so that remedial action can be taken. The pressure shall be at least double the actual pressure that the line is exposed to. For pressure testing, double pressure shall be retained in the pipeline for at least 24 h. During this time, the fall in the pressure shall be monitored. If there is no fall in pressure, it means the system is fit to operate. In case the pressure falls, it indicates any leakage in the system. Trace out the leakage and rectify it. Again, go for the pressure testing. This exercise shall be repeated till there is the stability of the pressure in the pipeline. Once the pressure run is conducted and found to be perfect for operations, switch on the entire HVAC system. Check for any leakages, vibrations, the flow of the air, cooling of the air, movement of the dampers, noise in the system, humidity levels and operation of the pumps, etc. This is the stage where the commissioning of the plant is complete. Now run the entire plant for at least 24 h at full load to clean the entire pipeline and the ducts. The purpose is to make the system free from any kind of dust particles, foreign bodies, or insects in the system.

Further Reading Editor. HVAC System Design for Multi-Specialty Hospital | Cooling India Monthly Business Magazine on the HVACR Business | Green HVAC industry | Heating, Ventilation, Air conditioning and Refrigeration News Magazine Updates, Articles, Publications on HVACR Business

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Industry | HVACR Business Magazine [Internet]. [cited 2021 Jul 12]. https://www.coolingindia.in/hvac-­system-­design-­for-­multi-­specialty-­hospital/ Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. India: Springer Singapore; 2022. Chapter 38, HVAC (Air Conditioning) System;. p. 407–23. HVAC Design Manual for Hospitals and Clinics [Internet]. [cited 2021 Jul 12]. https://www. ashrae.org/technical-­resources/bookstore/hvac-­design-­manual-­for-­hospitals-­and-­clinics HVAC Design Requirements for Medical Spaces [Internet]. [cited 2021 Jul 12]. https://www.hfmmagazine.com/articles/1755-­hvac-­design-­requirements-­for-­medical-­spaces Ocana G.  HVAC Design Manual for Hospitals and Clinics Second Edition. [cited 2021 Jul 12]; https://www.academia.edu/14124488/ HVAC_Design_Manual_for_Hospitals_and_Clinics_Second_Edition Reijula J, Holopainen R, Kähkönen E, Reijula K, Tommelein I. Intelligent HVAC systems in hospitals. Intell Build Int. 2013;5:101–19. Saran S, Gurjar M, Baronia A, Sivapurapu V, Ghosh PS, Raju GM, et al. Heating, ventilation and air conditioning (HVAC) in intensive care unit. Crit Care. 2020 May;6(24):194.

Chapter 9

Fire Safety Works of the Hospital Building

Fire safety, protection, and detection regulations are established by the legislation of individual countries or states, which develop their own specific rules and regulations to manage fire safety. These regulations vary depending on the jurisdiction. In addition, there are universally accepted codes and standards set by organisations, such as the National Fire Protection Association (NFPA), which have international recognition. Similarly, in India, the “National Building Code of India 2016” has been implemented and includes a comprehensive set of rules pertaining to fire safety, protection, and detection. While it is not feasible to discuss the regulations of all countries in detail, we will focus on providing an overview of the “National Building Code of India 2016” in this chapter. It is important to note that the content presented in this chapter is a summary of the “National Building Code of India 2016” and is not intended to be considered as plagiarism. The purpose is to provide a general understanding of the code and its guidelines.

9.1 Firefighting and Detection Works Inside the Hospital Building See Table 9.1. Fire protection in the hospital building has two components: The first is firefighting and the second is the fire detection system. As far as the firefighting system is concerned, water sprinklers, hydrants, and the downcomers are provided. First of all, the three main riser pipes are installed. One will be for water supply to the sprinklers, the second riser for the hydrant system to connect hose reels and the canvas pipes, etc., the third is a downcomer for the supply of water from roof top tanks downwards. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_9

225

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Table 9.1  Firefighting and detection inside the hospital building

Activity MS pipeline with required gate valves on the entire floor for sprinklers Connection of these pipelines to the main riser pipeline Fixing the sprinkler (fixed or flexible) Main riser pipeline for floor hydrant Providing hose reel/ nozzle and canvas pipe Providing main riser pipe for downcomer to supply water from roof tank to the floor Wiring for smoke detectors/MCB and hooters Installation of smoke detectors/MCB/ hooters Connecting the smoke detector wire with the main control panel Final pressure testing of the sprinkler system Fixing the fire doors at the fire exits Cut out in the staircases/ramps/lift lobbies and lift wells for fixing the smoke spill direct driven long-cased tube axial fans Fixing of diffusers/ grill in these cut-outs Ducting from the fan to the cut-out

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:::-

:-

:-

:-

:-

:::-

::-

9.2 Control Station of Firefighting and Detection System

227

For sprinklers, the network of lines of various diameters (as per drawings) is laid down in the entire building. Before installation, please take care of the rules, regulations, and guidelines of the country’s fire-controlling authorities and norms. Install the sprinklers as per the drawings. All these individual pipelines are connected to the main riser floorwise. The main riser is in turn connected to the main water supply line connected to the pump room. For the hydrant system, the outlets are given in the main riser for connecting the hose pipe and the lay-flat fire canvas hose. The hydrant valves shall be provided, and the nozzles shall also be made available. The hydrant riser shall in turn be connected to the main water supply line connected to the pump room. For the downcomer riser, the pipeline is laid from the roof and shall be terminated to the lowest floor of the building. On the roof, the pipeline is connected to the main water supply pump which is in turn connected to the fire water tanks installed on the roof top. On the downcomer riser pipe, the hydrant valves shall be provided separately on each floor to connect the lay-flat fire canvas hose. For the fire detection system, the network of the smoke detection system shall be provided. First, the cable is laid down by adopting the loop system. Loop means the wire starts from the central fire detection control panel, and terminates at the same control panel, hence creating a loop. In each loop, the smoke or heat detectors are installed so that the control panel is in regular communication with the smoke/heat detectors. Along with the smoke/heat detectors, the MCB and the hooters are also installed in the line. Similarly, each loop is connected to the control panel, and after installation of the central control panel, the system is commissioned and tested. The next step is installing the fire doors on all the fire exits. The doors shall be installed as per the drawings and designs. For smoke suppression, all the staircases lift shafts, ramps, and lift lobbies shall be pressurised. For doing this, the tube axial fans are installed on the roof top and the duct is laid down from top to bottom with the opening on stairs, ramps, and lift lobbies on all the floors. Suitable diffusers or grills shall be provided for these openings. Note: Please note that all the above activities of various services have to be carried out for all the floors of the building

9.2 Control Station of Firefighting and Detection System See Table 9.2. Given the significance of fire safety and protection, the hospital building must be constructed in such a fashion so that it can quickly respond to such crises and prevent any unfavourable fire incidents. As far as the fire protection, detection, and fighting system is concerned, the following systems shall be provided:

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Table 9.2  Control station of firefighting and detection system

Activity Fire pump room Foundation for the fire pump room Construction of the water storage tank as per the requirement of the law Installation of two main pumps Installation of two jockey pumps Installation of diesel engine pump with accessories like fuel tank, silencer, etc. Installation of the fire electric panel Connection of the pumps with the inlet from the water storage tank Connection of the pumps with the outgoing water supply line Electrical connection to pumps Pressure testing of the entire sprinkler and hydrant system Commissioning Hydrant system Laying of the main header line of the hydrant system Connection of building circumference line with main headers Connecting main header with the supply line of the pump room Wet riser Laying of the main header line of the wet riser

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::-

:::-

::-

:-

::-

::-

:-

:-

:-

9.2 Control Station of Firefighting and Detection System

229

Table 9.2 (continued)

Activity Providing the hose reel, hose, lay-flat fire hose, and nozzle near each hydrant on every floor Connecting main header with the supply line of the pump room Downcomer Providing fire tanks on the roof Foundation for roof pump for downcomer Pump installation Header connection with roof pumps Electrical connection of the roof pump Pressure testing of the downcomer system Fire detection system (smoke detectors) Lay down the network of the armoured cable creating the loop to provide about 100 smoke detectors in one loop Install the baseplate of the smoke detector and connect it to the loop cable Fix the MCP and hooters in the same loop of cable Fix the smoke detector or the heat detector in the base frame Installation of the control panel of the smoke detectors system

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

::::::-

:-

:-

:-

:-

:-

(continued)

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Table 9.2 (continued)

Activity Connection of the smoke detectors cables to the control panel Connecting the MCP and hooters to the control panel Connect the control panel to an electric panel specially designed for the fire detection system Commissioning of the control panel and providing a particular ID to each smoke detector Testing the system Smoke extraction system Providing the ducts for smoke extraction from the building Providing ducts for fresh air supply in the building Installation of the smoke extraction fans Installation of the air induction fans Commissioning of the control panel and providing a particular ID to each fan Automation of the smoke extraction system with the help of the control panel of the fire detection system Testing the system Automatic sprinkler system Connecting the branch line of the sprinkler inside the building with the main supply line

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:-

:-

::-

:-

:::-

:-

:-

:-

9.2 Control Station of Firefighting and Detection System

231

Table 9.2 (continued)

Activity Connecting the main supply line with the fire pumps in the fire pump house Automation of the sprinkler system with the help of the installation control valve Testing of the sprinkler Pressurisation of the lift wells, stair cases, and lift lobbies Providing the ducts for exhaust of air in the staircase and lift lobbies Installation of the co-axial pressurisation fans on the roof Connecting fans with the duct For pressurisation of the lift wells, no ducts are required, as the well itself acts as a duct Providing electrical control panels for the pressurisation system Connecting the fans with the control panel of the smoke detection system through the control module Automation of the fans with the help of the control panel of the fire detection system Testing the system Other issues related to fire Refuse area as per rules Adequate fire escape routes as per norms

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:-

:-

:-

::-

:-

:-

:-

:-

::-

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1. Automatic sprinkler system 2. Electrical fire alarm system 3. Wet riser 4. Downcomer with 5. Yard hydrant 6. Underground water storage tank 7. Terrace tanks 8. Fire terrace pump. 9. Hose reel 10. Hose boxes with delivery hoses and branch pipes 11. Autodetection system including a smoke detection system 12. Smoke extraction system 13. Pressurisation of the lift wells, stair cases, and lift lobbies 14. Refuge area 15. First-aid firefighting appliances 16. Public announcement system with talk-back facility 17. Emergency light 18. Auto D.G. set 19. Illuminated exit sign 20. Means of escape 21. Compartmentation 22. MCB/ELCB 23. Fire man switch in lifts Please ensure that the firefighting and detection system shall meet the requirement of the National Fire Protection Association (NFPA).

9.2.1 Fire Pump Room Fire hydrant system is a set-up to supply the water inside and outside the building so that in case of fire the water can be poured on the fire to suppress the fire. This system is essentially a water supply system that delivers sufficient pressure and flows through pipes throughout a building to a strategically located network of valves for firefighting purposes. The system starts from the fire pumps installed in the pump room and ends at the hydrant provided in the building. The entire fire hydrant system consists of the following components: 1. Water supply and storage facility 2. Pipework and valves 3. Fire pump sets 4. Hydrant or landing valve and coupling 5. Fire brigade booster inlets 6. First-aid hose reels and lay flat fire hose

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Let us start with the water supply and the storage of water for fire. The fire water supply tank is the only source of water used in fighting fires, and it must always be accessible in the form of an underground static storage tank with a capacity determined in accordance with the standards established by the government of the country in which the firefighting system has to be installed. The tank shall have provisions for replenishing the water from the primary water supply, such as a bore well, etc. The necessary amount’s static water storage tank must be provided underground and constructed of reinforced concrete. The tank’s size and water-holding capacity shall determine the thickness of the tank’s walls. The local fire service’s fire tenders must have easy access to this tank. If it is anticipated that fire tenders will land on the fire tank, the slab thickness must be such that it can support the weight of the fire tender. The household water supply tank must only be fed through an overflow arrangement from the fire tank to maintain the level at the minimum stipulated capacity to prevent water in the static tank from becoming stagnant. The static water storage tank shall have at least four 63-mm diameter instantaneous male inlets and outlets arranged in a valve box with an appropriate fixed pipe with a minimum diameter of 150 mm to discharge water into the tank. Now the pump room, the most important part of the complete firefighting system is the firefighting pump room since it contains the equipment that will protect the building from fire and needs a suitable location for maintenance and operation. The fire pump room shall be placed ideally outside the main building, at least 6 m away from neighbouring buildings. The pump rooms shall generally have brick or concrete walls, a non-combustible ceiling, and suitable drainage, lighting, and ventilation systems. If the pump house is inside, the building, whether on the ground floor or in the basement, needs to be separated from the rest of the building by a wall with a 2-h fire rating and have a fire check door installed at the entry. The fire door shall be rated for 1  h. Forced mechanical ventilation ought to be provided for the pump house in the basement. The pump house on the ground level shall be situated outside the building with easy access from a public space. The basement pump house needs to be easily accessible from the outside, preferably via ramp. Depending on the space available, drawings, calculations, and data sheet, the pump house may be built above or below the level of the water tank. A pump house with pumps underneath the water tank is ideal for firefighting since it avoids the need for a negative suction system with a priming tank, foot valve, various auxiliary valves, etc. The pump house shall have windows with extended metal guards for safety and sufficient natural ventilation. There shall be a mild steel girder available in the pump house at an appropriate height for fixing the chain pulley block to assist in the proper installation and maintenance of firefighting pumps. To drain away any water seeping from glands, valves, etc., the pump house floor shall be slanted towards the farthest end. Normal lighting and emergency lighting shall be available in the pump house from either a backup source or the generator.

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The pump house shall have enough space to accommodate all of the pumps, along with their supply pipes, fittings, starter control panel, air vessel, etc., and have enough room for circulation. It shall be capable of maintaining the pump with enough headroom all around it. For all pump houses, the headroom clearance shall be at least 2.75 m. The pump control panel, which shall also be located in the pump room but shall be easily accessible, shall be large enough to include a triple pole and neutral (TPN) switch and a high rupture capacity (HRC) switch, both of which have adequate capacities. Apart from this there shall be a space in the panel to install a selector switch, a voltmeter, an ammeter, phase indicating lights, start and stop push buttons, a singlephase preventer, an auto-manual switch, and auxiliary contractors for interlocking/ sequence of (the busbar shall be made out of copper of appropriate thickness). The panel shall be separated and floor mounted, with sufficient grouting on the floor. Where a diesel pump is provided, it shall have its own panel, which shall be situated in the same room as the pump or in a nearby separate room. The panel needs to have a separate battery, a battery charging system, and an auto-manual switchover set-up. To prevent the diesel pump and the electric pump from operating at the same time, it shall have an interlocking mechanism with the main pump panel. To prevent any fire emergency, adequate precautions shall be taken to prevent fuel spills. Installing an air vessel with sufficient capacity and adding pressure switches to the delivery line shall be done. Two pressure switches are required. One has an upper and lower restriction for the jockey pump, whereas the main pump simply has a lower pressure limit on the other. Only a manual push button that is clearly marked on the pump panel shall be used to stop the main pumps. To start the diesel pump automatically at a pre-set reduction in pressure, a similar lower pressure limit switch shall be added. Pumps shall be mounted on a concrete foundation with a minimum grade of M15 reinforced concrete in the initial stage of installation. Depending on the size of the pump, the foundation’s thickness shall range from 50 mm to 150 mm. The foundation shall be large enough to accommodate the pump’s entire length and width, as well as at least 150 mm on each side and 75 mm on the sidewalls for clearance. The baseplate shall be long and wide enough to comfortably house the pump and motor. Once the foundations with the baseplates are ready, next is to install two numbers of main pumps and two numbers of jockey pumps. Along with this one diesel engine pump along with the fuel tank and for discharging the exhaust, an exhaust pipe shall be provided which shall be extended to outside the pump house and terminate at an appropriate height in the open air. The fire pump’s capacity shall be carefully selected to fulfil the standard for risk protection. All pumps shall have the option to “Auto Start” if the main hydrant supply line encounters a pressure drop. Between each pump and the non-return valve on the delivery side, place pressure gauges. The electric supply to the pump set(s) shall be independent of any other equipment in the space; in other words, it shall remain operational even if the power is turned off across the entire space. The connection for the pump(s) can be taken from the incoming side of the main L.T. breaker to achieve this. However, the connection

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may be made through the busbars in cases where two or more transformers and/or other supply sources are connected to a single busbar or if a bus coupler is provided between the busbar sections. Once the pumps are installed, connect the pumps with the outlet of the water storage tank to the inlet of the fire pumps. Proper sluice valves shall be provided at a suitable place so that if required the water supply to the pumps can be stopped. Then, the outlet of the pumps shall be connected to the main hydrant line from where the water shall be supplied to the entire hydrant line. Connect the pumps to the electrical panel and energise the pumps. Switch on the pumps and test the pumps and mainline under high pressure. If no leakage is noticed, the pump house is ready to operate. Please also test that the pumps are running on auto mode so that the pumps automatically start as the water pressure in the main line falls down and is automatically switched off when the pressure reaches the set pressure.

9.2.2 Fire Hydrant System The purpose of a fire hydrant system is to provide water for the firemen to fight a fire. It comprises of a system of pipework that is directly connected to the water supply main at every hydrant outlet. The water is pumped into the fire hydrant, and the fire tender withdraws the water from the hydrant and fills up the fire tender to spray onto the fire. The fire hydrant system is basically a network of pipelines, which starts from the fire pumps and terminates at the hydrants provided around the entire building. The hydrants are also called yard hydrants. It is the yard hydrant, which is responsible to supply water to the fire tender, in case of fire, so the fire tender takes water from the yard hydrant and sprays it at the spot of fire. For the hydrant system, the main header line is laid down from the outlet of the fire pump. Depending on the hydrants to be provided around the building, the diameter of the main header line is determined. In the meantime, a network of pipelines is created around the entire building to provide yard hydrants. This pipeline shall then be connected to the main hydrant line to supply water to the hydrant line. Water after flowing via a lay-flat fire hose to a nozzle, water from the hydrant is then directed towards the fire. At the appropriate place of the hydrant line, the hydrants are provided. Along with the hydrant, the flat-lay fire hose shall be provided. Also, the brass nozzle is kept beside the lay-flat fire hose. This nozzle is connected to the lay-flat hose, and after opening the valve of the hydrant, the water can be sprayed on the fire. A fire hydrant system is built to guarantee that there is enough water pressure and flow at the most of hydrant sites that are accessible. A fire hydrant system normally contains pressurised water that is ready for use in an emergency. The system’s water pressure decreases when a hydrant valve is opened. An electromechanical device that detects a decline in water pressure activates the booster pump or pumps, which pull water from the water supply to raise the system’s water pressure.

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9.2.3 Wet Riser To supply water within a building for firefighting purposes, wet risers are used. Tall buildings shall have wet rising mains installed because it takes a lot of pressure to pump water up to those heights. A wet riser is a component of a building’s firefighting systems that supplies water to various floors or compartments. The main vertical pipes of a wet rising system include landing valves on each floor of the building. The fire pumps located in the fire pump room are used to link the pipe system to a permanent water supply, which is often from the fire storage tank. This water is supplied to the pipe system by two automatic pumps: one on duty and one on standby. Wet risers have a constant water charge. Wet risers have landing valves at specific positions on each floor. At all the locations on each floor where the hydrant is provided on the wet riser, a set of landing valves, hose reel, hose, branch pipe, and lay-flat fire hose fitted with nozzle shall also be provided. Once the wet riser has been installed, the wet riser from the ground floor shall be connected to the main hydrant line that in turn shall be connected to the fire pumps placed in the fire pump room. As far as the specification of the wet riser is concerned, the same shall depend on the specifications, as provided by the government of the respected country. Similarly, the distance of one hydrant to other shall also depend on the specifications, as provided by the government of the respected country. Hence, while designing the wet riser system, the rules, regulations, norms, and specifications of the respective country shall be checked.

9.2.4 Downcomer Downcomer system is also a form of an internal hydrant for the firemen to use and is always charged with water tanks located at the top of a building. The first step is to prepare the roof of the hospital building for the installation of tanks. The fact is that at least 20,000 L of water shall always be available in the roof tanks for the downcomer hydrant. For accommodating 20,000  L of water, it can either be in one tank or be divided into more than one tank. Usually, 4 tanks of 5000 L each shall be planned. Consider the tremendous weight of 20,000 L of water and the weight of tanks that the roof has to bear. Hence, it can be dangerous to place the tank directly on the roof. The remedy is to raise the four adjoining existing columns of the building to make a square or rectangular shape. Install the iron girder on all the columns, and connect each of the raised columns. On the girders, place the iron platform for the installation of the tank. By this exercise, the entire weight of the water and the tanks

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are directly transferred to the columns of the building, leaving no weight on the roof directly. Install the tanks on the platform made for this purpose. As per the norms relating to the downcomer, the monoblock pumps shall be provided at the outlet of the fire tanks. Hence, the pump needs to be placed on the roof. The inlet of this pump is connected to the outlet valve of the fire tanks. Hence, construct the foundation for the pump. Install the pump on the foundation. To save the pump from the rains, provide a covering all around the pump. Connect the outlet of the pump with the downcomer pipeline. Connect the pump with the electric connection. The pump shall have a provision to switch on automatically as soon as the pressure in the downcomer falls and switched off as soon as the pressure reaches the set level. The next step is to connect all the fire tanks to each other so that all the tanks can be used simultaneously. Provide the pipeline from the source water to the fire tank to fill up the tank. Please ensure the pipeline from the water source shall be directly connected to the fire tank, and the overflow from the fire tanks shall be diverted to the other domestic tanks installed on the roof. With this exercise, water shall always be available in fire tanks in case of emergency and there shall be no stagnation of the water in the fire tanks. The downcomer shall have an opening on each floor of the building. The hydrant valve shall be connected at this opening. Provide the firebox near the downcomer to place lay flat fire hose, and nozzle, so that in case of fire the same can be connected and used to suppress the fire. Fill up the fire tanks and switch on the fire pump installed with the fire tank. Check the pressure of water in the downcomer on each floor. Check for any leakages in the downcomer. If any leakage is found, set it right and make the system ready for use.

9.2.5 Fire Detection System (Smoke/Heat Detectors) Fire detection systems are designed to detect fires early in their spread when residents still have time to escape safely. Early detection improves the safety of those who respond to emergencies. Early detection helps prevent life and property loss and operational downtime because control efforts are initiated while the fire is still small. The majority of alarm systems alert emergency personnel to the location of the fire, which speeds up the firefighting process. To be effective, detectors shall be used in conjunction with alarms. Alarm systems, at the very least time, notify the building’s occupants and typically send a signal to a manned monitoring station, either on-site or remote. There are various types of fire alarm systems in the market such as: 1. Non-addressable fire alarm system (conventional) 2. Analogue addressable fire alarm system

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3. Radio fire alarm system (wireless) 4. Radio and analogue fire hybrid alarm system 5. Aspirating smoke detection systems 6. Fire suppression systems 7. OSID (Open Space Image Detector Systems) 8. Public address and voice alarm systems Out of all, the first two are important and mostly used for the fire detection system. Let us understand these. Non-Addressable Fire Alarm System (Conventional): The smoke detectors in a non-addressable system function as switches. They “Turn On” the panel when they are activated, which then “Turns On” the bells or sounders. These detectors at a specific location are wired to a single circuit, known as a zone so that when a zone is activated, an indicator on the control panel shall light up to indicate which zone it is. Typically, each sounder circuit is wired separately. In small hospitals, non-addressable technologies are very useful and preferred. The sounders are located on the zone circuits in a newer form. The term “Two Wires” is used to describe these systems. Where there are many devices close to one another, two-wire systems are especially helpful. Analogue Addressable Fire Alarm System: All smoke detectors in this kind of system are connected via ring circuits known as “loops.” The control panels and detectors communicate electronically. The smoke detectors’ devices send back their “analogue value” continually (information). The analogue value for a smoke detector corresponds to both the air temperature surrounding the device and the amount of smoke present. The “Intelligent” controls are capable of determining when a device has reached its “alarm” value. Some or all of the output devices may need to follow instructions from the controllers. The controls can be “Programmed” to operate specific outputs based on the status of the smoke detectors. Larger hospitals can benefit from these solutions. The first step towards the installation of the smoke detection system is to mark the locations in the building where the smoke and heat detectors are to be installed. Identify and number the loop. Define the route of the cable in that particular loop. Now start the laying of the cable. The cable shall be laid on the wall just near the ceiling. The cable shall be properly clipped on the wall if it has to be exposed. Alternatively, the cable can also be concealed in the wall by providing the cable conduit. The other option is to lay the cable above the false ceiling. In that case, the cable shall be laid in the cable conduit and tied to the frame of the false ceiling above the ceiling. At each location where the smoke or heat detector has to be installed, cut the cable, and connect it to the base of the detector. As it is a loop, both ends of the loop cable shall be terminated at the location where the fire control panel has to be installed because ultimately both ends of this loop cable shall be connected to the control panel to complete the circuit of the loop. Along with the laying of the cable, the hooters and the MCPs shall also be fixed in the loop and installed on the wall. Now fix the smoke detectors and the heat detectors in the base frame of the detector.

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The next step is to install the control panel for the fire detection system. All the cables of the loops shall be connected to the control panel. Supply power to the control panel having a power backup with the help of UPS. The electric supply to the control panel shall be made from a specially designed independent electric panel. This panel shall be fully automated and shall be continuously communicating with the control panel. Once the control panel receives the signal of any fire, the control panel gives a command to the electric panel to switch on the pressurisation fans and the smoke extraction system automatically. Similarly, once the temperature rises above 57°C, the heat detector shall send a signal to the alarm panel and trigger the alarm. Switch on the power and check the control panel. Also, check all the loops connected to the control panel. Ensure that the panel detects all the detectors installed within a particular loop. If not, check the entire loop to detect the fault and set it right. Once the panel is fully operative, programme the control panel and allot a unique ID to each detector. The complete list of all the detectors with their ID, location, and the room numbers where it is installed is fed into the control panel. In case of fire, the detector that has detected fire shall get activated and send signals to the control panel. The control panel shall command the hooter of that area to start beeping. The ID of the activated detector shall be displayed on the control panel, and the fireman shall immediately come to know where the fire has been detected. Test the entire fire detection system along with all the smoke and heat detectors.

9.2.6 Smoke Extraction System The smoke extraction and ventilation systems are designed to effectively remove smoke from the areas affected by fire and, at the same time, proportionally supplement the system’s output with external compensating air. This system is particularly important for the maintenance of the fire safety of buildings, basements, escape routes, staircases, etc. The smoke exhaust system is provided for the prevention of smoke spreading in case of fire, prevention of fumigation of evacuation corridors, sealing the smoke to spread in the areas not affected by fire, and saving the health and lives of occupants. There are two types of smoke extraction and ventilation systems, which are static or dynamic. In the static system, all fans in case of fire are stopped immediately. Why, the basic principle is that when there is no oxygen, there shall be no possibility of fire spreading further. This system is very basic and crude and is used only in a small set-up where the possibility of fire is less, and there are no other additional hazardous factors.

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In the dynamic system, on the one hand, the smoke and heat are exhausted and simultaneously the fresh air from outside is inducted into the space, hence creating areas of excessive air pressure, functioning as smoke barriers. The first step for installation of the smoke extraction system is the fabrication of the smoke extraction ducts, pipes, and chimney. The fabrication shall be done as per the drawings and the specifications provided by the engineers. Once the ducts, pipes, and chimneys are ready, they have to be mounted on the walls or suspended from the ceiling as per the drawings. Please remember that all the pipes, ducts, and chimneys are properly insulated by the material as per the fire norms of the state or country where it has to be installed. Apart from the main duct and pipe, the branches shall also be fabricated and installed so that all the zones of the area are fully covered with the smoke extraction system. All the smoke ducts and pipes shall lead towards the smoke shaft which in turn shall terminate at the top of the building above the roof level. At the termination point of the smoke shaft, an exhaust fan shall be installed. Fans shall be mounted directly at the exit of the smoke mines. Above the fan, there is a small section of the shaft that leads to the sunroof. Next are the ducts and pipes for the intake of the fresh air. These ducts and pipes shall be installed parallel to the exhaust ducts and pipes. The air vents shall be opened in the walls of the building and air dampers are provided. It is better if the dampers are automated. If automated, as soon as the exhaust starts, the intake air dampers are activated and opened to intake the fresh air. Once the fabrication of the air induction ducting and piping is completed, the same shall be fixed on the wall or hung from the ceiling, just similar to the exhaust ducts and pipes. After installation, provide the air induction fans to suck air from outside and blow it off in the spaces of the building. Both the exhaust and air induction fans shall be connected to the electrical panel to provide power for the fans to operate. Similarly, the dampers, if automated, shall also be provided with the electrical supply. The supply shall be in three phases, and the cables to be used shall be fire rated and non-combustible. To avoid the short-­ circuiting and burning of the cables, please ensure that the cables shall not come into contact with the heating parts of the ducts, pipes, and chimney. The final step is to automate the entire smoke extraction system. To do so, the electric supply to the smoke extraction system and the dampers shall be given from the fire control panel that is being used for the control panel of the smoke detection system. The purpose is that in case there is a fire in any particular zone of the hospital, the smoke detectors shall communicate with the control panel. Once communicated to the control panel, the control panel shall communicate with the electrical panel, and in turn, the electrical panel shall activate the fans and dampers of the smoke extraction to start. Once switched on, the fans and dampers shall start functioning and extract the smoke from the building and also provide fresh air intake. Test the entire smoke extraction system, and if found to be working properly, approve and certify it.

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9.2.7 Automatic Sprinkler System Installation of the sprinklers inside the building has already been mentioned in Chap. 5 of this book. Once all the branches of the sprinkler pipeline in the building are connected to the main supply line of the building, the main supply line is in turn connected to the main water supply line that leads to the pump room. The main water supply line is now connected to the fire pumps installed in the fire pump room. Nowadays, the sprinkler system can also be automated through the fire control panel. For automation, the installation control valve is provided. In this case, as soon as the fire control panel activates the fire alarm, the control valve opens the valve of the sprinkler water supply line of that particular zone and the sprinklers start functioning. Test the entire sprinkler system for any leakages, and if found OK, give approval for use.

9.2.8 Pressurisation of the Lift Wells, Stair Cases, and Lift Lobbies During a fire, the smoke is more fatal than the fire itself. If people are escaping through the staircase, it has to be ensured that the smoke shall not enter the staircase and slow down the evacuation. Furthermore, for firefighters to safely and effectively use the service lift, it has to be ensured that the smoke shall not enter the lift lobby as well. Therefore, the staircase and lift lobby shall be pressurised. The pressurisation system draws outside air and pressurises the staircase to prevent the smoke from flowing in. To pressurise a staircase, all staircase doors shall have an automatic door closer (mechanical type). For pressurisation of the staircases and the lift lobbies, first of all, the vertical ducts, called pressurisation ducts, are installed starting from the roof itself. The top end of the duct is for fixing the fans. The ducts shall have a cut-out on all the floors in the staircase and lift lobby. The bottom end of the duct shall be closed. Air grills of dampers shall be provided on all the cut-outs of the ducts. Now install the high-speed co-axial pressurisation fans on the rooftop. These fans are then connected to the vertical pressurisation duct. For pressurisation of the lift wells, ducting is not required because the lift well is in itself a duct and only needs pressurisation. For lift well pressurisation, an opening is provided in the lift well on the top floor of the roof. The co-axial fan is directly fitted in the opening. Connect all the fans with the automated electrical control panel, which in turn is connected to the main fire control panel. As soon as the fire control panel detects the

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fire signals, an alarm is raised, and the control panel sends a command to the control panel of the pressurisation fan, which in turn switches on the pressurisation fans. Provide electrical supply to the electrical control panel and activate the pressurisation fans. Test the entire pressurisation system, and if found ok, give approval for use.

9.3 Firefighting Outside the Hospital Building See Table 9.3. For firefighting, outside the hospital premises, the arrangement shall be done for providing outlets for water supply in case of fire. These water outlets are used to spray the water on the building from the outside and are also used by the fire tender for refilling. Hence, alongside the entire perimeter of the hospital building, the ring of the fire pipeline has to be provided. This ring is called the yard hydrant ring. At a suitable distance (as defined by the norms and regulations issued by the concerned state or country), the hydrants are provided. Just near these hydrants, the box shall be fixed on the wall to accommodate the flay-lay canvas hose pipe. The fire nozzle, which can be fixed on this flat-lay canvas pipe, shall also be placed in this box.

Table 9.3  Firefighting outside the hospital building

Activity Providing the hydrant ring around the building Providing hydrants at the designed place Providing boxes for fire flat lay canvas pipe Connecting the ring hydrant with the main supply line of fire water from the fire pump room Painting of the hydrant ring Commissioning and testing of the hydrant system

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

::-

:-

::-

Further Reading

243

The yard ring hydrant pipeline shall be ultimately connected to the fire pumps placed in the fire pump room directly or can be connected to the main line coming out of these fire pumps. Once the yard hydrant line is completed, paint the entire yard hydrant pipe ring line. The last step is the pressure test of the yard hydrant ring line, and if no leakage is noticed, the system can be approved for use.

Further Reading Fire Safety in Healthcare Environments [Internet]. [cited 2021 Jul 15]. https://buildingbetterhealthcare.com/news/article_page/Fire_safety_in_healthcare_environments/139696 Fire Safety Management [Internet]. Fire magazine | Safety magazine | Security magazine | Disaster relief equipment and services. 2016 [cited 2021 Jul 15]. https://firesafetysecurityindia.com/ fire-­safety-­management/ Fire Safety and Protection in Hospital [Internet]. Scholarly articles on hospital infrastructure, renovation, up-gradation, refurbishment, setting up new hospital in India. [cited 2021 Jul 15]. http:// www.hospitalinfrabiz.com/fire-­safety-­and-­protection-­in-­hospital.html Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. Chapter 47, Fire Safety. India: Springer Singapore; 2022. p. 479–84. Loria G, Choudhry N, Sharma K. Fire management in hospitals. Apollo Med. 2012;9(1):74–6. Omidvari F, Jahangiri M, Mehryar R, Alimohammadlou M, Kamalinia M. Fire risk assessment in healthcare settings: application of FMEA combined with multi-criteria decision making methods. Math Probl Eng. 2020;2020:e8913497. Tabish SA. Fire safety in hospitals. 2010.

Chapter 10

ELV, ICT, IBMS, and Information Technology Works of the Hospital Building

ICT, which stands for Information and Communication Technologies, focuses on services related to processing information (data, voice, video) and connecting devices. On the other hand, ELV (Extra Low Voltage) systems concentrate on services such as connectivity, security, safety, and automation. Both of these systems play a crucial role in the functioning of a hospital. The local area network (LAN) infrastructure within a hospital is responsible for providing IP connectivity to various services. These services may be located in different areas of the building but require connectivity through the same physical network to share data or commands. Examples of applications that rely on this network infrastructure include CCTV, data sharing, public address systems, voice communication, video streaming, nurse call systems, queuing systems, Hospital Information Systems (HIS), Picture Archiving and Communication Systems (PACS), and more. Efficient implementation of the IT or computer network is essential within a hospital. This is because the software used to operate the hospital, typically referred to as the Hospital Information System (HIS), is utilised in all locations and departments of the facility. As the software is installed on central servers within the hospital, it is necessary to connect all workstations to these servers to establish a complete network. The enclosed checklist provides the sequence of works related to ELV, ICT, IBMS, and IT, which shall be completed inside the building, aiding the site engineer to plan the start and end day of each activity along with the present status of that particular activity.

10.1 CCTV System Inside the Hospital Building See Table 10.1. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_10

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Table 10.1  CCTV system inside the hospital building

Activity Conducting for CAT 6/6A cable CAT 6/6A wire for CCTV Installation of cameras Connecting wiring to the DVR and PC server in the CCTV control room Final testing of cameras

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

::::-

:-

For the CCTV system, first of all, the location of the cameras shall be finalised as per the design and drawings. Based on the location, the conduits are laid down for wiring. The conduits shall either be concealed in the walls or otherwise; if the drawings permit, the conduits can be placed on the false ceiling. Now, for cabling, the CAT 6/6A shall be used and cabling work to be completed. The cabling shall on one hand start from the location of the cameras and shall terminate at the DVR and PC server installed in the control room. Once the painting work and the finishing jobs are over, the cameras shall be installed and tested before final use.

10.2 Central Control Station for CCTV System See Table 10.2. The security of individuals and materials on the premises is a major concern for hospitals due to their size and complexity. Generally, there are a lot of people present in hospitals, some of whom may be experiencing mental stress. Therefore, there is always a danger of suicide or self-harm. Additionally, there is a strong likelihood that expensive equipment will be stolen and hospital data will be leaked out. Hospitals must therefore have comprehensive and efficient closed-circuit television (CCTV) systems to tackle such concerns. The system must keep track of every action that takes place inside the building, especially in high-risk areas, including entrance lobbies, cash stations, OPD waiting rooms, ICU complexes, emergency rooms, morgues, kitchens, and other busy, cluttered places. This recording can be used to track an incident if necessary. The CCTV system makes it possible for video pictures to be displayed online, records them in real time, and makes them accessible for later tracking, as needed.

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Table 10.2  Central control station for CCTV system

Activity Installation of NVR/ DVR in the control room Installation of the required number of display screens in the control room Providing the central server for CCTV recording in the control room with UPS Providing the PC for CCTV monitoring and viewing in the control room with UPS Connection of server and PC to the NVR/ DVR Connection of NVR/ DVR to the display screens Connection of cameras in the building with NVR/ DVR preferably by fibre cable Final testing

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

:-

:-

:-

:-

:-

:-

:-

The following steps need to be followed to install the CCTV system in the hospital. As was mentioned earlier in Chap. 5 of this book, the CCTV cameras shall be fixed in the building and these cameras shall then be connected to the central control unit. As far as the control system is concerned, it includes network video recorder/ digital video recorder (NVR/DVR), a display screen, a computer server to record the videos, and a computer to display the recordings. To establish the control room, the first step is to install the NVR/DVR. All the cables originating from the cameras are terminated at this NVR/DVR. Along with this, the display screens also shall be installed near the NVR/DVR to display the live recording of the cameras, which is viewed by the security personnel or any other authorised person of the hospital to detect any mishappening immediately.

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It is always recommended to record the live videos and save the same for a particular duration, say 2 to 3 months, so that they can be retrieved as and when needed. Hence, a central server, called a CCTV server, shall be installed and attached to the NVR/DVR, where the live streaming of the cameras is recorded. This server shall be placed at some other place away from the NVR/DVR, say in a separate room. As it is recommended that the server shall not be used for day-to-day work, the personal computer (PC) needs to be hooked on to the CCTV server for routine work. This personal computer shall be placed in the control room, where the display screens are installed. This personal computer shall be connected to the CCTV server. The computer will thus help the security or other authorised person to retrieve the recordings or view the recordings as and when needed. The next step is to connect all the cables, originating from the individual cameras, to the NVR/DVR. The cable can either be the audio-visual cable or preferably the fibre cable. Supply electric power to the NVR/DVR from a dedicated MCB. Please ensure that the power backup is provided to the NVR/DVR through the UPS so that the NVR/DVR is continually functioning. Check the entire CCTV system, including the cameras, NVR/DVR, and the recordings of the cameras. Also, ensure that the cameras are positioned properly and are angled accurately to capture the area as required by you and there are no hurdles in between, which may hamper the recording. If everything is found to be satisfactory, approve it and keep it ready for utilisation.

10.3 Public Announcement (PA) System Inside the Hospital Building See Table 10.3. For public address (PA) system, first of all, the location of the speakers and the mikes shall be finalised as per the design and drawings. Based on the location, the conduits are laid down for wiring. The conduits shall be either concealed in the walls or otherwise; if the drawings permit, they can be installed in the open above the false ceiling. Now, wiring work shall be completed by using the recommended and designed wire. The wiring shall on one hand start from the location of the speakers and mike and shall terminate at the amplifier and PC server installed in the central PA control room. Once the painting work and the finishing jobs are over, the required speakers (wall-mounted or ceiling-mounted) and the mikes shall be installed and tested before final use.

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Table 10.3  PA system inside the hospital building

Activity Conduiting for the wiring of the PA system Wiring for PA system Fixing of ceiling/ column speakers Connection of speakers Fixing of microphones at the required locations Connecting wires to the central control amplifier system and PC in the PA control room Final testing of the PA system

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

::::-

:-

:-

10.4 Control Station of Public Announcement (PA) System See Table 10.4. In a hospital, communication is crucial to improving healthcare delivery and saving lives. At all times, staff must be able to contact the required medical specialists. The personnel must also be able to broadcast general and emergency announcements across the hospital and ensure that the intended audience is receiving them. Hospital communication systems, including intercom and public address (PA) systems, are crucial in this situation. Public address systems can be used in hospitals to broadcast prayers, play background music, and make announcements in waiting rooms and corridors in addition to emergency announcements. As was mentioned earlier in Chap. 5 of this book, the speakers of the PA system are fixed in the building and these speakers are then connected to the central control unit. As far as the setting up of the control room is concerned, first of all, the amplifiers shall be installed in the control room of the hospital. Apart from the amplifiers, the PA control unit also needs to be installed. This control system helps control the volumes, zoning of the building, sound quality, and amplification of the sound, etc. Connect the amplifier to the control unit. Also, connect all the cables originating from the speakers and connect them to the central PA control unit.

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10  ELV, ICT, IBMS, and Information Technology Works of the Hospital Building

Table 10.4  Control station of public announcement (PA) system

Activity Installation of amplifiers in the control room Installation of PA control station in the control room Providing the micro phone in the control room and other required areas for the announcement Automation of the PA system with fire detection control panel for an emergency announcement Connection of speakers and microphones in the building with the PA control station Final testing

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:-

:-

:-

:-

Next is to provide microphones in all the areas of the hospital, from where the announcements are to be made. The microphone shall also be provided in the control room. Connect the microphones to the central PA control unit. Wherever the fire control panel is installed, the fire control panel and the PA control units shall be connected. This will help in an automatic announcement in case any fire or smoke is detected by the fire control panel. Check the entire PA system, including the speakers, amplifier, control unit, and the linking with the fire control panel. Ensure that the speakers are positioned properly and the voice reaches all desired areas in the hospital. Also, check that the voice is clearly audible and free from any disturbances and echo. If everything is found to be satisfactory, approve it and keep it ready for utilisation.

10.5 Electronic Private Automatic Branch Exchange (EPABX) System Inside the Hospital Building See Table 10.5. For the EPABX system, first of all, the location of the intercom and the EPABX control room shall be finalised as per the design and drawings. Based on the

10.6 Control Station of EPABX System

251

Table 10.5  EPABX system inside the hospital building Status of works Activity Laying conduits for the cable of the EPABX system CAT 6 cabling for EPABX Installation of individual intercom phones Connecting cables to the central EPABX in the control room Final testing of intercoms

Start date

End date

Not Responsible Complete In-progress started person

Remarks

:-

::-

:-

:-

location, the conduits are laid down for wiring. The conduits shall be either concealed in the walls or otherwise; if the drawings permit, they can be installed in the open above the false ceiling. Now, for cabling, the CAT 6 shall be used and cabling work shall be completed. The cabling shall on one hand start from the location of the intercoms and shall terminate at the EPABX control unit installed in the control room. Once the painting work and the finishing jobs are over, all the intercoms shall be installed and tested before final use.

10.6 Control Station of EPABX System See Table 10.6. For quick and simple two-way communication in hospitals, either an audio intercom system or a combined audio/video intercom system shall be provided. The use of IP-based solutions is encouraged for more operational flexibility. As was mentioned earlier in Chap. 5 of this book, the intercoms are installed inside the building. These intercoms are subsequently connected to the central control unit called EPABX. The first step towards the installation of the EPABX system is to provide the distribution box in the control room. This box is fixed on the wall, and as an incoming, the cables originating from the EPABX are connected to this distribution box. On the delivery end of the distribution box, the cable originating from the individual intercoms is connected. Each location shall be allotted a unique intercom number and connected to a cable/wire.

252

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Table 10.6  Control station of EPABX system Status of works Activity Providing distribution box in the EPABX console room Installation of EPABX control system Connecting floor lines to the distribution box Connection of distribution box with the EPABX Individual intercom phones installation Final testing

Start date

End date

Not Responsible Complete In-progress started person

Remarks

:-

:-

:-

:-

::-

Install the EPABX unit. Check all the incoming and outgoing cards of the unit. Supply power to the EPABX control unit. Please ensure that the power supply to the EPABX shall have proper power backup through the UPS. Check the entire intercom system, including the intercoms. Also check that the facilities, programmes, and features given in the EPABX are working properly. If everything is found to be satisfactory, approve it and keep it ready for utilisation.

10.7 IT Networking and Wi-Fi System Inside the Hospital Building See Table 10.7. For the IT network system, first of all, the location of the individual personal computers (PC), distribution switches, and server rooms shall be finalised as per the design and drawings. Based on the location, the conduits are laid down for cabling. The conduits shall either be concealed in the walls or otherwise, if the drawings permit, they can be installed in the open above the false ceiling. Now for cabling, the CAT 6/6A shall be used and cabling work shall be completed. The cabling shall commence from the location of the PC and shall terminate at the floor distribution switches. The distribution switches shall in turn shall be connected to the central data central server kept in the server control room. At each location of the PC, a sufficient number of electrical outpoints shall be provided to connect the PC, UPS, printer, and other computer accessories and devices. Similarly, at the location of each of the distribution switches an electrical outlet shall be provided. It has to be ensured that all these electrical outlets (PC or

10.8 Control Station of IT Networking and Wi-Fi

253

Table 10.7  IT networking and Wi-Fi system inside the hospital building

Activity Laying conduits for cable IT network CAT 6/6A cabling for IT network Providing electrical points at the location of the computer to connect the PC/printer and other computer accessories Installation of the floor distribution switches for the data network Providing electrical points at the location of the distribution switch duly connected through the UPS supply Connecting and cabling from individual IT point to the distribution switch Connecting cables from distribution switches to the central data server in the server room Final testing of IT points

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::-

:-

:-

:-

:-

:-

distribution switches) shall be connected to the UPS for an uninterrupted power supply. Once the painting work and the finishing jobs are over, the distribution switches and the PCs shall be installed, connectivity to be completed and the system shall be tested before final use.

10.8 Control Station of IT Networking and Wi-Fi See Table 10.8. The hospital’s computer network needs to be set up effectively. This is vital because all of the hospital’s sites and departments use the software known as the

254

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Table 10.8  Control Station of Information Technology (IT) Networking and Wi-Fi

Activity Raised artificial flooring of the server room Placing the server cabinets Providing steel cabinets for storing backup devices and accessories Installation of server UPS Providing necessary electrical points Providing distribution switch box Installation of servers (data server, report server and backup server) Connecting servers with distribution switches Loading of the HMS software in servers Configuration of the software Fixing of Wi-Fi router in the building Final testing

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

::-

:::-

:-

:-

::::-

HIS (Hospital Information System), which is necessary for the operations of the hospital. As was mentioned earlier in Chap. 5 of this book, we have described the installation of the distribution switches, and the personal computer units inside the building. These individual PCs are connected to the distribution switches, which in turn are connected to the central server. The first step towards setting up the central server room is to prepare the flooring of the server room. Generally, anti-static raised flooring is used in the server rooms. This flooring is prepared with the base frame made out of metal, and on the top of the frame, the perforated anti-static tiles are fixed. All the cables and the wires are laid down below the raised flooring to keep the server room free from visible wires and cables.

10.9 Television System

255

Once the flooring is ready, place the fireproof, self-cooling server cabinets on the raised flooring. Install the servers in this cabinet. Usually, there are several servers used in the hospital depending on the utility of the server, such as a data server, report server, backup server, and PACS server. Now install the distribution box in the server room. This box is fixed on the wall, and as an incoming, the cables originating from the server are connected to this distribution box. On the delivery end of the distribution box, the cable originating from the individual distribution switches is connected. Install the UPS as a power backup to the server. The server shall be connected to the power supply through UPS. Switch on the power and check the server. It is advised to provide a lockable fireproof steel cabinet near the server to store the backup devices and other accessories used in the server. Now is the time to load the Hospital Management Software on the server. Configure the software as per the requirement. Allot a unique IP address to each PC. If a Wi-Fi system has to be installed in the hospital, provide the Wi-Fi routers at the desired location within the hospital building. Check the entire IT network system, including the individual PCs. Check the entire networking including the distribution switches. Ensure that the individual PCs are properly connected to the server. Check that the HMS software and other software are working on the individual PCs. If everything is found to be satisfactory, approve it and keep it ready for utilisation.

10.9 Television System See Table 10.9.

Table 10.9  Television system

Activity Conduiting for AV cable from the source Laying of AV cable Providing an electrical point near the television location Connecting and wiring from individual TV points to the signal supply source Final testing of TV points

Status of works Start End Not Responsible date date Complete In-progress started person :::-

:-

:-

Remarks

256

10  ELV, ICT, IBMS, and Information Technology Works of the Hospital Building

For the television network, first of all, the location of the televisions shall be finalised as per the design and drawings. Second, the source of television signals shall be designed. It can be either through the hospital’s own distribution system or from the dish. Based on the location of the television, the conduits are laid down for wiring. The conduits shall either be concealed in the walls or otherwise, if the drawings permit, they can be installed in the open above the false ceiling. For cabling, the AV cable shall be used and cabling work shall be completed. The cabling shall on one hand start from the location of the television and shall terminate at the television signal source. At each location of the television, a sufficient number of electrical outpoints shall be provided to connect the television and the distribution box. Once the painting work and the finishing jobs are over, the televisions and the distribution boxes shall be installed, connectivity shall be completed, and the system shall be tested before final use.

10.10 Nurse Call System See Table 10.10. For the nurse call system, first of all, the location of the bed (where the nurse call system has to be installed) and the nursing station (where the control of the nurse call system has to be installed) shall be finalised as per the design and drawings. Table 10.10  Nurse call system

Activity Laying conduits from the patient bed to the nurse station for the nurse call system Laying of CAT 6 cable Providing electrical point at the nursing station for the nurse call system Connecting and wiring from individual patient bed to the central nurse call unit placed at the nursing station Final testing of nurse call points

Status of works Start End Not Responsible date date Complete In-progress started person :-

::-

:-

:-

Remarks

10.11 Access Control System

257

Based on the location, the conduits are laid down for connecting the unit at the patient bed with the control station installed at the nurse station. Please ensure that for each and every in-patient area such as each ward, group of rooms, etc., separate nurse call units shall be installed. The conduits shall either be concealed in the walls or otherwise, if the drawings permit, they can be installed in the open above the false ceiling. Now for cabling, the CAT 6/6A shall be used and cabling work shall be completed. The cabling shall commence from the location of the bed and shall terminate at the nurse control unit kept at the nurse station. At each nurse station, a sufficient number of electrical outpoints shall be provided to connect the nurse control unit. It has to be ensured that all these electrical outlets shall be connected to the UPS for an uninterrupted power supply. Once the painting work and the finishing jobs are over, the nurse call buttons shall be installed at the bed end of the patient and the nurse control unit at the nurse station. For each system, connectivity shall be completed and the system shall be tested before final use.

10.11 Access Control System See Table 10.11. For the access control system, first of all, the location of the access doors and the access control station shall be finalised as per the design and drawings. Based on the location, the conduits are laid down for connecting the access doors with the access

Table 10.11  Access control system

Activity Laying conduits from the control unit to the door that is under access control Laying of CAT 6 cable Providing an electrical point at the access door Connecting and wiring from the control unit to the access door Final testing of the access door

Status of works Start End Responsible Not date date Complete In-progress started person :-

::-

:-

:-

Remarks

258

10  ELV, ICT, IBMS, and Information Technology Works of the Hospital Building

control station. The conduits shall either be concealed in the walls or otherwise, if the drawings permit, they can be installed in the open above the false ceiling. Now for cabling, the CAT 6/6A shall be used and cabling work shall be completed. The cabling shall commence from the location of the door and shall terminate at the access control unit. At each door, a sufficient number of electrical outpoints shall be provided to supply electricity for door operation. Similarly, an electrical point shall be provided near the access control unit to supply electricity to the unit. It has to be ensured that all these electrical outlets shall be connected to the UPS for an uninterrupted power supply. Once the painting work and the finishing jobs are over, the access doors and the access control unit shall be installed. The connectivity shall be completed and the system shall be tested before final use.

10.12 IBMS See Table 10.12. For Integrated Building Management System (IBMS), first of all, the decision has to be taken as to which services of the building have to be connected to the IBMS. It can be air-conditioning, water supply, electricity, etc. Then, the location of the concerned central control of the concerned service has to be decided. Apart from this, the location of the IBMS control station has to be finalised. All these locations Table 10.12 IBMS

Activity Conducting form IBMS control station till the concerned unit is attached to the IBMS Laying of CAT 6 cable Providing electrical point at the central IBMS control station Connecting and wiring from the IBMS control station till the concerned unit is attached to IBMS Final testing of the IBMS

Status of works Start End Not Responsible date date Complete In-progress started person :-

::-

:-

:-

Remarks

10.13 Pneumatic Tube System (PTS) Inside the Hospital Building

259

shall be drawn on the design and drawings. Based on the location, the conduits are laid down for connecting the individual control units with the IBMS control station. The conduits shall either be concealed in the walls or otherwise, if the drawings permit, they can be installed in the open above the false ceiling. Now for cabling, the CAT 6/6A shall be used and cabling work shall be completed. The cabling shall commence from the location of an individual service control unit and shall terminate at the IBMS control station. An electrical point shall be provided near the IBMS control station to supply electricity to the station. It has to be ensured that all these electrical outlets shall be connected to the UPS for an uninterrupted power supply. Once the painting work and the finishing jobs are over, the IBMS control station shall be installed and connected to the individual service control unit. The connectivity shall be completed and tested before final use.

10.13 Pneumatic Tube System (PTS) Inside the Hospital Building See Table 10.13. A pneumatic tube system (PTS) is used for the quick transportation of small items such as blood samples and medicines inside the hospital building. The items are kept in a capsule-type carrying container. This container moves in the pneumatic tube at a high speed and delivers the materials to the selected station. To install the system first of all the high-grade Polyvinyl Chloride (PVC) tube network is installed above the false ceiling with the help of pipes and fittings.

Table 10.13  Pneumatic tube system (PTS) inside the hospital building

Activity Laying of the PTS tube across the building on different floors with required pipes and fittings Installation of the delivery station at the desired location for receiving and sending the capsule Connecting the tubes to the central blower station of the PTS Testing of the PTS

Status of works Start End Not Responsible date date Complete In-progress started person :-

:-

:-

:-

Remarks

260

10  ELV, ICT, IBMS, and Information Technology Works of the Hospital Building

The delivery stations are provided at the selected location from where the materials have to be sent and also at the locations where the material has to be received. The tubes are connected to the individual delivery station on one end and to the central blower station on the other end. The blower station controls the movement of the carriers inside the PTS tube.

10.14 Control Station of Pneumatic Tube System (PTS) See Table 10.14. A pneumatic tube system (PTS) is basically an internal logistics and transport system that is used to move small items like paperwork within the hospital complex. In this method, the items and papers are placed in a carrier (a structure resembling a capsule) and moved from one location to another via an air-pressurised tube network. The air pressure pump for the PTS, an air-operated system, is connected to the control station. This system is utilised for the transportation of paperwork, supplies, and medications. For documents, samples, materials, and medications, this is the most reliable, precise, and efficient route of transportation. In Chap. 5 of this book, we have detailed the installation of the tubing network for PTS and the PTS stations in the hospital. Now we have to set up the control station for the PTS. The first step is to prepare the blower room to install the blower pump. The foundation for installing the blower pump shall be constructed. The specifications and the size of the foundation shall be designed as per the details provided by the original manufacturer of the PTS.

Table 10.14  Control station of pneumatic tube system (PTS)

Activity Foundation of blower pump Providing the required electrical points in the blower pump room Fixing of blower pump Connection of the PTS tube network with the blower pump Commissioning of blower pump Final testing of PTS

Status of works Start End Not Responsible date date Complete In-progress started person ::-

::-

::-

Remarks

Further Reading

261

Install the blower pump on the foundation. Now connect the blower pump to the PTS tube network that was erected inside the building. Provide an electrical connection to the blower pump. Ensure the power backup to the blower pump with the help of UPS. Commission the PTS. Allot a unique station ID to each PTS station inside the building. Check the entire PTS, including the individual PTS stations. Check the entire PTS ducting networking for any air leakage. Ensure that all the PTS stations can receive and send the PTS carriers. If everything is found to be satisfactory, approve it and keep it ready for utilisation.

Further Reading Aswin S, Narayanamurthy G, Jeyender S, Prasanna R, Kumar SP. Design development and implementation of wireless nurse call station. 2011 Annu IEEE India Conf INDICON; 2011. Dašić P, Dašić J, Crvenković B. Improving patient safety in hospitals through usage of cloud supported video surveillance. Maced J Med Sci. 2017;5:101–6. Editor. Integrated BMS for Healthcare Building | Cooling India Monthly Business Magazine on the HVACR Business | Green HVAC industry | Heating, Ventilation, Air conditioning and Refrigeration News Magazine Updates, Articles, Publications on HVACR Business Industry | HVACR Business Magazine [Internet]. [cited 2021 Jul 14]. https://www.coolingindia.in/ integrated-­bms-­for-­healthcare-­building/ Emergency Public Address System Requirements and Maintenance [Internet]. Jensen Hughes. [cited 2021 Jul 14]. https://www.jensenhughes.com/insights/ public-­address-­systems-­what-­you-­need-­to-­know Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. Chapter 40, ELV, ICT and IBMS Services; p.  433–440, Chapter 41, Information Technology and Computerization. India, Springer Singapore; 2022. p. 441–50. Hospital Building Management System (BMS) [Internet]. Med and Tech. [cited 2021 Jul 14]. http://hospital-­tech.com/solutions/hospital-­building-­management-­system-­bms/ Hospital Management Software Development: Modules, Features, and Main Benefits [Internet]. [cited 2021 Jul 14]. https://steelkiwi.com/blog/hospital-­management-­software-­development/ How Good Public Address and Intercom Systems Help Save Lives in Hospitals—asmag. com Rankings [Internet]. [cited 2021 Jul 14]. https://www.asmag.com/rankings/m/content. aspx?id=30879 How to Create the Perfect Public Service Announcement [Internet]. GovTech 2021 [cited 2021 Jul 14]. https://www.govtech.com/education/news/how-­to-­create-­the-­perfect-­public-­service-­ announcement.html Information Systems in Health Care [Internet]. Health Care Service Delivery. 2014 [cited 2021 Jul 14]. https://drdollah.com/hospital-­information-­system-­his/ Mehdipour Y, Zerehkafi H. Hospital Information System (HIS):At a Glance. Asian J Comput Sci Inf Technol 2013;1:2321–5658. Miller ET, Deets C, Miller RV. Nurse call systems: impact on nursing performance. J Nurs Care Qual. 1997;11(3):36–43. Nurse Call System Upgrades [Internet]. [cited 2021 Jul 14]. https://www.hfmmagazine.com/ articles/1664-­nurse-­call-­system-­upgrades

Chapter 11

Medical Gases Pipeline System (MGPS) Works of the Hospital Building

Medical gases are one of the main support services used in hospitals. Medical gases are specific gases that are separated from the air individually for various medical applications. Commonly used medical gases in hospitals are 1. Oxygen (O2) 2. Nitrous oxide (N2O) 3. Medical air 400 KPa or 4 bar (MA 4) 4. Medical air 700 KPa or 7 bar (MA 7) 5. Carbon dioxide (CO2) 6. Nitrogen (N2) 7. Medical vacuum

11.1 Medical Gases Pipeline System (MGPS) Inside the Hospital Building See Table 11.1. The Medical Gases Pipeline System (MGPS) is installed in the hospital for the supply of piped oxygen, nitrous oxide, compressed air, vacuum, and carbon dioxide. To start with, the shop drawings of the MGPS network shall be prepared. The drawing shall depict the routing of the pipeline. It shall also provide details of the diameter of the pipe to be used. To start the erection of the pipeline network, first of all, the main riser pipeline shall be installed. The pipeline shall be properly fixed on the wall with pipe resting on the saddles. If required, the pipe tray can also be used. Sometimes the routing is such that the riser pipe needs to be suspended from the ceiling. In that case, the pipe shall be hung on the hangers.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_11

263

264

11  Medical Gases Pipeline System (MGPS) Works of the Hospital Building

Table 11.1  Medical Gases Pipeline System (MGPS) inside the hospital building

Activity Preparation of the shop drawing for MGPS Laying of the risers for oxygen, vacuum, compressed air, nitrous oxide, etc. from the manifold room Laying of the gas pipeline for oxygen, vacuum, and compressed air on the floors Laying of the gas pipeline for nitrous oxide and CO2 till Operating Room (OR)’s Fixing of hangers/ saddles to lay pipeline Fixing of the required floor isolation valves and zonal valve boxes at the required places Room-wise gas supply lines up to gas outlet points Fixing and connection of the room bed head panels or gas outlets Connection of room lines with main lines Fixing the required area line pressure alarms at the required places Pressure testing of the pipelines Painting and coding of the pipelines Fixing of point accessories such as flow meter, suction jars, etc. Fixing of bed head accessories such as monitor tray, baskets, etc.

Status of works Start End Not Responsible date date Complete In-progress started person :-

:-

:-

:-

::-

:-

:-

::-

:::-

:-

Remarks

11.2 Central Plant Works of MGPS System

265

After the riser, the floor main lines are installed. These are generally horizontal lines and are installed on the walls, or suspended from the ceiling. In the case of the wall, the pipeline shall be properly fixed on the wall with the pipe resting on the saddles. If required, the pipe tray can also be used. If the pipeline has to be suspended from the ceiling, hang it on the hangers. Once the floor main lines are installed, the branch lines shall be installed. The installation process shall be the same as the main lines. These branch pipelines travel across the room on the wall over the patient’s bed. At respective places, the drops pipeline is provided, which shall subsequently be connected to the gas outlet. It has to be ensured that separate pipelines shall be installed for all the gases, and there shall be no chance of mixing one gas with the other because it can be very dangerous. During the installation of the pipeline, all required accessories, such as isolation valves, zonal valve boxes, and area line pressure alarms, shall be installed in the pipeline as per the drawings. Connect the main pipeline with the riser pipe, which in turn shall be connected to the main supply line of the system in the gas control room. Once the piping network is completely installed, pressure testing shall be done to ensure that the pipeline is free from any kind of leakage. If testing passes, the pipeline shall be painted as per the prescribed colour coding. Now comes the gas outlets. The gas outlets shall be installed above the patient bed. It can either be affixed on the wall directly or otherwise in the bed head panel affixed on the wall just above the patient bed. Once the outlets are affixed at the place, the outlet shall be connected to the drop pipe left during pipeline installation. Fix the point accessories such as flow meter, suction jar, etc. Similarly, if the bed head panel accessories, such as a monitor tray or the utility basket, are supplied along with the bed head panel, the same shall be installed. Test the entire system and connect it to the main control station of MGPS. Note: Please note that all the above activities of various services have to be carried out for all the floors of the building

11.2 Central Plant Works of MGPS System See Table 11.2. Medical gases are one of the main support services used in hospitals. Commonly used medical gases in hospitals are • • • • • • •

Oxygen (O2) Medical air 700 KPa or 7 bar (MA 7) Medical air 400 KPa or 4 bar (MA 4) Medical vacuum Nitrous oxide (N2O) Nitrogen (N2) Carbon dioxide (CO2)

266

11  Medical Gases Pipeline System (MGPS) Works of the Hospital Building

Table 11.2  Central plant works of Medical Gases Pipeline Supply (MGPS) system

Activity Manifold room Erection of manifold of oxygen (O2) with provision for emergency manifold as per the drawings Installation of the manual/semi auto/ automatic control panel for O2 including provision for liquid O2 if any Connection from the control panel to the main O2 supply line (main riser) Erection of manifold of N2O with provision for emergency manifold as per the drawings Installation of the manual/semi auto/ automatic control panel for N2O Connection from the control panel to the main N2O supply line (main riser) Pump room for air Construction of foundation for compressed air pump and storage tank Installation of oil-free compressor pumps and required accessories Installation of the compressed air tank and required accessories Connection of compressed air pumps with tank

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:-

:-

:-

:-

:-

:-

:-

:-

11.2 Central Plant Works of MGPS System

267

Table 11.2 (continued)

Activity Installation of dryers and filtration system Installation of air pressure regulating systems Connection of compressed air tank with main air supply line (main riser) through dryers and filters Electrical connection of the pumps and other equipment through the automatic control panel Pump room for vacuum Construction of foundation for vacuum pump and storage tank Installation of vacuum pumps and required accessories Installation of the vacuum tank Connection of vacuum pumps with tank and required accessories Installation of bacteria filters Connection of vacuum tank with main vacuum line (main riser) Electrical connection of the pumps through the automatic control panel Liquid oxygen gas system Prepare the foundations

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::-

:-

:-

:-

:-

::-

::-

:-

:(continued)

268

11  Medical Gases Pipeline System (MGPS) Works of the Hospital Building

Table 11.2 (continued)

Activity Approval from the government for the installation of the liquid oxygen tank Install the cryogenic tank Install the coil Install the valves, pressure gauges, and pressure controller Connect the coil to the control unit with the help of a copper pipeline Lay down the copper pipeline and connect the control unit of the liquid gas system with the main riser pipeline Provide fences all around the liquid gas plant Test the plant for its operation

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:::-

:-

:-

:-

:-

A set of components/equipment shall be installed to supply all of these gases to the final point of use. This system runs from the gas source to the outlet point on the patient’s bed. All of these system components are collectively referred to as MGPS systems. Each medical gas must be supplied by its own system. The gases shall never be mixed or cross-connected between systems. The source for supply of the oxygen gas can be cryogenic vessels or a high-­ pressure manifold where the tank is filled up with liquid oxygen; a manifold system where a set of gas cylinders are connected in a series and forming a bank of cylinders or oxygen concentrators, which takes air from the atmosphere, separates the oxygen component, and fills up the tanks. Similarly, the source of nitrous oxide is generally a manifold system where a set of gas cylinders are connected in a series and forming a bank of cylinders. As far as the source for medical air and the vacuum is concerned, it is from the air compressors and the vacuum pumps. Various components are used for setting up the MGPS system, such as: (a) A copper pipeline distribution system that delivers gas or vacuum to endpoint or terminal units (b) Valves to control the flow of the gases

11.2 Central Plant Works of MGPS System

269

(c) Warning and alarm systems to provide alerts in the event of system failure or inadequate gas pressures (d) Area line pressure alarm boxes (e) Outlets that are the MGPS’s final endpoints from where gases are delivered to patients (f) Other materials such as hoses, gas flow meters, gauges, and vacuum regulators Infrastructure-wise the MGPS shall have: (a) Liquid oxygen tank area with landing bay (if a liquid oxygen tank is to be installed) (b) Oxygen and nitrous oxide manifold room (c) Pump room for installation of plants for compressor, vacuum units

11.2.1 Manifold Room The manifold room is provided in the hospital to install the manifold for oxygen and nitrous oxide gases. The manifold is basically a system in which multiple cylinders are connected in series and in turn connected to a common outlet. This set of cylinders connected in a series is called a BANK. Usually, “D-type” jumbo cylinders are used for the manifolds. Each bank of cylinders may have 2–20 cylinders. The number of cylinders to be installed in each bank shall be decided based on the number of outlets that are required as of the date and adding the provision for additional outlets that may be required in future. Based on the number of cylinders to be installed in a bank, a common connecting copper pipe shall be fixed on the wall, and the outlet’s sockets shall be provided on this common pipe at a distance of about 1 ft. from each other. One socket shall be provided for each cylinder of the bank. The copper tailpipe shall be attached to these sockets, which in turn shall be connected to the regulator of the cylinders. Each cylinder shall have a separate tailpipe and regulator. This regulator shall be fixed on the cylinders. Now the common connecting pipe, on which all the cylinders of the bank are attached, is connected to the control panel, which controls the flow of the gas. It shall be kept in mind that the temperature of the gas may fall as low as −30 °C as the gas passes through the regulator at maximum capacity. Hence, the equipment shall be designed accordingly. To complete the manifold setup, two such banks are installed and both are connected to the control panel. One bank is termed as a “Duty Bank” and the other as a “Standby Bank.” The control panel functions to control the flow of gases. As both the banks are connected to the control panel, this panel allows one bank to be operated at a time. As soon as the pressure of the current bank drops, the control panel automatically switches to the other bank. This job is done with the help of pressure-­ regulating valves fitted with each bank. Once the empty bank is cut-off, the

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cylinders of that bank are replaced with the filled cylinders and make it ready for the next use. The control panel can either be automatic or semi-automatic type. The automatic control panel automatically switches between “Duty Bank” to “Standby Bank,” and vice versa. However, in the case of a semi-automatic panel, the warning is issued as soon as the bank pressure drops and the operator have to manually shift to the other bank. The manifold headers shall be fitted with a non-return valve to allow the removal and replacement of any cylinder and to prevent the discharge of a bank of cylinders in the event of pig tail-pipe rupture. From the control panel, the outlet shall be given which is connected to the copper pipe of the main supply line of the gas, which is also called the main riser. The main riser is the line that transports the gas to the hospital building. To be on the safer side, it is anticipated that an emergency may arise at any time due to the failure of the manifold system. To overcome such an emergency, an emergency manifold with two to four cylinders shall also be provided. The design of the emergency manifold shall be the same as that of the main manifold, with the difference that no control panel is provided on the emergency manifold. The output of the emergency manifold shall be directly connected to the main supply line where the main manifold is already connected. In case of failure of the main manifold system, and as soon as the emergency manifold is switched on, the gas flow starts in the same main pipeline. A non-return valve and isolating valve shall be installed immediately upstream of the reserve manifold connection to the pipeline distribution system. The manifold system shall be prepared for oxygen supply and the nitrous oxide supply. So, for both the gases, the main bank and the emergency supplies shall be provided.

11.2.2 Pump Room for Air The production of medical air is done with the help of the compressor. The plant consists of electric motors, air compressors, air reservoir, an automatic/semi-­ automatic control panel, bacteria filter, and the air dryer along with the required non-return valves, isolating valves, gauges and pressure switches, an operating and indicating system, an exhaust system, and a test point. There shall be a set of two such units as both will be operative reciprocally one after the other at a fixed interval of time. The first step is the construction of the foundation for placing the pump and air compressor. The foundation shall be raised from the ground level depending on the water logging in the room. It can be anywhere between 150 mm and 450 mm. The size of the foundation shall be able to easily accommodate two sets of air compressors and also have some space all around the compressors for easy maintenance. There are two options. First is to have a combined foundation for both sets of

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compressors on the same foundation. Second is the construction of a separate foundation for each compressor pump. Strength-wise, the foundation shall have the sufficient load-bearing capacity to easily tolerate the load of the pump and also be able to tolerate the vibration load of the compressor pumps. Similarly, the foundation has to be constructed for the air reservoir. The size and load-bearing capacity shall be decided as per the design given by the original manufacturer of the reservoir. Once the foundations are ready, the next is to place the compressor pumps on the foundation. The compressor unit comprises two machines. One is the electric motor, and the second is the air compressor. Both these machines are mounted on the base frame, which is fabricated for this purpose. The coupling of both shall be done with the help of V-belts. This base frame (mounted with motor and compressor) shall be fixed on the pre-constructed foundation with the help of fasteners. Please ensure to provide the anti-vibration pads while fixing the base frame as the unit creates a lot of vibration when operative. It has to be ensured that the compressors shall be oil-free compressors, failing which there are chances that the produced air may have traces of oil, which may be harmful to the patients or medical devices. The plant shall have all-around access for maintenance purposes and allowance shall be made for changing major components. The outlet of both compressors shall be combined and connected to the air reservoir. The air reservoir is a tank made out of thick MS steel and is provided with an air inlet, air outlet, and gate valve to drain the water (collected in the tank due to the moisture in the air). This tank shall be installed on the raised foundation (say by 150–450 mm). The air normally contains traces of impurities such as carbon monoxide, carbon dioxide, sulphur dioxide, nitrogen monoxide and dioxide, moisture, and oils. These contaminants can enter the compressed air system from three sources: the atmosphere, the compressor, and the pipeline distribution system. Hence, the air filtration unit has to be provided to filter the air before sending it out to the user end. This air filtration system can be in different stages depending on the type of filter. It can be from a single-stage filter to a four-stage filter. The air filters shall be provided just near the outlet of the air reservoir. Provide the electric point near the air filtration equipment to supply electricity to the filter equipment. As the air contains moisture, it needs to be dried before sending it further to the user. If it is not dried, the wet air can be dangerous for the patients and also harmful to the medical equipment where it shall be used. The dryer system shall be a twin system, so only one is operational at a time and the other is on standby. From time to time, switching is done from one to another. Just at the outlet point of the filters, the dryer system shall be installed and connected to the filter system so that the filtered air can reach the dryer unit. For both the dryer units, separate power supply outlets shall be provided near the dryer units. The functioning of the air compressors is controlled by the automatic/semi-­ automatic control panels. The electric connections to the motors shall be done through this control panel. The control panel switches from one set of compressor units to the other automatically at the pre-set interval of time. At any moment, both

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compressors shall be in working condition. If one unit goes out of order, the other unit of compressors shall be able to take the entire load of the air requirement. At last, the outlet from the dryer shall be connected to the main riser copper line that in turn shall be connected to the copper pipe network inside the hospital building to supply air till the final air outlet is used by the user. Switch on the compressor plant and test both the compressor pumps, air reservoir, and pipeline for any leakage of the Air. If everything is found to be satisfactory, approve it and keep it ready for utilisation.

11.2.3 Pump Room for Vacuum The creation of the vacuum is done with the help of vacuum pumps. The plant consists of electric motors, vacuum pumps, vacuum reservoir, an automatic/semi-­ automatic control panel, and a bacteria filter with drainage traps along with the required non-return valves, isolating valves, gauges and pressure switches, an operating and indicating system, an exhaust system, and a test point. There shall be a set of two such units as both will be operative reciprocally one after the other at a fixed interval of time. The first step is the construction of the foundation for placing the vacuum pump. The foundation shall be raised from the ground level depending on the water logging in the room. It can be anywhere between 150 mm and 450 mm. The size of the foundation shall be able to easily accommodate two sets of vacuum pumps and also have some space all around the pumps for easy maintenance. There are two options. First is to have a combined foundation for both sets of vacuum pumps on the same foundation. Second is the construction of a separate foundation for each vacuum pump. Strength-wise, the foundation shall have the sufficient load-bearing capacity to easily tolerate the load of the vacuum pump and also be able to tolerate the vibration load of the vacuum pumps. Similarly, the foundation has to be constructed for the vacuum reservoir. The size and load-bearing capacity shall be decided as per the design given by the original manufacturer of the reservoir. Once the foundations are ready, the next is to place the vacuum pumps on the foundation. The vacuum unit consists of two parts. One is the electric motor, and the second is the vacuum pumps. Both these machines shall be mounted on the base frame, fabricated for this purpose. The coupling of both shall be done with the help of V-belts. This base frame (mounted with a motor and pump) shall be fixed on the pre-constructed foundation with the help of fasteners. Please ensure to provide the anti-vibration pads while fixing the base frame as the unit creates a lot of vibration when operative. It has to be ensured that the vacuum pumps shall be oil-free. Water-sealed pumps shall not be used. It is desirable if rotary vane pumps are used instead of reciprocating vacuum pumps that are now obsolete. The plant shall have all-around access for maintenance purposes and allowance shall be made for changing major components.

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The outlet of both the vacuum pumps shall be combined and connected to the vacuum reservoir. The vacuum reservoir is a tank made out of thick MS steel and is provided with an inlet connected to the vacuum pump, and an outlet connected to the filtration system. This tank shall be installed on a raised foundation (say by 150 mm–450 mm). The vacuum system shall be connected to the bacteria filters. The purpose is that any suction air coming towards the reservoir passes through the filtration system. Therefore, the bacteria filter station and secretion trap are provided in the system. The filtration system can be in different stages depending on the type of filter. It can be from a single-stage filter to a four-stage filter. Hence, the filter unit shall be connected at the receiving end of the filter unit. The delivery end of the filter unit shall be connected to the vacuum reservoir. The functioning of the vacuum pumps shall be controlled by the automatic/semi-­ automatic control panels. The electric connections to the motors shall be done through this control panel. The control panel switches from one set of pumps to the other automatically at a pre-set interval of time. At any moment, both vacuum pump units shall be in working condition. If one unit goes out of order, the other unit of the pump shall be able to take the entire load of the vacuum requirement. Switch on the vacuum plant and test both the vacuum pumps, vacuum reservoir, and pipeline for any leakage. If everything is found to be satisfactory, approve it and keep it ready for utilisation.

11.2.4 Liquid Oxygen Gas System In hospitals where the consumption of oxygen is quite high, it practically becomes difficult to handle the cylinders. Also, if the availability of the cylinders is not adequate, the hospital may face problems in fulfilling the demand for the oxygen required. Hence, the best option is to consider the installation of a bulk liquid oxygen tank or so-called vessel. The tank used for storing the liquid oxygen is a cryogenic pressure vessel made of stainless steel supported within an outer vessel, similar to a vacuum flask. The liquid oxygen plant consists of the cryogenic tank and the coils. The coils have a gas outlet, which is connected to the copper pipeline. Passing through the valves, pressure monitors, and pressure controller, this pipeline is ultimately connected to the main oxygen supply line of the hospital. Working-wise, the liquid oxygen in the vessel flows to the coils where it is converted into the gaseous form. This gas then flows to the main pipeline for further supply to the endpoint. Identify the space for the vessel, which shall be about 18 m × 9 m. On the front side, the space of about 9  m × 9 m shall be left empty for parking the vehicle carrying the liquid oxygen to unload the liquid gas into the tank. For installation of the liquid oxygen tank, first of all, the foundation shall be constructed. The size of the foundation shall depend on the size of the tank. Similarly, the foundations are prepared for the coils. Usually, the height of the

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foundations shall be from 230 mm to 450 mm. It is advised that the detailed specification and drawing shall be obtained from the original manufacturer of the tank. Then, the vessel shall be installed on a pre-constructed foundation and properly screwed to the foundation with the help of heavy-duty fasteners. Install the coil units on the foundation constructed for that purpose. Connect the vessel with the inlet of the coil units. Install the control unit consisting of the pressure regulator, pressure gauges, isolation valve, etc. Connect the inlet of the control unit with the outlet of the coil unit. Now connect the outlet of the control unit with the main riser copper pipeline to distribute the oxygen at the oxygen outlet at the patient end. The flooring of the vehicle parking area on the front side of the vessel shall be made out of concrete, which shall be capable of bearing the load of the vehicle. The entire plant area shall then be enclosed by the fencing to prevent unauthorised entry into the plant area. In the plant enclosure, a running water tap shall be provided for melting the ice accumulated on the copper pipeline from time to time. Before installing the plant, it may be necessary to comply with local authority planning constraints in some areas. Even before installations, the drawings have to be approved from a competent authority such as the explosive department. Once completed, an inspection may be done by the department before issuing the licence to operate the plant.

Further Reading 14:00–17:00. ISO 7396-1:2007 [Internet]. ISO. [cited 2021 Jul 10]. https://www.iso.org/cms/render/live/en/sites/isoorg/contents/data/standard/04/04/40440.html Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. Chapter 30, Piped Medical Gas Supply System (MGPS). India: Springer Singapore; 2022. p. 333–48. General Procedure For The Design of MGPS | Chemical Engineering | Gases [Internet]. Scribd. [cited 2021 Jul 10]. https://www.scribd.com/document/481931877/ GENERAL-­PROCEDURE-­FOR-­THE-­DESIGN-­OF-­MGPS-­docx Group TM.  Key Instrumentation Considerations in Medical Gas Delivery Systems [Internet]. [cited 2021 Jul 10]. https://www.medicaldesignbriefs.com/component/content/article/mdb/ features/technology-­leaders/20932 Medical Gases and Vacuum Systems in Hospitals - Healthcare Articles [Internet]. [cited 2021 Jul 10]. https://www.asianhhm.com/articles/medical-­gases-­and-­vacuum-­systems-­in-­hospitals Designing of Medical Gas Pipeline System MGPS | HYDRO-GAZ-MED [Internet]. [cited 2021 Jul 10]. https://www.gazmed.pl/en/services/designing-­medical-­gas-­pipeline-­system/ NHS Executive. Medical gas pipeline systems: design, installation, validation and verification. Stationery Office; 1997.

Chapter 12

Construction Works Outside the Main Building

To make the building fully operational, apart from the inside works, a few works have also to be carried out outside the main building. These works/activities are the part and parcel of services or otherwise for the elegant looks of the building. Therefore, some of the activities/works to be carried out outside the building are internal road networks made out of RCC, PCC, tiles or bitumen; parking spaces for cars, two-wheelers, buses, and ambulances; elevation of the building, including surface treatment and building highlighters; roof treatment and rainwater drainage; main gates of the hospital; security posts with barriers; landing bays and porches; boundary wall; and landscaping and plantation. The enclosed checklist provided the list of such works and helps the site engineer to plan the start and end day of each activity.

12.1 Internal Roads See Table 12.1. The internal roads within the hospital compound are to connect the main approach road to the hospital complex. If the hospital compound is large enough and houses more than one building, the internal roads are used to connect all these individual buildings. Hence, the network of internal roads is as important as the main roads. There can be various methods to build internal roads. It can be reinforced cement concrete (RCC) roads, plain cement concrete (PCC) roads, tiles roads, and black tarcoal bitumen roads. Whatever types of roads are planned, the initial steps before starting the construction of the roads are the same. First of all, the location where the roads have to be laid down needs to be levelled. Here, levelling is defined in terms of the level of the road from the building and the main approach road. Please ensure that the level of the internal roads is higher than the main approach road. The reason is that if the © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_12

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Table 12.1  Internal roads Status of works Activity Levelling of the internal road areas Compaction of the road area RCC road Laying of the stone grit called WBM Levelling and compaction of the stone grit Laying of the PCC layer Provide the steel reinforcement Laying of the RCC Curing of the RCC road PCC road Laying of the stone grit Levelling and compaction of the stone grit Laying of the PCC Curing of the PCC road Tiles road Fixing the tiles Grouting of the tiles Providing footpath alongside the road if designed for Black bitumen tarcoal road Preparation of the existing base course layer Application of tuck coat Preparation and placing of premix Rolling of the road Finishing the road surface

Start date ::-

::-

::::-

::-

::-

:::-

:-

::::-

End date

Not Responsible Complete In-progress started person

Remarks

12.1 Internal Roads

277

level of the internal roads is low, the water will flow from the main approach road to the internal road, creating water logging. Similarly, the internal road level shall be lower than the hospital’s main building. Second, the levelling means, the entire road to be laid down shall be at the same level. The slopes within the internal roads shall be avoided. For proper levelling of the internal roads, if the land filling is required, please do it. Once the road is levelled, the next step is the compaction of the road area. Why compaction? The compaction is necessary to avoid sagging of the roads later on due to rains or landslides. The compaction shall be done by pouring the water on the road and pressing it with the help of the road roller. Please avoid hurrying in laying the roads, and wait till the road area is properly compacted. Once the levelling and the compaction are completed, the surface may be considered ready for laying the road. Let us discuss the road types one by one.

12.1.1 Reinforced Cement Concrete (RCC) Roads The first step for the RCC road is to lay the layer of stone grit. The size of the stone shall depend on the design and load-bearing capacity of the road. This layer is also known as water bound macadam (WBM). Compact the stone grit layer with the help of the road roller. The next step is to lay the PCC layer on the compacted surface. Let it dry and set it down. There is another option for laying this layer, which is called dry lean concrete (DLC), Difference between the two is that in the case of PCC, the mixture is a wet mortar which is laid down. However, in the case of DLC, the dried mortar is laid down and compressed and levelled with the help of the road roller. Lay down the steel bars for reinforcement. Please ensure that the steel bars are properly tied with the binding wire. Apply the shuttering on the sides of the road before pouring the concrete mixture. After pouring the concrete mixture, apply pin type vibrator and flatbed vibrator for proper compaction of the concrete mixture. Smoothen the upper surface of the concrete mixture. Do not forget to provide the expansion joint and construction joints as per the design and specifications. The thickness of all the individual layers and the specification of the materials shall be calculated during the design phase depending on the factors such as load bearing capacity of the road, size of the road, traffic movement on the road, etc. Let the concrete mixture settle down. After 24 h, start curing the road. Cure it for 7–21 days depending on the climatic conditions. Let the concrete settle down. Open the road for use after 15 days of curing.

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12.1.2 Plain Cement Concrete (PCC) Roads The first step for the PCC road is to lay the layer of stone grit. The size of the stone shall depend on the design and load-bearing capacity of the road. This layer is also known as water bound macadam (WBM). Compact the stone grit layer with the help of the road roller. Apply the shuttering on the sides of the road before pouring the PCC. The next step is to lay the PCC layer or the pavement quality concrete (PQC) on the compacted surface. Let it dry and set it down. There is another option for laying this layer, which is called dry lean concrete (DLC). Difference between the two is that in the case of PCC, the mixture is a wet mortar which is laid down. However, in the case of DLC, the dried mortar is laid down and compressed and levelled with the help of the road roller. The thickness of all the individual layers and the specification of the materials shall be calculated during the design phase depending on the factors such as load bearing capacity of the road, size of the road, traffic movement on the road, etc. Let the concrete mixture settle down. After 24 h, start curing the road. Cure it for 4–6 days. Let the concrete settle down. Open the road for use after 15 days of curing.

12.1.3 Tiled Roads To lay the tiled road, once the road surface is ready after compaction, lay the layer of the stone grit. The size of the stone shall depend on the design and load-bearing capacity of the road. Compact the stone grit layer with the help of the road roller. Now is the time to lay down the tiles in a pre-designed pattern. The top level of the tiles shall be the same and shall be laid down with the leveller. Avoid too much gap between the tiles. On the edges of the road, if full tile cannot be placed, cut the tile and palace the tile on the surface. Next is to fill up the filler in between the tiles. Generally, fine sand is used for filling up. With the help of a wooden sheet or with a hard broom, fill all the gaps properly so the sand is filled in each gap. Now pour enough water on the road, so that the filler sand settles down in the gaps. If after settlement more sand is required for the gaps, please fill it up again. Again, pour water on the road. Once the gaps are filled, the road is ready to be used. In some cases, the engineers may want to grout the gaps between the tiles. The same can be done with the help of pure cement. However, over a period of time, the cement grouting may get peeled off, which may have to be done again and again.

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279

12.1.4 Black Bitumen Road The first step for preparing the road surface is to remove all the pit holes or rust, if any, on the surface. These irregularities shall be filled up with premix chippings at least a week before laying the surface course. Now lay the stone grit on the surfaced road. Depending on the utility of the road, the thickness and the layers of the stone grit shall be designed and decided. Generally, the lower layer is 50 mm–65 mm grit. This layer is known as WBM. The size of the stone may vary depending on the design and load-bearing capacity of the road. Roll the same with the roller by pouring the water. Now lay the stone grit of 10 mm–20 mm. This layer is also known as RBM. Again, roll it by pouring the water on it. Now the road surface is ready to lay the bitumen layer. Now the surface is ready to apply a bituminous base course and a binder course on the ready surface. This coat is named as tack coat. This coat shall be applied manually or by machinery. These coatings spread to certain square meters according to the size of roads and pavements. It applies in 6–7.5 kg per 10 m2. Now is the time to lay the premix, which has been prepared in a hot mix plant of a required capacity with the desired quality control. Please ensure that the content of bitumen in the premix is 4–5%. Lay the premix layer with the help of a mechanical paver, taking care of the camber and the thickness of the layer as designed. The control of the temperatures during the mixing and the compaction is of great significance in the strength of the resulting pavement structure. Once the premix is laid down, and before it is cooled, thoroughly roll the road with the road roller, so that the road is properly compacted. Finishing of the road surface includes alignment, clearing undulations, etc. Provide the road markers with the road paint. Now the road is ready for use.

12.2 Elevation of Building See Table 12.2. Elevation of the hospital building shall be such which gives an appealing look from the outside. The design of the elevation is purely as per the desire of the promoter and the designers. However, the design shall have sufficient provision for the entrance of natural light in the building and shall also have a provision for cross ventilation in the building. The windows of the building shall be clearly demarcated in the elevations. The service shafts and the service ducts shall also be properly defined and placed while designing the elevations. There are various materials that can be applied to the elevations such as simple painting, stonework, tiles work, glass work, aluminium composite sheet, etc. Also, factors such as budget and time are important before choosing the elevation. The steps involved in completing the elevation are as follows.

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Table 12.2  Elevation of the building

Activity Closing the service shafts outside the building either by the bricks or other materials as designed for the elevation of the building Fixing the windows of the building Mild steel/aluminium framing work for elevation, if any Stone/tiles work for elevation, if any Sheet work for elevation, if any Glass work for elevation, if any Painting of the exterior walls, if any Preparing the ramps or stairs in front of entrances if required

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

::-

:::::-

First of all, the service shafts and the service ducts, as soon as the service pipelines are laid down in the service shafts and ducts, close these with the help of the brickwork or any other material, as prescribed by the designer. Please remember to prove the service windows in the service shafts according to the design provided by the designer. Now fix the window frame at the proper locations, if not already fixed from the inner side of the building. If the building is centrally air-conditioned, the windows may be glass windows that are usually not openable. In such a case, leave the glass fixing for a later stage because if the glass is fixed before the completion of elevation, the glass may break. If the windows are openable, fix the window frame and leave window panes to be fixed later on after the completion of the elevation work. Now depending on the type of material to be used for elevation, the wall surface has to be prepared. If the plans are to use sheets for elevation, the framing needs to be done, on which the sheets will be fixed. The framing can again be done by the various types of extruded sections of mild steel or aluminium. Wooden framing shall be avoided, as it may get eroded over a period of time. If mild steel is used, do not forget to paint the frame structure properly to prevent the frame from rusting. Properly and securely fix the frame onto the wall with the help of the fasteners. Now

12.3 Roof Treatment

281

fix the sheets on the frame and fill up the gaps between the sheets to give a finishing look. If the stone or tiles are to be used for elevation, the wall surface shall be rough so that the tile or stone can get proper binding. Fix the tiles or stone, as the case may be, on the wall surface. Fill up the gaps and finish the surface. If the elevation is simply to be painted, apply the first coat of wall putty. Once the wall putty is dry, rub the same with the sandpaper. If required, again apply the second coat of the wall putty and again rub the surface with the sandpaper till the wall surface is smooth. Now apply the wall primer on the wall surface. Once it is dry, apply the first coat of paint. Let it dry. Apply the second coat of paint. If required, apply a third coat of paint on the wall. Fix the glass or glass panes on the windows and clean them properly. If the height of the building is more, to clean the outer surfaces and glass of the building, create a provision for the pressure washing, vacuum chamber, lifting cable, cleaning platform (operated manually or electrically), or the bosun’s chair. It is up to the designer of the elevation, which method he/she opts for cleaning the outer surfaces. Prepare the ramps or the stairs in front of the entrances. The location, size, and design of the ramps and the stairs shall depend on the design as provided by the designer.

12.3 Roof Treatment See Table 12.3. One of the important issues with the building’s completion is the roof treatment. The advantages are that it improves structure durability, reduces the cost of repairs of the building, offers energy efficiency, offers an easy flow of rainwater, prevents the onset of health concerns, and improves the life of interior work and furniture. For roof treatment, the first and foremost step is the waterproofing of the roof surface. As the chemicals used for waterproofing requires proper adhesion, cleaning the roof surface is important. Hence, the cleaning shall be done by removing all the dust particles and substances from the roof and then pressure washing the roof. Let it get dried. All the penetrations on the roof such as vent pipes, skylights, drains, parapet walls and termination edge flashings, or rooftop HVAC units shall be properly treated. Special attention shall be paid to proper and correct capping over the parapet wall. Next is the application of the primers on the surface. The primer improves the adhesion of the waterproof chemical and aids to block the bleeding of the bituminous oils from the existing roof through the liquid membrane. Now is the time to apply a waterproof compound on the roof. The compound shall be applied in three coats: horizontal, vertical, and diagonal. Let the waterproof compound dry.

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Table 12.3  Roof treatment

Activity Cleaning of the roof Water proofing of the roof Laying of the tarcoal sheet Laying of the mud phuska Levelling of the mud faska and providing adequate slopes for drainage of rainwater Lay the layer of PCC Laying of the brick tiles or any other surface as designed Grouting of the tiles

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:::::-

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:-

As a precaution, some of the designers recommend affixing the layer of the bitumen tarcoal sheet on the roof for better waterproofing. The next step is to apply a layer of mud faska on the roof. While laying the mud faska, please check the slope of the roof. Provide adequate slope for quick drainage of the rainwater. The slopes shall be towards the rainwater harvesting pipes. Let the mud faska dry up. Once the surface is dried, lay the layer of PCC for preparing the surface to fix the tiles of bricks. Now fix the tiles or the bricks on the PCC layer. Properly fill up the gaps and grout the gaps. If the designer recommends the mosaic floor on the roof, apply the mosaic layer on the PCC surface. After the mosaic, the water curing shall be done properly. Please ensure that no gaps are left on the roof surface from where the water can sweep in the roof. This seepage of the water can be very dangerous for the building.

12.4 Main Gates See Table 12.4. The main gate of the hospital is the entrance through which patients and visitors enter the campus. This main gate serves as a link between the public road and the hospital road. The following issues shall be considered while erecting the main gate. The first step is to get the main gate fabricated as per the design. The gate shall be manufactured using mild steel or stainless steel. However, the material to be used

12.5 Security Posts

283

Table 12.4  Main gates Status of works Activity Fabrication of the main gates Fixing the main gates Providing electrical points if the door is electrically operated Painting of the main gate, if required

Start date

End date

Not Responsible Complete In-progress started person

Remarks

:::-

:-

for the fabrication of the main gate shall be rustproof; hence, it is recommended to use stainless steel. Typically, the hospital shall have two or more such main gates: one for entering and one for exiting. Please keep in mind that the main gate shall be at least 20 feet wide. In addition to the main gate for traffic, it is recommended that a small additional gate be provided for pedestrians. With the evolving technology, providing automated gates or automated barriers can also be considered. Now as the gate is ready after fabrication, it is time to install the gate. The main gate shall be fixed in the boundary wall of the hospital. The gate shall be securely fixed with the columns provided for this purpose. Please ensure that the levels of the gate are perfect, and the gate is easily operatable. Avoid any hump or speed breaker at the main gate. If required, paint the surfaces of the main gate. If the door is automated or electrically operated, provide the necessary power point for the operation of the gate.

12.5 Security Posts See Table 12.5. Security posts are provided in the hospital to guard the main gate and other areas of the hospital around the clock. Hence, depending on the size of the hospital premises, one or more security pots shall be provided. As a first step, the security posts shall be either constructed with the masonry work or otherwise temporarily fabricated post. Paint the surfaces of the security post. Whatever may be the structure, the post shall be provided with proper electrical points for the fan, light, charging points, and other security gadgets. Also, provide the telephone/intercom lines and the Closed Circuit Television System (CCTV) cameras. Just at the entry of the hospital and near the security post, the security barriers shall be provided. The security barriers can be the manually operated boom barriers

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Table 12.5  Security posts

Activity Construction or fabrication of security posts Providing required electrical points in the post Providing telephone/ intercom line in the post Painting of the post Provide a fire hooter system in the main security post connected to the fire detection control panel Barrier near the security post

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:-

::-

:-

gate or otherwise the automatic boom barriers gate. There shall be proper provision for stopping the vehicles, entering the hospital, for checking. As an additional precaution, at the security post, provide a parallel line of the fire hooter system (which shall be connected to the fire control panel), so that in case of any fire, the security personnel get alerted.

12.6 Landing Bay and Porches See Table 12.6. There shall be landing bays outside all hospital entrances for patients and visitors to be dropped off and picked up. This landing bay shall preferably have a porch at the entrance gate to provide shelter from inclement weather. The porch shall be large enough to accommodate two vehicles at once. The porch’s height from the road shall be at least 4572 mm. Outside the lobby, there shall be a clear traffic pattern. A trolley bay outside the lobby shall be provided for the parking of wheelchairs and stretcher trollies so that patients arriving on the porch can use them.

12.6 Landing Bay and Porches

285

Table 12.6  Landing bay and porches

Activity RCC structure Lay down the columns Cast the RCC roof Plaster the columns and the ceiling Steel structure Fabrication of the structure of the porch Painting of the structure Fixing the sheets on the top of the porch Common activities for the landing bay Providing provision for drainage of water such as gutters, etc. Fixing the sheets/ tiles/glass on the bottom surface and columns of the porch False ceiling of the porch Fixing the lights on the porch The flooring of the porch Painting of the porch if required Final finishing of the porch

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:::-

:::-

:-

:-

:::::-

12.6.1 RCC Structure If the landing bay has to be built up by the masonry work using the concrete mixture, the first step is to cast the columns of the landing bay. Start with digging the soil for the foundation of the columns. Cast the foundation of the columns with RCC. Now cast the columns with RCC. Please ensure proper curing of the casted columns. Once the desired height of the columns is reached, prepare to cast the roof of the landing bay. For casting the roof of the bay, the beams on which the roof will rest have to be casted. Hence, start with steel works for the beams. Place the shuttering for casting

286

12  Construction Works Outside the Main Building

the roof slab. Next is to provide the steel reinforcement for the slab. Once ready, cast the beans and slab simultaneously. After proper curing, of the slab, open the shuttering of the slab. Plaster the columns and the ceiling of the landing bay. If the false ceiling is to be provided in the landing bay, the plastering of the slab can be avoided.

12.6.2 Steel Structure If the landing bay is to be fabricated from mild steel, the first step shall be to fabricate the columns of the structure. For fixing the fabricated columns, the RCC foundation shall be provided. To provide the RCC foundation, start with digging the soil for the foundation. Cast the foundation of the columns with RCC. The fabricated columns shall rest on this RCC foundation. Hence, as per designs and drawings, proper anchor bolts shall be casting the foundation. Side by side the beams and purlin for the roof shall also be fabricated. Now place the columns on the foundation and tie them with the anchor bolts. Once the columns are ready, fix the beams and purlins. Next is to paint the entire mild steel structure with red oxide and finally paint with enamel paint. It is time to fix the sheets on the top of the porch. Tie the sheets properly with the help of bolts to avoid blowing off the sheets due to air velocity.

12.6.3 Common Activities for the Landing Bay Whatever may the type of structure of the porch be, few works are common to both of them. Provide a proper mechanism of water drainage. The gutters and the drainage pipes shall be provided. The roof shall have a proper slope so that the water immediately flows into the gutter and is drained. If the porch is not an open type, fix the sheets/glass/tiles on the lower surface of the porch, such as columns, side walls, etc. If a false ceiling is designed, fix the same. The ceiling can be made out of plaster of paris, PVC sheets, or the grid ceiling. However, it is advised to avoid the false ceiling made out of plaster of paris as the same may get damaged due to moisture, particularly during the rainy seasons. Do not forget to provide cut-outs for the ceiling lights in the false ceiling. Fix the lights in the ceiling or the walls, as designed. As a lot of traffic shall be moving under the porch, the flooring of the porch shall have sufficient strength to bear the weight of the traffic. The flooring can be made by providing bitumen road, stones, tiles, or RCC. The final painting of the porch shall now be done and make it ready for use.

12.7 Boundary Wall

287

12.7 Boundary Wall See Table 12.7. A boundary wall shall be provided to surround the hospital premises. The boundary wall serves as the initial line of defence against intruders. Apart from this, it also helps to protect the hospital premises from animals and thieves. There are various options to construct boundary walls. These are boundary walls constructed using cement concrete, bricks, stones, metal panels, and wooden panels, and polyvinyl chloride fencing is often known as PVC fence, or wire mesh. Generally, the boundary walls are constructed using brickwork or stones. Hence, we will explain the steps involved in constructing this type of boundary wall. For the construction of the boundary wall, the first step is to excavate the soil for laying down the foundation of the boundary wall. Once the soil is excavated and dressed properly, the PCC layer shall be laid down. The thickness of the PCC layer shall be as per the specification and drawings provided by the designer. Now lay the foundation on the PCC layer. In case the length of the boundary wall is large, in between the brickwork, the support columns shall be provided. If designed for columns, the columns shall be constructed with the help of RCC as per the specification and drawings provided by the designer. Table 12.7  Boundary wall Status of works Activity Excavation for boundary wall Laying the foundation for the boundary wall Waterproofing of the foundation Erection of boundary wall with bricks/blocks/stone Grill on the top of the boundary wall, if any Electrical conducting of the boundary wall, if any Plastering the boundary wall Painting of boundary wall

Start date ::-

::-

:-

:-

::-

End date

Not Responsible Complete In-progress started person

Remarks

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12  Construction Works Outside the Main Building

Once the foundation is complete, apply waterproofing on the top of the foundation. For waterproofing, the waterproof compound shall be used and applied in two to three layers. Now is the time to erect the boundary wall with bricks or stone blocks. These days, fly-ash blocks are also used instead of bricks. It will depend on the design and specifications as provided by the designer. The standard height of the boundary wall shall range between 1000 mm and 2400 mm. Once the brick/stone/block work is over, if required, the grill made out of mild steel or stainless steel shall be fixed on top of the boundary wall. Provide conduit in the boundary wall by chase cutting and concealing the conduit in the wall. The conduiting is to lay electrical wires and cables for electric supply to the light fitting on the boundary wall. Plaster the entire boundary wall from both sides. Once the plaster is dry, paint the entire boundary wall.

12.8 Landscaping and Plantation See Table 12.8. A well-kept outdoor area of the hospital gives it a nice appearance and is equally important for patients’ recovery and well-being in terms of their physical, Table 12.8  Landscaping and plantation

Activity Levelling of the land and lawn spaces Identify the location of the lawns, flower beds, and trees Laying pipeline for irrigation water system Laying the grass on the lawns Plantation of the trees, decorative plants, and flower plants as designed Providing artificial plants, if required Constructing a fountain system, if designed Outlets for irrigation water supply

Status of works Start End Not Responsible date date Complete In-progress started person ::-

:-

::-

::-

:-

Remarks

12.9 Car Parking Lots

289

psychological, and social well-being. The landscape at hospitals is not just gorgeous. It promotes healing. Plants, trees, and flowers increase positivity, relax muscle tension, lower blood pressure, and improve positive attitudes. They also reduce stress and anxiety. Patients who have a chance to look out of the windows onto trees, and green areas generally stay in the hospital for fewer days and require less pain medication than patients who do not get a chance to look at green areas and trees but look out onto buildings or concrete. The hospital landscape shall include a peaceful walking path, which shall be wide enough and non-slippery, to burn off some stress, rejuvenate, and recuperate. Plants and flower beds with lavender, roses, tuck rosemary, catnip, sweet marjoram, and sage shall be encouraged. Positioning the trees, plants, and flowers, so they are visible from the inside, can be very pleasing to the admitted patients. Fountains or small waterfalls can be provided in the common areas, courtyards, and gardens. As a first step for landscaping is to level the land and the spaces reserved for the lawn. The levelling need not be in the same plane or say zero levelling. The levelling can be different for different zones, such as different levels for lawns, flower beds, etc. The zoning shall be done as per the specifications and the drawings provided by the landscaping designer. For irrigation, lay down the irrigation water supply pipeline under the soil. Provide sufficient outlets for water supply and fix the taps or valves on these water outlets. Once the levelling is done, the grass shall be planted in the lawns. Before planting the grass, please prepare the lawn and prepare the lawn bed by putting the manure and required sand. Now plant the trees at the selected location. Please ensure that the protection cage is provided around the tree sapling so that it is not damaged. Plant the flower plants in the flower bed. If required, the artificial plants can also be placed at the selected location. If designed, construct or provide the fountains at the selected locations. Connect the fountains with the water supply for the operation of the fountain. Complete the landscaping by providing other items such as pathways, sun shelters, birdhouses, lightning, etc.

12.9 Car Parking Lots See Table 12.9. While preparing the site plan, the designer shall keep the provision of the car parking lots for parking the cars, two-wheelers, and buses that may be arriving in the hospital. While preparing the design of the car parking area, separate spaces shall be allotted for parking cars, two-wheelers, and big vehicles such as buses, trucks, etc., even a separate parking area shall be provided for the ambulances arriving in the hospital. As a first step for constructing the parking area, level the car parking area. It will be better if the whole of the parking area is at the same level.

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12  Construction Works Outside the Main Building

Table 12.9  Car parking lots

Activity Identify the car parking location Level the car parking space Separate parking for cars and two-wheelers Separate parking for the big vehicles such as buses, etc. Separate parking for the ambulances Marking of the parking area for each car Provide spaces for turning the cars Construct proper dividers so that the vehicle does not collide with each other Provide separate entry and exit gates for the parking Construct the roads of the car parking area Prepare the floor of the car parking area Separate public utility areas in the parking area Providing a restroom for the drivers in the parking area Providing a canteen or cafeteria in the parking area Provide sufficient lighting in the car parking area Provide sufficient signage in the parking area

Status of works Start End Not Responsible date date Complete In-progress started person ::::-

::-

::-

:-

:::-

:-

:-

:-

:-

Remarks

Further Reading

291

Table 12.9 (continued)

Activity Provide a boom barrier for security to control the vehicles going in and coming out of the parking area If designed construct the multi-level parking lots

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

:-

Now mark the spaces that have to be allotted to each vehicle. Based on these markings, the dividers shall be constructed to avoid collision of the vehicle. Provide sufficient spaces for the turning of the vehicles. If possible, provide separate gates for entry and exit from the parking area. Construct the roads of the parking area. Also, construct the flooring of the parking area. The specification and the material to be used for the construction of the roads and parking floor shall be capable enough to bear the load of the loaded vehicles. At the entry and exit, provide the boom barrier gate for security to control the entry and exit of the vehicles from the parking area. Provide sufficient lighting in the parking area, and proper signages shall be provided for easy identification of the parking area and the direction of movement of the vehicles. The signage shall preferably be glowing so that in the dark also, it is clearly visible. Provide separate public utility services in the parking areas for the convenience of the drivers. The public utility shall consist of toilets (separate for males and females), handicapped toilets, and the facility for drinking water. Try providing a small canteen or cafeteria inside the parking area, where the drivers can have their meals. If possible, provide a small restroom for the drivers in the parking area. In some of the large hospitals, vehicle movement can be large and a big area may be required for parking. Providing such a large area may be difficult and a costly affair due to the heavy costs of land. To this, if the spaces inside the hospital allow and the funds are available, multi-level parking can be thought of. The multi-level parking shall then be constructed as per the design provided by the designer.

Further Reading Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. India: Springer Singapore; 2022.

Chapter 13

Ancillary Activities and Implementation

To make the hospital operational, all the activities/works must be completed well in time. Although, in all the above monitoring tools, we have tried to mention all the activities, still some of them are left because there does not relate to any of the particular department/areas. Some of such activities are as follows: Formation of the identity as an owner of the hospital. It can be a sole proprietor, partnership firm, charitable trust, private limited company, or the limited company. Then, there are some ancillary works such as printing of stationery, procurement of consumables, linen, medicines, and drugs. Before giving the go-ahead for operations, the detailed and thorough checking of the services is essential to ensure the proper working of such services. Checking patient facilities, attendants’ facilities, equipment and instruments, electric supply, water supply, IT network, and medical gases is very essential. Equally important are the approvals, registrations, and licences. Before starting the operations, the promoter has to ensure that all the approvals, registrations, and licences are obtained from the respective departments/agency and the same shall be in compliance with the law of the land. Once everything is clear, the approval can be given to GO-LIVE. This set of monitoring tools shall help the planner and designer to remember all such activities and ensure compliance well in time.

13.1 Other Ancillary Works See Table 13.1. Hospitals require a different types of forms, registers, books, and diaries during their routine functioning. These can be registration forms, bill books, progress

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_13

293

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13  Ancillary Activities and Implementation

Table 13.1  Other ancillary works Status of works Activity Designing of the hospital printing stationery Printing of the hospital stationery Procurement of the small instruments Procurement of the hospital consumables Procurement of the house keeping consumables Installation and testing of computers and accessories Stitching of the hospital linen Finalising the list of hospital pharmacy Procurement of drugs and medicines for pharmacy Finalising the schedule of charges of the hospital

Start date

End date

Not Responsible Complete In-progress started person

Remarks

:-

:::-

:-

:-

:::-

:-

sheets, nurses’ records sheets, diet charts, medication sheets, charge slips, OT notes, various types of consents, OPD books, and summary sheets. Hence, before starting the operations of the hospital, all these forms and stationery shall be made readily available. Hence, these stationery items shall be designed well in advance. Once the hospital is near to starting the operations, these items shall be got printed and made ready for use. The physicians/doctors and the para-medical staff require small instruments for the routine work and treatment of the patient. These items can be weighing machines, height scales, scissors, knee hammers, suturing sets, suture removal scissors, BP apparatus, chital forceps, cidex trays, ear specular, examination lamps, laryngoscopes, needle holders, nebulizers, splints and tourniquets, otoscopes, stethoscope, torch, suction machine, tongue depressor, and X-ray view box. Hence, these items shall be procured well in advance and kept ready for use before starting the operations of the hospital.

13.2 Facilities for Patients

295

Similarly, the procurement of daily use items, such as bowls, dressing drums, dressing forceps jars, dust bins, feeding cups, instrument trays, and kidney trays, shall also be ready before starting the operation of the hospital. All the consumables items such as caps, masks, gloves, Central Sterile Supply Department (CSSD) consumables, Intensive Care Unit (ICU) consumables, emergency drugs, Out Patient Department (OPD) consumables, Operation Theatre (OT) consumables, sleepers, and ward consumables such as cotton, bandage, gauze, betadine, disinfectants, etc. also be procured by now and distributed at all the required departments in the hospital. The material to be used for cleaning such as mops, scrubbers, detergents, and disinfectants shall also be procured and ready for use. The linen bed-sheets, blankets, doctors’ dresses, draw sheets, linen sets, Macintosh, patient dresses, pillow covers, and towels shall also be got stitched and ready to be used. The same shall be distributed in all the wards and departments. The IT network, including switch boxes, computers, printers, and scanners shall also be installed at this stage, commissioned and tested before starting the operations. The staff who is supposed to use these computers shall be got trained well before the actual operations start. It needs to be ensured that the HMS software has also been installed and customised by now. The list of pharmacy items shall be prepared well in advance and now is the time to procure all the drugs and medicines and keep them ready for use. Importantly, the schedule of charges for the entire hospital shall be ready by this time. This schedule of charges shall have the approval of the management and shall be fed into the computer system and copy sent to the billing and reception counter for patient enquiry.

13.2 Facilities for Patients See Table 13.2. Every human being in his daily routine performs some activities that become the part and parcel of his life. Such activities can be like bed tea in the morning, getting fresh, shaving, bathing, and timely diet. Similarly, all human beings are habitual in using basic facilities such as telephones, refrigerators, air-conditioners, and television in their daily life. If he/she is deprived of these activities, he/she may feel disturbed. The same happens when the patient is sick and he/she is admitted to the hospital. As he/she is not provided with these facilities, he/she feels disturbed. Just imagine if all of these or even some of these facilities are provided to him/her in the hospital itself, how satisfied he/she will feel. This satisfaction also helps in the early recovery of the patient. Hence, the facilities mentioned in the above table shall be provided to the patient.

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13  Ancillary Activities and Implementation

Table 13.2  Facilities for patients Status of works Activity Television on room Refrigerator Bed side lockers Kit at the time of admission Valuable deposit Cloth deposit Barber Diet Private waiting area in OPD Room billing Telephone in room Nurse call system Sputum cup Kidney tray Water flasks and glass Mosquito repellent Dust bin Bucket and mug

Start date

End date

Not Responsible Complete In-progress started person

Remarks

::::::::::::::::::-

13.3 Facilities for Attendants See Table 13.3. While the patient is admitted to the hospital for treatment and care, the near and dear of the patient including friends and relatives are usually afraid and in a disturbed state of mind, which may lead to irrational behaviour. The attendants need to be handled tactfully. The second reason for the disturbance of the attendants can be the lack of facilities for these attendants. If the necessary facilities are provided to these attendants, they may feel satisfied with the services of the hospital. It is a fact that satisfied customers can promote the hospital much more than any other marketing technique. When we talk about patient satisfaction levels in the hospital, we mean how satisfied the patient is. But in a true sense, the satisfaction of

13.3 Facilities for Attendants

297

Table 13.3  Facilities for attendants Status of works Activity Television in waiting lobby Drinking water Rest room Guest house STD/PCO Canteen Meeting lobby for indoor Cloth washing General toilets Attendants couch in wards and patient areas wherever required Sofa set in wards and patient areas wherever required Visitors’ chairs in wards and patient areas wherever required Centre table in wards and patient areas wherever required Stool in wards and patient areas wherever required Night stay facility Visiting hours

Start End date date

Not Responsible Complete In-progress started person Remarks

::::::::::-

:-

:-

:-

:-

::-

the patient is secondary compared to the satisfaction of the attendants. If the attendants are satisfied, they will make the patient also satisfied. Just imagine if few facilities are provided to the attendants, where will be their satisfaction levels? Therefore, it is recommended that the facilities mentioned in the above table shall be provided to the attendants of the patient. Some of these can be proper waiting spaces, public utilities, drinking water, restrooms, place for meals and refreshments, meeting spaces, meditation spaces, couches or sofa set in the patient’s room, and television.

298

13  Ancillary Activities and Implementation

13.4 Systems Details See Table 13.4. Each department of the hospital is governed by a certain set of rules, regulations, and guidelines to discharge the duties. Even the activities to be performed in the department has certain defined steps to be taken to complete the activity. Hence, before the start of the hospital activities, all the standard operating procedures (SOP) for running the department shall be defined, noted down, and circulated. The hospital staff shall be instructed and trained enough to follow these SOP for discharging their duties. Table 13.4  Systems details

Activity Drafting the systems and working procedures relating to the following Organisation Medical staff Duties and responsibilities Emergency department Disaster plan Outpatient department Investigation department Indoor and ward management Nursing care Operation theatre Sterilisation Medical records Dietary department Purchase department Financial management Stores Security Quality control Computerisation Training to the hospital staff about systems Start induction training

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

::::::::::::::::::::-

:-

13.5 Approvals, Licences, Sanctions, and Registrations

299

13.5 Approvals, Licences, Sanctions, and Registrations See Table 13.5. Every country and/or state frames the set of acts, rules, legislation, by-laws, norms, etc. based on which the government or the private organisation operates. Table 13.5  Approvals, licences, sanctions, and registrations

Activity Applying for and registering for income tax Applying for and getting PAN No. Clearance from fire department Clearance from PWD for construction Applying for and getting provident fund registration Applying for and getting Importer and exporter code Applying for and getting an electrical connection Applying for and getting registration for a hospital from state/central government Applying for and getting Licence from AERB (for radiation) Applying for and getting licence for Pre Conception and Pre-Natal Diagnostic Technique (PC-PNDT) (for ultrasound) Applying for and getting licence for blood bank

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

::::-

:-

:-

:-

:-

:-

:-

(continued)

300

13  Ancillary Activities and Implementation

Table 13.5 (continued)

Activity Applying and getting solar power approval and net metering Applying for and getting water connection Applying for and getting sewerage connection Applying for and getting the assessment of house/ water/sewerage tax Applying for and getting the telephone connection Applying for and getting the vehicle registration Applying for and getting the diesel storage licence Applying for and getting the cooking gas connections Applying for and getting the clearance from pollution department Applying for an getting the sales tax registration Applying for and registration with Employees State Insurance (ESI) Applying for and licence for pharmacy of out patients Applying for and licence for pharmacy of In-Patients Applying for and licence for narcotic drugs Applying for and licence for biomedical waste

Status of works Start End Not Responsible date date Complete In-progress started person :-

:-

:-

:-

:-

:-

:-

:-

:-

:-

:-

:-

:-

:-

:-

Remarks

13.5 Approvals, Licences, Sanctions, and Registrations

301

Table 13.5 (continued)

Activity Applying for and licence for lifts and escalators Applying for and licence for boilers Applying for and licence for procuring and storing spirit Applying for and licence for keeping arms for security Applying for and licence for a human organ transplant

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

::-

:-

:-

Apart from this, there may be some regulatory authorities and accreditation agencies who in turn again frame their norms and by-laws. Similarly, for hospitals also, the country/states frame the set of acts, rules, legislation, by-laws, and norms which the hospital has to follow. These acts, rules, legislation, by-laws, and norms are usually framed to prevent loss of direct and indirect taxes; safety of staff and patients; safety from fire; employees' benefits; import or export; availing government facilities such as electricity, water supply, and waste disposal; prevent the pollution; safety form hazardous chemicals, fluids, and rays; registration of vehicles and machines; and control the sale of drugs and pharmaceuticals. The following are some of the approval, registrations, licences, and sanctions that may be required to operate the hospital. We have tried to list out such approval, registrations, licences, and sanctions, but this may not be the complete list. The actual requirement may differ from country to country, state to state, and city to city, and may also differ from one hospital to another. Hence, we advise you to assess these requirements in your city, state, or country. 1. Registration for Income Tax: This is to get the organisation registered under the Income Tax Acts of the Country. 2. Getting PAN No.: To get the Permanent Account Number as a taxpayer of income tax. 3. Clearance from Fire Department: To obtain a No Objection Certificate as proof that the hospital is equipped with fire detection and fighting arrangements. 4. Clearance from PWD for Construction: Approval from the Public Works Department for storing and stacking the construction material while construction of the hospital. 5. Provident Fund Registration: For deduction and depositing of the provident fund of employees.

302

13  Ancillary Activities and Implementation

6. Importer and Exporter Code: Specific code for importing or exporting any equipment or other items of the hospital. 7. Electrical Connection: For the approval of the electricity connection with the customer ID. 8. Registration for Hospital from State/Central Government: Permission to operate the hospital. 9. Licence form AERB (for Radiation): For radiation safety of the employees and the patient. 10. Licence for PNDT (for Ultrasound): Licence to operate Ultrasound machine and undertaking for not performing ultrasound for sex detection. 11. Applying for and Getting Licence for Blood Bank: Permission to operate the Blood Bank and undertaking to comply with the rules and regulations framed for operating a blood bank. 12. Solar Power Approval and Net Metering: Permission to install captive solar energy plant and permission for net metering (to connect the generation with the main power grid). 13. Water Connection: For availing the water supply from the government resources. 14. Sewerage Connection: Permission to connect the drainage lines of the hospital to the main sewerage line of the government. 15. Assessment of House/Water/Sewerage Tax: Registration to pay the municipality taxes as applicable. 16. Telephone Connection: To avail of the telephone facility for the hospital. 17. Vehicle Registration: To register the vehicle belonging to the hospital such as ambulances, cars, etc. 18. Diesel Storage Licence: Permission to store the Diesel in bulk for generators, etc. 19. Cooking Gas Connections: For supply of the cooking gas for canteens, cafeteria and laboratory, etc. 20. Clearance from Pollution Department: No Objection to safe disposal of waste, chemicals, human parts, etc. 21. Sales tax registration: Registration for collecting and paying the sales tax, if any. 22. Registration with ESI: Registration to cover the employees under the Employees State Insurance for treatment. 23. Licence for OPD pharmacy: Licence to stock and sell drugs and medicines as a retail shop to the patients. 24. Licence for IPD pharmacy: Licence to stock and sell drugs and medicines to the admitted patient. 25. Licence for Narcotic Drugs: Licence to stock and sell narcotic drugs and medicines as a retail shop to patients. 26. Licence for Biomedical Waste: Licence and undertaking for safe disposal of biomedical waste. 27. Licence for Lifts and Escalators: Licence to install and operate the lifts and elevators keeping in mind the safety of human beings. 28. Licence for Boilers: Licence to install and boilers safely. 29. Licence for procuring and Storing Spirit: Licence to purchase and stock the medical spirit.

13.6 Final Testing of the Equipment and the Services

303

30. Licence for keeping arms for security: Licence for purchasing, retaining, and using the arms by security personnel. 31. Licence for human organ transplant: Licence to perform surgeries involving transplantation of human organs like eye, kidney, liver and heart, etc. The list given above is not complete in itself. Depending on the country where the hospital is located, the acts, rules, legislation, laws, and norms may vary. Therefore, there can be inclusions and exclusions from this list. The management has to check and confirm as to which all licences, permissions, clearances, and approvals are required for that respective country or state, and proceed accordingly.

13.6 Final Testing of the Equipment and the Services See Table 13.6. Table 13.6  Final testing of the equipment and the services Status of works Activity Testing all the service instruments and equipment Testing all the medical equipment. If required on dummies Checking all the sanitary fittings Checking all the electrical fittings Checking the points, alarms, and valves of the central gas line Checking all the door locks, latches, etc. Checking all the locks and drawers of the furniture Testing of the software with dummy entries Finally making the software live

Start date :-

:-

:::-

:-

:-

:-

:-

End date

Not Responsible Complete In-progress started person

Remarks

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13  Ancillary Activities and Implementation

This is the stage where all the departments have given the clearance that everything including all the wards, laboratories, imaging, operating rooms, and emergency are ready for operation and all the pieces of equipment have been installed and commissioned. Once the clearances have been received from the staff, the management has to depute a team for the final testing of all the equipment and instruments and the trial run to be carried out. The team shall check and test every piece of equipment and instrument and check the configuration of these items before giving the final clearances. Similarly, all the electrical points and the sanitary fittings have to be checked to ensure that everything is in place and working properly. This checklist shall be prepared separately for every room. The entire system of the Central Medical Gas Supply, including manifold, pumps, tanks, alarms, valves, outlets, etc., has to be checked and ensured that proper pressures are achieved, no leakage is noticed, and all the fittings are in place. Similarly, all the doors, windows, and furniture have to be checked and ensured that they are in place, properly screwed, and all fitting such as handles, stoppers, latches, and locks are in place and working. It also has to be ensured that the Hospital Management Software is working properly and that the staff is trained enough to handle the software. If required, a few dummy entries can be done in the software to check the authenticity of the software and the performance of the staff on the software. Once the software is ready, and performance is satisfactory, the dummy entries can be removed and the software may be made live. The whole of these activities have to be recorded and signed by the concerned departmental head and the head of the team deputed for checking. Once checklists are signed, the report shall be submitted to the management, along with the checklists, with the recommendation to start the operations of the hospital and go live.

13.7 Start and Go See Table 13.7. Now is the stage for final testing and inspections so that the hospital can be given a green signal to start the operations of the hospital. First of all, the OPDs. Before the start of the OPDs, ensure that each OPD is equipped with the required furniture such as a table, chairs, examination couch, and the patient stool. Check that all the required instruments such as BP apparatus, stethoscope, examination lamp, etc. are readily available. The requirement of the instruments may vary from one OPD to the other and will depend on the discipline for which the OPD is to be used. For example, the requirement of the eye OPD may be different from that of Ear Nose Throat (ENT) OPD. Check the availability of the consumables and the accessories such as cotton, gauze, thermometer, scissor, and forceps.

13.7 Start and Go

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Table 13.7  Start and go

Activity Setting up all the rooms of OPD with required furniture, consumables, fittings, and accessories Starting OPD Setting all the indoor rooms and wards with required furniture, consumables, fittings, medicines, and accessories Starting IPD Setting all the ICUs with required furniture, consumables, fittings, medicines, and accessories Starting critical care wards Setting up of all the operation theatres with required furniture, consumables, fittings, medicines, and accessories Starting OT Formal inauguration of the hospital

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

::-

::-

::-

:-

With this, the green signal shall be given to start the OPDs. Now it is the time to test and inspect the IPD areas, i.e., all the wards and the rooms. Check for required furniture such as patient bed, attendant couch, over-bed table, bedside locker, etc. Check that all the required gadgets for amenities are provided such as television, refrigerator, etc. See that all the fittings including the bathroom are in place such as hangers, monitor stand, mirror, towel rods, taps, flush valves, etc. Check the availability of the consumables and the accessories such as cotton, gauze, thermometer, scissor, and forceps. Similarly, concentrate on the medicines in the crash cart and check that it has been fully loaded as per requirement. With this, the admission of the patient to IPD can be started. As was done in the IPD, the testing and inspection of the ICUs can be started. Check for required furniture such as patient bed, attendant couch, over-bed table, bedside locker, etc. Check that all the required equipment and instruments, such as

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monitors, defibrillators, invasive ventilators, bi-pap ventilators, ECG machines, dressing trollies, and required surgical instruments, are available. Check the availability of the consumables and the accessories such as cotton, gauze, thermometer, scissor, and forceps. Similarly, concentrate on the medicines in the crash cart and check that it has been fully loaded as per requirement. Now the clearance can be accorded to start the services of the ICUs. Finally, an inspection of the operating theatre. Check that all the required pieces of equipment such as an OT table, OT light, anaesthesia workstations, End Tidal Carbon Dioxide (ETCO2) monitor, defibrillator, surgical cautery, surgical instruments, etc. are readily available. Check the supply line of the medical gases. Check the availability of hospital furniture such as dressing and instrument trollies, step stools, etc. in place. Check the availability of the consumables and the accessories such as anaesthetic reagents and drugs, cotton, gauze, betadine, micropore, etc. Specifically, to concentrate on the medicines in the crash cart and check that all the required medicines and disposables are available in the cart. Now the promotors shall initiate the proceedings to formally inaugurate the hospital.

Further Reading Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. India: Springer Singapore; 2022.

Chapter 14

Equipment Planning, Procurement, Installation and Management

The definition of equipment varies depending on the context, but in hospitals, it is typically understood to mean ‘the machines, items and implements required to accomplish specified activities.’ When analysed for a hospital, the equipment consists of the devices, instruments and processes that make it easier for healthcare professionals to conduct diagnostic tests to identify diseases and aid in their treatment. True hospital equipment, as opposed to fixtures and fittings, refers to the electronic and mechanical devices used for diagnosis and treatment. The hospital’s medical equipment includes anything from modest, simple devices like sphygmomanometers to large, complicated gadgets like magnetic resonance imaging (MRI) machines. This rating results from variations in the technologies used and the intended uses. Fixed equipment or loose and mobile equipment can be found in hospitals. Fixed equipment is generally defined as equipment that is permanently attached to a building and can include X-ray, CT scan, MRI, mammography, LINAC or a large steriliser, among other things. Loose equipment is anything that is not attached to a building and can be easily moved to another location as needed. ECG machines, monitors, ultrasound machines and surgical instruments are examples of such items. Similarly, medical equipment and machines can be either electronic or mechanical machinery type. Nowadays, most medical equipment are electronically based, and very few are purely mechanical. Though some medical equipment is a combination of both electronics and mechanical. As medical equipment is the most vital component in any hospital, it is important that hospitals efficiently manage their medical equipment to keep their expenditures under control as well as ensure the quality of services delivered by the hospital. The best tool for efficient controlling of medical equipment is ‘Medical Equipment Management (MEM).’ If a proper MEM system is implemented in the hospital, it will assist hospitals in properly developing, monitoring and managing their equipment, as well as promoting the safe, effective and economical use and maintenance of equipment. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_14

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Responsible organisations should set up and review MEM regularly to ensure that a suitable medical device is used following the manufacturer’s instructions, is kept in a safe and reliable condition and is disposed of properly at the end of its useful life. The total MEM consists of nine different stages, which are as follows: 1. Planning of the medical equipment in terms of requirements and specifications 2. Identification of the vendors 3. The procurement process for the medical equipment 4. Preparing the purchase order 5. Inspection of the equipment delivered in terms of quality and quantity 6. Inventory and documentation of the equipment received 7. Installation, commissioning and testing of the equipment 8. User training and certification 9. Handing over the equipment 10. Monitoring the performance at regular intervals 11. Maintenance, safety and care of medical equipment 12. Condemnation, disposal and replacement of the equipment

14.1 Planning of the Medical Equipment in Terms of Requirements and Specifications Hospital planners shall conduct detailed planning and coordination, as well as an assessment of clinical needs and equipment requirements before proceeding with procurement. Efficient hospital equipment planning necessitates a thorough understanding of clinical requirements as well as detailed knowledge of budgeting, architectural design and the construction process. The ultimate goal of equipment planning is to ensure that all products chosen are appropriate for hospital operations, are within the budgeted amount and are procured, delivered and commissioned within the time frame specified and following project requirements. While assessing the requirement of the equipment, the following factors should be considered: 1. Which all medical departments are to be operative in the hospital? Like General Medicine, General Surgery, Paediatric, Gynaecology, Urology, Cardiology, Neurology, etc. 2. Which all medical equipment is required for a particular medical department? 3. Which investigations are to be carried out in the hospital? 4. What will be the level of the medical equipment? Will it be a low-ended machine or otherwise a high-ended machine? 5. Functionality of equipment.

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6. Frequency of use of the equipment. 7. The financial cost of the equipment. 8. Income likely to be generated from the equipment. 9. The useful life of the equipment. 10. Period of return on investment for equipment. 11. Expected technology changes in the equipment. 12. Determine equipment reuse and relocation options. After conducting interviews with department heads, the planner can understand equipment preferences, concerns and priorities. He shall also go over the architectural drawings and details to ensure that all of the building’s elements meet the requirements for the equipment to work properly. A variety of equipment is required in hospitals for the efficient operation of the facilities. Some are too small and less expensive, whereas others may require large spaces and are more expensive. The step-wise activities for planning the medical equipment, machinery, instruments and tools are as below (Table 14.1). The first activity for procurement of medical equipment, machinery, instruments and tools is to access the requirement of such items. Next is the finalisation of the specification and configuration of the medical equipment. This has been described in Sect. 14.1 of this chapter. As far as the number of each such medical equipment, machinery, instruments and tools to be procured is concerned, it is the planner who has to decide. While deciding, the planner has to keep in mind the number and type of beds in the hospital, the number of patients expected, the type of diseases generally prevailing in the area and the uptime of the equipment. The planner is advised to involve the medical physician, technicians and the actual users of such items, as they can be the better source who can guide the planner to decide the number of such items to be procured. The planner and the promoter shall decide well in advance about the type of medical equipment to be procured. The medical equipment can be hi-tech equipment with the latest technology, which will cost more. The second can be the medium-quality equipment, which will be a bit cheaper but the technological advancement will be compromised. Third can be the cost-saving equipment, which will be low costing but may have the older technologies, which might be obsolete in a short period. The planner and promoter have to jointly decide on this issue well in advance, considering the issues like budget for such medical equipment, the demand of the city where the hospital is located, paying capacity of the patient in that area, the type of diseases in the area and of course the financial viability of the said equipment. The next issue is the manufacturer of equipment. In today’s world, medical equipment is being manufactured around the globe. Apart from foreign manufacturers, indigenous manufacturers are available in most countries. It is the quality of the medical equipment which is an important issue. If the quality of indigenous equipment is better, the planner shall decide to choose the same. However, if the quality of foreign equipment is better, the same shall be chosen.

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Table 14.1  Planning and requirement of medical equipment

Activity Plan the equipment to be purchased Finalise the numbers and configuration of the equipment What type of equipment do you want Which make of equipment do you want Identify the seller Get quotations from the suppliers Prepare the technical and financial comparative sheets of the quotations that have been received Arranging for the demonstration of the equipment if required and checking the cross references Negotiations with the sellers What will be the mode of transportation Do you want to freeze the annual maintenance contracts for the next 10 years

Start date

Status of works End Not date Complete In-progress started

Responsible person Remarks

:-

:-

:- Hi-tech

Medium quality

Cost saving

:- Imported

Indigenous

Any

::-

:-

:-

::- Arranges by hospital :- Yes

Arranged by supplier No

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Table 14.1 (continued)

Activity How much guarantee period do you prefer Do you want to put a delay delivery clause Finalise the deal Preparing the purchase order Paying of advances Wherever the installation requires changes in the building, get the drawings of the same Installation of the equipment Commissioning of the equipment Final testing of the equipment Handing over the equipment

Start date :- 1 year

:- Yes

Status of works End Not date Complete In-progress started 2 years 3 years

Responsible person Remarks More than 3 years

No

::::-

::-

::-

14.1.1 General Issues to Be Considered while Planning and Purchasing the Medical Equipment While planning, procuring, installation and commissioning, the following issues should be considered carefully. 14.1.1.1 Choosing the Desired Equipment Once the planner has finalised the list of equipment to be purchased, he or she shall select the desired equipment from the market. In today’s competitive market, many manufacturers produce the same equipment and each manufacturer produces different models of the same equipment. Depending on the specifications, configuration, capacity, size, performance and facilities,

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different models may cost differently. It is up to the planner to determine what is required and which model best meets the requirements. 14.1.1.2 Quality of the Equipment When selecting medical equipment, tools and devices, the quality of these items must not be compromised under any circumstances. Look for a vendor with a quality mindset that prioritises patient safety, product quality and compliance. All healthcare facilities use a variety of medical equipment and devices, ranging from simple equipment to complex machines combined with various technologies. Whatever the case may be, the quality of such devices and equipment must be ensured and never compromised, even if the cost of such quality equipment is slightly higher. The primary factors in favour of quality assurance are as follows: 1. Low-quality products may have flaws or malfunctions, exposing patients to serious risks such as injury, illness and even death. 2. Unstandardised equipment may not have been calibrated following standards, resulting in incorrect results and the physician’s inability to properly diagnose the ailment. 3. Quality products are generally safe and free of unacceptable risks to people, property or the environment. 4. Medical equipment and devices are subject to extensive rules and regulations all over the world, and there are a variety of different standards and regulation systems to follow. As a result, medical equipment and devices must meet the standards of regulating authorities such as the United States’s Food and Drug Administration (FDA); QSR to ensure product performance and safety; Standard ISO 13485 supplements the Medical Device Directive and so on. 5. It is true that if the quality of medical equipment and devices meets the established standards, the equipment will last longer as compared to the nonstandard equipment and devices. 6. Quality equipment and devices will have lower repair and maintenance costs than others.

14.1.2 Points to Be Considered While Planning the Medical Equipment As medical equipment is generally a costly proposition and is usually a one-time purchase, and buying being a tedious task, a lot of care, knowledge and skills are required for buying the medical equipment. Therefore, before finalizing the purchase of any medical equipment/machinery, the following few issues shall be considered and evaluated in detail.

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14.1.2.1 Assessing the Requirement of the Medical Equipment First of all, the list of medical equipment, instruments, tools and machinery required in the proposed hospital has to be prepared. While preparing this list, the factors like medical departments planned to be operative in the hospital; type of investigations to be provided in the hospital; type of surgeries to be undertaken in the hospital and other services to be made available in the hospital should be considered carefully. After conducting interviews with department heads, the planner shall understand equipment preferences, concerns and priorities. He shall also go over the architectural drawings and details to ensure that all of the building’s elements meet the requirements for the equipment to work properly. 14.1.2.2 Finalising the Specification and Configuration of Equipment Once the list of the medical equipment, instruments, tools and machinery is finalised, the next step is to decide and finalise the specifications and configuration of all such items as mentioned in the list. While finalising the specification and configuration of the equipment, the medical professionals and/or the concerned technicians of the machines shall be taken into confidence and his/her requirements shall be considered carefully. It is fact that one particular medical equipment may have a different technical specification in different models, e.g. let us take the case of an ultrasound machine. This machine may have different platforms like radiology, gynaecology or cardiology. Again, for each platform, different types of transducers are available. Similarly, different models may have different software and facilities. Now, it is up to the user and the planner as to what he/she exactly wants. The finalisation of the specifications and configuration requires a lot of skill and knowledge and has to be done very carefully. If at this stage of planning, any errors are committed or if the planning is defective may lead to severe problems in future because medical equipment being a costly affair cannot be changed frequently. The hospital will be forced to bear with it, which may have an adverse effect on the services of the hospital. The planner must consider the most recent technology and specifications available in the market when finalising the specification and configuration of the equipment. The reason we insist on the most recent technology is that in today’s world, technologies change quickly and current technology may become obsolete in a few years. Adopting older technologies may make it difficult for the hospital to compete with those that use cutting-edge technology. In such a case, the hospital will have no choice but to replace the equipment in a few years. Another important factor while finalising the specifications is the cost of such medical equipment and its financial feasibility. It is the planner who has to balance the latest technology vs financial feasibility. However, a careful comparison must be made between the increased costs of newer equipment and the hospital’s technology requirements.

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14.2 Identification of the Vendor of Medical Equipment After finalising the specification and configuration of the medical equipment, that has to be purchased, the vendors who manufacturers or supplies the equipment with such specifications have to be identified. There can be different sources to identify the vendors like personal contacts, internet surfing, advertisement in the print media or social media, enquiry from other hospitals and directories provided by different agencies. While identifying the vendors, the following issues shall be kept in mind.

14.2.1 Warranty Choose the vendor or manufacturer that offers the longest warranty period. The longer the warranty period, the less worried hospital administrators are about equipment maintenance.

14.2.2 Maintenance Contracts Many equipment manufacturers offer an Annual Maintenance Contract. The maintenance contract can include or exclude spare components. The maintenance contract without spares is known as AMC, and the maintenance contract with spares is known as CMC (Comprehensive Maintenance Contract). It is preferable to select CMC over AMC because it allows hospital management to be less concerned about the cost of spares that need to be replaced. Select vendors who can offer better maintenance contract terms and conditions. In some cases, the hospital chooses to pay an insurance company rather than the service provider directly. The insurance company then contacts a medical equipment support service provider. If that is the case, when selecting vendors, the same shall be clarified with the vendor, if he/she is willing to do so.

14.2.3 Availability of the Workshops and Service Engineers Before procurement, the planner must ensure that the vendor has their own workshop and a team of engineers nearby so that the breakdown call can be attended to in the shortest time possible. Furthermore, the preventive maintenance schedule can be followed regularly. Besides that, it must be ensured that the vendors keep

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sufficient stock of the machine’s spare parts to repair it without having to call for the spare parts from a different location, which may result in a time delay and increase the machine’s downtime. As a result, discourage the vendor from a distinct location.

14.2.4 Period of Spare Part Availability Before procurement, the planner must ensure that the vendors will be able to provide spare parts for the equipment for the specified period or years. This period shall not be less than 10  years. Avoid such vendors or manufacturers who provide a shorter period for spares availability or a shorter duration of the service period.

14.2.5 Cost of Consumables Some medical equipment, such as laboratory analysers, require consumables to function properly on a daily basis. Before purchasing the equipment, the cost of such consumables must be checked and compared to the cost of other vendors. Some laboratory equipment are designed using closed system technology (meaning that reagents from the same manufacturer can be used), while others are open system (reagents of any make can be used). It is preferable to use an open system rather than a closed system because otherwise the hospital will have to rely solely on the same supplier for reagents, who can charge whatever he/she wants. Choose a vendor who can provide consumables at a lower cost; otherwise, the cost per test will rise, reducing the hospital’s margins.

14.2.6 Life Expectancy of the Equipment The expected life of the equipment shall be ensured before purchase. In addition, an assessment of technological changes and improvements in the design or specifications of the equipment shall be assessed. Select the vendors or manufacturers who can provide more life expectancy of the equipment.

14.2.7 Vendors Evaluation Planners must investigate the vendor’s track record in terms of the quality of after-­ sales service, efficiency, spare part availability, infrastructure for after-sales service and so on.

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14.2.8 Checking Regulations Some of the equipment are bound by local building code regulations, controlling authorities, accreditation agencies, other norms and regulations of the federal and state legislatures, and industry standards that the equipment must conform to. As a result, select vendors or manufacturers who adhere to the established standards and are certified.

14.2.9 Assistance in Getting the Licenses or Approvals Some of the equipment requires approval for operations like approval for operating the X-ray machine from the regulatory authority, or say providing a nuclear scan may require licensing, etc. Hence, choose the vendors or manufacturers who can assist the hospital in applying for and getting such licenses.

14.3 Procurement of the Medical Equipment Once the vendors are identified, now is the stage where the hospital can start the process of procurement. The steps involved in procurement are:

14.3.1 Inviting Financial and Techno-Commercial Quotations After tracing out the vendors, the next step is to ask the vendor for detailed financial and techno-commercial quotations. As far as the technical part of the quotation is concerned, the quotation shall clearly contain the details about the item name, make, model, detailed technical specifications of the equipment, technical data sheet, the catalogue of the equipment, comparison of the technical features with that of other manufacturers and pros and cons of his/her equipment. Regarding the financial part of the quotation, the quotation shall contain the details of price, taxes, delivery period, packing, insurance and transport cost, warranty, charges for a maintenance contract, installation cost, terms of payment, etc.

14.3.2 Comparative Statement of Financial and Techno-Commercial Quotations After receiving the financial and techno-commercial quotation from the manufacturers or the vendors, two comparative sheets shall be prepared to have a summarised view of the costing vis-à-vis the technical parameters of various vendors or

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manufacturers. One sheet is for the technical comparison, and the other is for the financial comparison. The format of such a comparative sheet can be like Tables 14.2 and 14.3. After or during the preparation of the technical and financial comparative sheets, the manufacturers or the vendors may be asked to provide the user lists of those who are actually using the said equipment. This user list shall have the name of the user, the concerned person’s name and the contact details. Based on this user list, the purchaser shall contact the concerned user and ask him/her about the satisfaction and performance of the equipment, services of the vendor or manufacturers, efficiency in providing service by the manufacturer/vendor and other issues like reputation of the vendor etc.

Table 14.2  Technical comparative statement Head of comparison Make Model Features

XXXXXX AAAAA ACB Adult and paediatric ventilator with all modes of ventilation, both vol and pressure cycled Product of unparalleled experience in respiratory technology. Consistent R&D efforts and an on-going dialogue with the customer.

Optional features

Standard accessories

YYYYY BBBBB XYZ Adult and paediatric Ventilator with all modes of ventilation, both vol and pressure cycled

ZZZZZZ CCCCC MNO Microprocessor-­ controlled continuous adult/paediatric ventilator

Adaptive, biphasic and compact ventilation concept

Special modes such as ASV (auto mode), DUOPAP, APRV, tube resistance Monitoring packages for loops for pressure– volume, volume-flow and pressure-flow Trends facility for 1 h, 12 h and 24 h of 19 monitored parameters Ventilator Trolley Operating manual Tubing holder set

Main features of the equipment

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Table 14.3  Financial comparative statement Head of comparison Make Model Quote for the standard equipment based on the finalised specifications Price Add Optional items Transducer Software Etc. Etc. Total price Add taxes Total cost of equipment Terms and conditions Payment

XXXXXX ABC 123

AAAAAA DEF 567

YYYYY XYZ 891

135,000.00

150,000

240,000.00

5000.00 2000.00

5500 7000

6000.00 3000.00

142,000.00

162,500.00

249,000.00

50% advance, balance against delivery

100% advance

Delivery Taxes

25% advance with order and balance against delivery. 2–3 weeks Included.

Warranty

1 year

Validity Terms of maintenance contract Transportation Transit insurance Etc.

30 days

Sales tax extra @ 10% 1 year

1 year from the date of invoicing 1 month

14.3.3 Demonstration of the Equipment Once confirmed and satisfied, the manufacturer or the vendor may be asked for a demonstration of the equipment. The vendor shall demonstrate the machine at the purchaser’s premises or at the place of another user.

14.3.4 Discussion and Negotiations If everything is affirmative and the hospital is satisfied with the equipment and services of the manufacturer/vendor, he/she may be called for further discussion and negotiations. The negotiations shall be carried out on the issues like changes in

14.4 Purchase Order and its Contents

319

specifications, price, taxes, transportation, warranty, maintenance contract, delivery period, installation and commissioning, the penalty for delay, dispute dissolution, etc. Once the final negotiations have been concluded, the concluded points shall be recorded in the minutes of the meeting and signed by both parties. This is the stage where both parties have finalised the deal.

14.3.5 Preparing the Purchase Order The next step is to prepare the purchase order. The purchase order is a final document wherein both the parties, i.e. the purchaser and the manufacturer/vendor, are bound with. Hence, the purchase order being an important document shall be prepared in detail and shall be exhaustive. A complete description of preparing the purchase order has been given below in this chapter in Sect. 14.4. Once the purchase order is prepared, checked and signed, the same shall be delivered to the manufacturer/vendor and the acceptance of the purchase order shall be taken from him/her. The next step shall be paying the advance to the manufacturer/vendor against the accepted purchase order.

14.4 Purchase Order and its Contents After all the specifications, costing and other terms and conditions of the purchase are finalised and settled, the purchase order shall be prepared. The purchase order (PO) is an important document and once signed and accepted by the vendors, it becomes binding on both parties. The terms and conditions as detailed in the purchase order bind both parties for a long period as long as the machine/equipment is being used in the hospital. Hence, the purchase order shall be drafted very carefully, and each sentence and word shall be carefully mentioned to keep binding both parties. On acceptance by the vendor, the purchase order becomes a sort of agreement for the supply and fulfils all the terms and conditions of the purchase order. The purchase order shall normally have the following conditions.

14.4.1 Purchase Order Number The PO number shall be mentioned on the top of the purchase order and may be on the left-hand side.

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14.4.2 Purchase Order Date The date of the PO shall also be mentioned on the top of the PO and maybe on the right-hand side

14.4.3 Name of the Vendor The PO shall be addressed to the manufacturer/vendor along with the detailed official address. Sometimes, the manufacturer may supply equipment through their official dealer or distributors. In such a case, the PO shall be addressed to the original manufacturer and after that mention ‘Supplies Through _________.’

14.4.4 Details of the Items To mention the item number/code, quantity, rate and amount of the equipment, insert the table in the purchase order containing details of all the items like 1. Serial number of the items. 2. Item number/code number of the item or part thereof. 3. Mention the detailed name of all the items in this table, even if it is part of the total equipment. 4. Quantity of that particular item. 5. Rate of that particular item. 6. Amount towards that item. 7. At the end of the table calculate the total amount of the order. 8. Write the total amount in words also.

14.4.5 Taxes and Duties Mention the taxes, duties and Government levies applicable and payable on the purchase of the equipment. If these taxes and duties are included in the price, mention them as ‘Inclusive of Taxes.’ If the taxes and duties are to be paid extra, please mention ‘Taxes and duties to be paid extra at actuals.’ It may also happen that at the time of the actual supply of material, the Government levies any additional taxes or otherwise increase/decrease the tax rates. At the time of placing the purchase order, it shall be decided and clearly mentioned in the purchase order as to who will bear the liability against increase or decrease in taxes.

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14.4.6 Technical Details Mention full technical details of the equipment to be purchased. Give the detailed technical configuration as has been finalised along with the accessories and software finalised along with the equipment. These technical details will help to bind the vendor for providing all the items with the same technical specifications as has been mentioned in the order.

14.4.7 Currency Fluctuations At the time, it happens that the equipment for which the order has been placed may not be manufactured in the home country and may have to be imported from other country/countries. Importing involves foreign currency transactions. In today’s world, currency conversion rates fluctuate very frequently. Due to this, the rates of equipment may also fluctuate. Hence, at the time of finalizing the deal, it shall clearly be decided as to who will bear such currency fluctuation costs. The same shall be recorded in the purchase order.

14.4.8 Delivery and Installation Period The purchase order shall clearly define the issues relating to the delivery and installation of the equipment. The following issues need to be addressed for delivery and installation. 1. Specify the exact place of delivery and mention the address of the location along with the postal code and landmark. 2. Clearly specify the date by which the material will be delivered and installed. 3. If needed, the penalty clause for delayed delivery of installation can be imposed and mentioned in the purchase order. 4. Specify the issues relating to the transport documentation and approvals as to how and who will arrange them. 5. Clearly mention as to who will bear the cost of packing, forwarding, insurance, transportation, loading and unloading. 6. If temporary storage is to be provided, please specify. 7. The manufacturer/vendor shall be bound to provide the original software licence, in the name of the purchaser, together with the equipment, where applicable. 8. The vendor shall make all consumables, measurement and calibration instruments, and tools required for actual day-to-day operations available to the purchaser.

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9. Together with the equipment, the vendor shall deliver the operation and maintenance manual in hard copy as well as in soft copy. The language of the manual shall be one in English and the other in the local language.

14.4.9 Installation and Commissioning As installation and commissioning are the responsibility of the vendor/manufacturer, the terms related to installation and commissioning shall be clearly defined in the purchase order. The following issues need to be addressed, 1. Clearly fix the responsibility of the vendor/manufacturer to install and commission the equipment. 2. Mention about the charges for installation and commissioning as to who will bear the cost of same. 3. Define who will be responsible for transporting the equipment within the hospital to the installation site, opening the packages and installing it following the installation requirements. 4. After installation, the vendor must be held responsible for cleaning up any packaging/shipping material and original boxes must be left with the purchaser for disposal. 5. The vendor/installer shall instal the equipment while taking into account the hospital’s construction characteristics. 6. Define the vendor’s liability for any damage to hospital structures or finishing caused during installation. 7. Mention in the purchase order that the vendor must test, calibrate and commission the equipment/machinery so that it is fully operational and ready to use after the completion of installation. The purchaser retains the right to observe the vendor’s testing and commissioning without relieving the vendor of his obligation to provide goods in fully operational condition. 8. Following the final receipt of the equipment, the purchaser shall be given a complete set of commissioning forms, including the entire set of tests run and the results obtained.

14.4.10 Payment Terms While finalizing the deal, the payment terms shall be clearly settled down and clearly mentioned in the purchase order. The amount either in figures or percentages shall be mentioned. Generally, some token advance is released along with the order and part payment after delivery, after installation and the last payment after successful commissioning and handing over the equipment. However, if the payment terms are through a Letter of Credit (LC), no advance is required to be paid, just opening an LC will do.

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14.4.11 Warranty Try to bargain for a maximum period of warranty. It is fact that the ‘More the warranty period, the more relaxed will be the user.’ Issues related to warranty shall be as below. 1. Tenure of warranty shall be clearly mentioned in the purchase order in both figures and words. 2. The warranty shall start from the date of commissioning or handing over, whichever is later. 3. Clearly define the scope of the warranty and clearly mention what all items are covered in the warranty and what are the exclusions from the warranty. 4. The complete machine, including all components, spare parts, software modules, accessories and consumables thereof, shall be covered by the guarantee. If the vendor provides any items which he/she is not manufacturing and buys from outside for supply along with this order shall also be covered under the warranty. Except in instances of proven misuse, intentional damage or unavoidable force majeure, the warranty coverage will be applied fully and without incurring any costs on the part of the purchaser or the users, including but not limited to the cost of visits, labour and replacement parts. It will also be valid for an unlimited number of engineer visits during the warranty period. 5. The warranty certificate shall be issued by the manufacturer and shall be in the name of the purchaser. 6. The warranty shall be on-site, and the vendor shall be bound to provide the services on the hospital premises. All the costs and expenses for providing warranty services shall be borne by the vendor. 7. The scheduled on-site preventive maintenance and calibration visits shall be performed at least twice a year during the warranty validity period. The schedule of the visit shall be pre-planned and communicated to the hospital authorities. After such preventive maintenance, the service report shall be given duly signed by the engineer and the authorised person of the hospital.

14.4.12 Up Time Guarantee The vendor and the installer shall give an undertaking, which shall be binding on the vendor, to ensure that equipment/machine shall be working at least 95–98% of the time during the warranty period, failing which the warranty period will increase by double the days of short Uptime Guarantee. It means that at least 98% of one single year of full functioning, i.e. 358 days out of 365/366 days, will be guaranteed by the vendor within the warranty period. If the equipment supplied has been

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malfunctioning for more than 7 days of one single year of the warranty period, the vendor shall extend the warranty period for a duration of double the days of short working days in a year.

14.4.13 Site Preparation In the purchase order, clearly specify and define the scope of pre-installation activities for both parties, e.g. civil works, electrical works, welding works, data networking, water supply plumbing works, air-conditioning and drainage, etc.

14.4.14 Training In the purchase order, the vendor shall be bound to provide training to the staff of the hospital. The following issues shall be addressed while mentioning this clause. 1. The vendor shall provide training to all the actual users of the hospital for the technical operation of the system and shall issue the training certificates for the same. 2. Similarly, the vendor shall also train the staff for proper maintenance and calibration of the items mentioned in the purchase order. 3. The user training course must be both theoretical and practical, utilising the equipment in the approved configuration and including simulations of all potential errors committed when using the equipment. 4. The time duration of such training can also be defined in the purchase order. 5. It shall also be agreed and mentioned in the PO that in between if any problem is faced by the operator of the equipment/machine, the vendor shall immediately send his team to train them again and resolve the issue. 6. The training location must be where the equipment is installed. 7. Insist on qualified experts from the manufacturing company and/or company representatives serving as trainers. 8. Presentation; general equipment functions; configuration details; alarm and error signals; calibrations; daily cleaning and maintenance and correct equipment utilisation, among other things, shall all be part of user training. 9. The vendor shall be bound to train hospital technicians and make them aware of the most common problems that may arise during equipment utilisation as well as solutions to such minor issues. 10. Maintenance technicians shall be trained in general equipment functions, main electrical and functional schemes, specific technical characteristics and alarm signals, calibrations (if requested), preventive maintenance, daily maintenance and its regular recurrence, corrective maintenance and equipment safety controls, among other things.

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14.4.15 Post-Sales Maintenance The vendor shall be made bound to maintain and repair the system, without any additional cost, for the period of warranty. It shall be mentioned clearly that no extra cost shall be paid towards such service.

14.4.16 Period to Attend After-Sale Service The period required to attend any complaint during the warranty period shall be decided at the time of placing the purchase order and shall be mentioned in the PO.

14.4.17 Financial Guarantee Against Post-Sale Service As a financial commitment, the vendor shall be bound to provide a kind of financial commitment against the performance of the post-sales service. It is rightly said that ‘there is no commitment if finance is not involved.’ This commitment can either be in the shape of a bank guarantee to be provided by the vendor or otherwise a retention amount which can be paid after the warranty period. The financial commitment can be a percentage of the total purchase order value like 10% of the invoice value.

14.4.18 Availability of Spares During finalization, a written undertaking shall be taken from the manufacturer or the authorised agent of the manufacturer regarding the number of years during which the spare part and maintenance service shall be made available. Even the penalty clause can be added that in case the manufacturer fails to provide spares, the manufacturer or the vendor shall be liable to pay the mentioned penalty.

14.4.19 Testing and Handing Over Once the commissioning is over, the installation team shall conduct self-testing to ensure the proper functioning of the machine. Before transferring the ownership, the following issues need to be attended to and clearly mentioned in the purchase order: 1. The equipment shall be inspected and tested by the Biomedical Engineer. 2. Following that, the equipment shall be tested on dummies and phantoms.

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3. Before giving the final approval, issues such as electrical safety inspection and radiation safety shall be addressed during testing. 4. The vendor/installer shall provide the purchaser with a written letter requesting official testing and commissioning. 5. Following the installation phase, the purchaser shall evaluate, item by item, the consistency of the goods and services supplied following the contract conditions and technical specifications. 6. Official testing and commissioning are considered successful when all items of equipment function properly. 7. The hospital shall have all the right to inspect the delivered goods, including checking their quantity and integrity. 8. Once all the equipment is functioning properly, quantities and quality of equipment are ascertained, all the terms and conditions are fulfilled and the training has been provided, the hospital shall finally take the handing over of the equipment from the vendor.

14.4.20 Annual Maintenance or Comprehensive Maintenance Contract At the time of discussions and negotiations with the vendor, the maintenance contracts shall be finalised for 10 years after/or (whichever the case may be) including the warranty period. All the details relating to the AMC/CMC (whichever the case may be), shall be specifically mentioned in the PO. The details shall include the type of maintenance contract, number of years for which the contract is finalised, amount to be paid annually, escalation of maintenance amount on a year-to-year basis, taxes to be paid, signing of the contract on a year-to-year basis, inclusion and exclusion in the maintenance contract, etc. Usually, for AMC/CMC, the agreement is signed between the purchaser and the manufacturer/vendor every year on a year-to-year basis. It is advised that while placing the PO, a copy of the draft agreement of such AMC/CMC shall be asked from the manufacturer/vendor. This copy of the agreement shall be checked thoroughly, particularly the terms relating to the inclusion and exclusions of the spares, parts, accessories, maintenance kits, etc. After discussion with the manufacturer/ vendor settle the terms and conditions of the AMC/CMC agreement. It is also advised to make this agreement a part and parcel of the PO, so that the manufacturer/vendor and hospital are bound by these terms and conditions of AMC/CMC. At times, it happens that the purchaser purchases the equipment from the dealer and the dealer himself/herself approves the AMC/CMC. However, down the years, the original manufacturer refuses to give the AMC/CMC support. The manufacturer

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gives the plea that the dealer has not taken any consent from the manufacturer for AMC/CMC support. Hence, if the purchase is being done from the dealer of the manufacturer, insist on the AMC/CMC approval from the original manufacturer of the equipment or otherwise enter into a triparty agreement with the dealer and original manufacturer of the equipment. Please be aware that this maintenance clause will be applicable and binding on both parties till the agreed tenure of the maintenance contract. Hence while mentioning this clause in the PO, utmost care shall be given and the words and language carefully drafted.

14.4.21 Government or Regulatory Approvals Through the condition in the PO, the vendor shall be bound to arrange for the required approvals from the Government or the Regulatory authorities. In case, officially it has to be done by the purchaser, the vendors shall be at obligation to help out the hospital in obtaining such approvals.

14.4.22 Other Conditions If any specific condition relating to the equipment has been agreed upon during the discussion or negotiations with the vendor, the same shall be mentioned in the PO.

14.4.23 Up-Gradation Clause The vendor shall be made bound to upgrade the equipment including software that is available from time to time with the manufacturers. Please try to negotiate with the manufacturer/vendor and mention that this service of upgradation shall be free of cost and nothing needs to be paid against such service.

14.4.24 Dispute Dissolution The procedure for dissolution of the dispute shall be agreed upon by both parties and the same shall be mentioned in the PO. This procedure shall be binding on both parties.

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14  Equipment Planning, Procurement, Installation and Management Sample Format of Purchase Order

Dt. ______________ To, M/s _______________ ___________________ ___________________ ___________________ Reg.:

Purchase Order for Supply, Installation, Commissioning of (Mention Name of Equipment) __________________________________________________________________________________

Ref.

Your quotation no. ______________ Dt. __________________

Dear Sir, In reference to your above said Quotation, we are pleased to place the order for SUPPLY, INSTALLATION AND COMMISSIONING OF _______________________(Mention Name of Equipment) _____________ as per the terms and conditions enclosed herewith,

1.

ITEMS:

S.

ITEM

NO.

NUMBER

ITEM DESCRIPTION Supply of items as per the details below:

A

Name of the item _______________________________

1 2 3 The equipment has to have all the standard features as provided by the

QTY.

RATE

AMOUNT

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original manufacturers and stated in your catalogue and the quotation TOTAL AMOUNT

(Amount in words______________________________________________) 2.

TAXES, DUTY ETC.

The above rates are inclusive/exclusive of taxes (Specify Inclusion of Exclusion), and nothing will be paid extra. All other taxes like Excise Duty, Custom, Octroi, Local taxes and demurrage etc., or any other charges levied by the law will be to your account and is included in the price agreed above. If there is any variation in the tax rates or any new tax is being imposed by the Govt., it will be to the account of the Supplier. 3.

TECHNICAL DETAILS. Give the detailed technical details of the item to be purchased.

4.

CURRENCY FLUCTUATIONS The price of the machine has been fixed in _____________ (Country Currency) as per the cost given above. If any fluctuation due to the foreign currency rate, it will be to the supplier’s account.

5.

DELIVERY and INSTALLATION PERIOD You will supply, install and commission all the machines complete in all respects latest by ____________(Date). If the installation is not complete within the time frame, a penalty to the tune of ______________ (State the amount of penalty) per day of delay will be payable by you to the ________________ (Specify the name of purchaser).

6.

DELIVERY Delivery of the machines will be ____________________ (Specify the location and address of the delivery point). All the necessary documents and approvals (if applicable) etc. will be provided by us. It is assumed that the transport charges, insurance, loading and unloading have been included in the cost agreed upon above.

7.

INSTALLATION and COMMISSIONING You will be totally responsible to complete the installation within the fixed time period. All types of charges for the installation of the equipment will be free.

8.

TESTING AND HANDING OVER You will test the entire equipment in presence of our authorised team member, and perform the required

procedures and applications. Once the team members are satisfied, then you will hand over the equipment under a written and signed the handing-over report.

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9.

The payment will be as follows: _________

-

Advance along with the order

__________

-

Through irrevocable Letter of Credit to be negotiated after _______ months from the date of Sales Invoice

(Specify the agreed terms of payments) 10.

WARRANTY

The equipment will be under warranty for a period of _________ (Specify the period of Warranty), from the date of commissioning, against any manufacturing defects. The warranty will apply to all the items given in the order whether manufactured by __________ (Give the name of manufacturer) or are boughtout items. 11.

UPTIME GUARANTEE

You will give an Uptime Guarantee of 98% during the Guarantee Period, failing which the warranty will increase by double the days of the short Uptime Guarantee. 12.

SITE PREPARATION

You will help us in preparing the site for which you will guide and provide us with the drawings for interior designing, flooring, doors, wall claddings, lighting, ventilation, air conditioning, civil work , etc. However, these works will be carried out at our cost. We will provide you with the proper environmental conditions recommended by the supplier so that the equipment does not suffer damage due to humidity, dust, pests, temperature, etc. 13.

TRAINING

You will train our staff for the technical operation of the system and will issue the certificates for the same. Similarly, you will also train our staff for proper maintenance and calibration of the items mentioned above. The training will be for ____________ (Specify the period of training required). In between, if any problem is faced by our operator, you will immediately send your team to train them again and resolve the issue. 14.

POST SALE MAINTENANCE

You will maintain and repair the system, without any additional cost, for the period of warranty. It is understood that the cost of rendering this service is included in the selling price as agreed above.

14.4 Purchase Order and its Contents 15.

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FINANCIAL GUARANTEE AGAINST POST SALE MAINTENANCE

As a financial commitment to better service, you will provide us with a Bank Guarantee from any Nationalised Bank, equivalent to the amount _________ (Specify amount) of the total value of the order, valid till the warranty period of the machines, before the final payments against this order.

16.

PERIOD TO ATTEND AFTER-SALES SERVICE

You will attend to the complaint within __________ (Specify hours/days) after getting information. 17.

AVAILABILITY OF SPARES

You will ensure that all the required spares are made available for a period of ______________ (Specify years, usually 10 years) from the date of supply, failing which you and your principals will be liable for damages. 18.

GOVERNMENT APPROVALS

You will help us and guide us in getting the required approvals from the Govt. authorities like _____________________ (Specify the approving authorities). 19.

OTHER CONDITIONS

Whatever has been agreed has been mentioned in the above-said clauses of this purchase order. Other conditions whatsoever mentioned by you in your various quotation will not apply to this purchase order and for us, all those conditions are null and void. 20.

COMPREHENSIVE MAINTENANCE CONTRACT

The comprehensive maintenance contract after the warranty period, i.e. ________ (Specify warranty period as mentioned above) will be as given below. The charges for CMC will remain the same as mentioned below, but the terms and conditions will be as per mutually agreed upon every year, and the contract for CMC will be signed every year. The charges of CMC will be paid in advance at the start of the CMC. However, the taxes as applicable will be extra. Year

Amount of CMC

1st Year

:

2nd Year

:

Till 10th Year

:

The Comprehensive Maintenance Contract will include all the items (Manufactured by ______________ (Specify manufacturers name) or otherwise bought out items) whether it is a part of the machine or a supporting part.

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14.5 Inspection of the Equipment Delivered in Terms of Quality and Quantity

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14.5 Inspection of the Equipment Delivered in Terms of Quality and Quantity 14.5.1 Inspection of the Material at the Time of Delivery As soon as the packages containing the equipment arrive at the site, the Biomedical Department of the hospital shall inspect such packages. First, they shall count the number of packages and compare it with the numbers mentioned in the invoice and delivery challans. Second, they shall also ensure that all the packages are intact and none of them is broken, damaged or opened. If everything is in order, he/she shall give a receipt of the same to the transporter. If any shortage is noticed or if any of the packages are found to be broken, damaged or opened, he/she shall immediately inform the vendor in writing and shall not issue any receipt of the material to the transporter. Once the material is received, the Biomedical Department shall arrange for the safe custody of the material at the site. Please ensure that the material is kept in a lockable enclosure and protected from rain or sunlight. It shall be strictly ensured that nobody, including the Biomedical Department, shall open any of the packages or boxes that have been received from the vendor. Why we stress this issue is that while opening the packages or boxes if any of the equipment, or part thereof is found to be broken, damaged or missing, the vendor might put the onus on the hospital for such damage or shortage. Opening of the packages or the boxes is the responsibility of the installation team of the vendor.

14.5.2 Inspection of the Material at the Time of Installation Once the installation team arrives at the site for the installation of the equipment, first of all, the Biomedical Department shall hand over all the packages and boxes, as were received from the transporter to the installation team under the written receipt. Now, it is the responsibility of the installation to open the packages and the boxes. These boxes shall be opened in front of the Biomedical Department of the hospital. Please ensure that a quick check is not enough, and a detailed inspection is needed to avoid problems in the future. Once the packages and the boxes are opened, the Biomedical Department of the hospital shall check the incoming equipment carefully for any possible shipping damage to the material. He/she shall verify that the equipment or part thereof is not damaged or broken. He/she shall also verify the number of items in the packages/ boxes, accessories, manuals, consumables and kits that may have been supplied with the equipment. The Biomedical Department shall compare all these items with the purchase order and shall ensure that all the items have been supplied as was ordered and

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complies with the specifications as mentioned in the purchase order. If there is any shortage or any of the items are found to be damaged, broken or missing, or mismatched, he/she shall inform the vendor immediately in writing. Another important issue that the Biomedical Engineer shall be vigilant of is that he/she shall ensure that the equipment supplied is brand new (if re-furbished equipment is not purchased). To ensure himself/herself, he/she shall check the labels and stickers on the equipment containing the date of manufacturing or shipping from the original manufacturers. The vendors may supply the used equipment of the demo piece of equipment. If the Biomedical Engineer is intelligent enough, he/she may easily trace it out by checking the cleanliness of the equipment, scratches on the equipment, etc. If any irregularity is noticed, the installation process may be halted and the vendors shall be called for to take clarifications.

14.6 Inventory and Documentation of the Equipment Received Once the inspection of the equipment is completed, the Equipment Record File should be created both in physical mode and electronic mode. This file shall contain every minute detail of the equipment right from the purchase order, store receipt details, issue details, installation, commissioning, testing, training, warranty, maintenance, preventive checks, log sheet, equipment ideal time, repairs history, repair expense, contact person of the vendor for repairs and service, etc. This file shall be open and active for the entire life of the equipment. Once the equipment is condemned and disposed of, the file shall be closed and stored. The hospital may have different types of medical equipment and each type may be in large quantities, e.g. the quantity of Multipara monitors may be large. Each item has a different serial number and may be placed in different departments of the hospital. Therefore, a ‘Unique Identification Number’ shall be allotted to every piece of equipment in the hospital. This number shall be marked in such a style that it gives details of the type of equipment, location, installation date etc. Let us take an example: Suppose the Invasive Ventilator is installed in the ICU on 12th May 2022 by ABC hospital, the unique ID shall be ABC/BME/ICU/ VEN/2021–22/001. Here, ABC means: Name of Institute. BME means: Biomedical Engineering. ICU means: Location of the equipment. VEN means: Invasive Ventilator. 2021–22 means: Year of Installation. 001 means: Item number in terms of the total quantity of a particular type of equipment.

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The Equipment Record File shall generally contain documents and information like 1. An Equipment Unique Identification Number (UIN). 2. Name of the equipment. 3. Technical specification of the equipment. 4. Technical and financial comparison sheet. 5. Copy of the purchase order with all the terms and conditions. 6. A generic description of the equipment. 7. The equipment’s Make, Model and Serial Number. 8. Name of the vendor with its contact details like name of the person, phone number, address, etc. 9. Contact person for repair and maintenance with details like name of the person, phone number, address, etc. 10. Cost of the equipment. 11. Copy of the invoice and delivery challan. 12. Details of payments to the vendor. 13. Copies of the installation, commissioning and testing reports. 14. Date of handing over the equipment. 15. Copies of the training certificates issued by the vendor. 16. Warranty certificates with conditions and expiration date. 17. Copies of the maintenance agreements. 18. Department and the location of the equipment. 19. Schedule of preventive maintenance with service reports. 20. An abbreviated service history. 21. Operation manuals. 22. Service manuals. 23. Repair history with the repair expenses during the entire tenure of the equipment. 24. Any correspondence with the vendor or manufacturer of the equipment. 25. Condemnations reports. 26. Details of disposal of the equipment after the end of life.

14.7 Installation, Commissioning and Testing of the Equipment The most important part of the entire equipment planning, procurement and management is the installation of the equipment. A lot of planning is required before placing the order for the equipment and after placing the order for the equipment. While the delivery of the equipment is awaited, it is time to prepare the site where the equipment has to be installed. Depending on the requirement of the equipment, the preparation may include the construction of the foundation,

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providing electrical, water, and gas supply lines, environmental control like airconditioning and humidity, lightening of the room, etc. Detailed issues for the installation, commissioning and testing of the equipment are given below.

14.7.1 Proper Location of Installation While planning for the procurement of medical equipment, the location where it has to be installed shall also be finalised. Each medical equipment may have a specified area or department where it has to be used. Hence, it is advised to install that equipment in that particular area only. For example, let us take the case of a CT scan or say MRI, as these are heavy machines, preferably shall be installed on the ground floor and in the department of radiology. It is still important because the delivery and unloading of the machines can be done direct-to-site where it has to be installed.

14.7.2 Area Requirement The area required for medical equipment shall be planned well in advance while planning the layout of the hospital building. This is important because some of the medical equipment may require a certain defined area in terms of room size etc. Why it is so? There are various reasons for this. First, the size of the medical equipment matters. For the size of the equipment, it will be better if the dimensions of the machine vis-à-vis the room size required are taken from the original manufacturer of the equipment. Second, the service or attached rooms for the equipment. Some medical equipment may require an attached service room, e.g. MRI requires the machine panel room, UPS room and the space for a chiller. Hence, it is advised that before finalising the layout plan of the hospital, it will be better if the original manufacturer of the equipment is contacted and the requirement of such service/attached is taken from them. Third, the operational area. Each medical equipment may require some operational area like a movement room etc. Such area shall be planned well in advance. Next is the rules, regulation and guidelines of the regulatory authorities of the Government of the respective state of the country. E.g. for the installation of the nuclear scan equipment, the government may have certain regulations and guidelines, etc. Hence, the area planning shall be done considering all such regulations or guidelines.

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14.7.3 Power Supply Requirements for Electrical Medical Devices Mostly all medical equipment needs an electrical power supply to operate the equipment. This power requirement may differ from one piece of equipment to other. Further, the source of the power supply may be different like supply from main electrical lines, a special separate power source or an internal one, such as a battery etc. Hence, while planning for the power supply of equipment, detailed equipment-­ wise assessment is essential and this exercise shall be done well in advance. As the requirement of the power supply/electricity may vary from one piece of equipment to others in terms of electrical load requirement, voltage, ground earthing etc., it is advised to contact the original manufacturer of the equipment regarding such requirement of the power supply. While planning for the power/electrical requirement, the following issues shall be considered and taken care of 1. The requirement shall specify the maximum rated mains voltage required for the equipment. 2. The range of the acceptable limits of voltage fluctuation shall be considered. 3. Similarly, the acceptable range of frequency of power shall be considered. 4. Because the majority of problems in this area involve the plugs, sockets and cables that supply electrical power, it is critical that: A convenient and safe socket outlet should be provided to plug in the equipment. As there are all the chances of water spillage on the electrical socket, it is advised that the socket outlets should be at least 2 m away from a sink or wash basin. If not possible, some kind of partitions shall be provided to avoid water spillage. The capacity of the electrical socket outlet should be adequate to handle the load of the equipment. All three pin sockets shall be properly grounded by providing the earthing. Two pin sockets need not be earthed. The capacity of the plugs attached to the equipment supply cable shall match the socket outlets. 5. Since wiring of the electrical circuits is one of the most critical aspects of electricity/power supply, the following issues shall be addressed while laying the wiring and cables. The size and capacity of the cables and wires shall be adequate to handle the load of the equipment. Under capacity or over capacity is not suggested. The wiring of a plug is colour-coded to help guard against electrical accidents. The colour codes of the wiring shall be maintained as per the rules, regulations and guidelines of the respective state of the country.

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The main cable and wires supplying electricity/power to the equipment shall be properly insulated and shall be fireproof or at least fire retarded. No bare metal or internal coloured wire should be used. All the cables or the wire shall be underground. If the cable and wires are laid in the wall, the chase cutting shall be done on the walls, the conduit laid down and then the cable/wires shall pass through the conduit. Similarly, if the cable and wire are laid under the floor, they should also pass through the conduit. Open wires and cables are not advisable, if the cable or wires are laid above the false ceiling, the same shall be through the conduit. Conduits can either be made of metal or other fire retarded material. The shortest possible flexible leads shall be used because long leads are harmful. 6. Ground earthing is one of the biggest safety features for any medical equipment. Hence, it is suggested that all the major equipment shall be properly earthed. Heavy equipment like MRI or CT scan may require double earthing also. Electrical devices like UPS etc. may also require separate ground earthing. If equipment is housed in a metal case, the earthing of that metal case is also necessary. All the Distribution Boards (DBs) shall also be earthed. 7. The Miniature Circuit Breakers (MCBs) or fuses shall be of the specified and correct rating and underrating or overrating MCBs or fuses shall not be used, as there are chances of getting the equipment damaged. 8. The voltage shall be constant, and the voltage fluctuation shall be within the acceptable range. 9. As most of the medical equipment are electronic, there are all the chances of electronic circuits of equipment being damaged because of the sudden spikes in the AC current. Hence, to achieve a pure Sine Wave of current, the Spike Bursters shall be installed at the main supply panels like the main switch panel, floor panels, servo stabilizers or the UPS. 10. It is advised that the hospital can arrange for a pre-installation Electrical Safety Inspection by a government-approved agency.

14.7.4 Positioning of the Medical Equipment Equipment placement should always be given a thoughtful consideration. The below issues shall be addressed carefully: 1. Equipment should be positioned in dry, clean, well-ventilated areas on a sturdy level base and prevent damp situations.

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2. Extension leads shall be avoided, and equipment shall be placed as close as feasible to the electrical supply outlet. 3. If the equipment is to be positioned on the ground, a proper foundation shall be provided. Particular care shall be taken for heavy equipment like Linear accelerators, MRI or CT scan. As these equipment are very heavy, the foundation shall be designed in such a fashion that it can easily take the load of the equipment. Before designing the foundation, it is advisable that the details of such foundation may be taken from the original manufacturer of the equipment. 4. The equipment shall be properly screwed to the foundation. If required, the vibration pads shall be used. 5. If the equipment is tabletop type, proper shelves or countertops shall be provided. 6. Proper furniture shall be provided for the equipment or accessories if required, like a computer table for computers and printers etc. 7. The room where the equipment has to be installed shall be properly painted. 8. The room or the area where the equipment is to be installed shall be lockable and the entry of an unauthorised person shall be restricted. 9. Interior of the room shall be pleasant and soothing. No fast colours shall be used.

14.7.5 Environmental Conditions Environmental conditions include air-conditioning and humidity control. For efficient working and the long life of the equipment, environmental control is necessary. Hence, the below factors shall be taken care of: 1. Provide comfortable climatic conditions for patients and equipment. 2. Usually, the temperature in the room shall be between 22 °C and 24 °C. However, some equipment may require still lower temperatures. Therefore, it is advised that the original manufacturer of the equipment shall be contacted for details of the temperature in the room. 3. Similarly, the humidity in the room shall be between 50%rh and 60%rh. However, some equipment may require still lower or higher humidity levels. As humidity level can be one of the main causes of equipment being damaged, controlled humidity levels are very important. Therefore, it is advised that the original manufacturer of the equipment shall be contacted for details of the humidity levels in the room. 4. Use air filters if required or if recommended by the original manufacturers of the equipment.

14.7.6 Other Issues There are a few other issues which need to be addressed before preparing for the installation of the equipment. Some of them are

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1. Some of the equipment may require a supply of normal water for its operations, like a water supply for cleaning the endoscopes. Hence, the water supply shall be provided near the equipment. 2. Similarly, some of the equipment like dialysis may require demineralised water, purified water, distilled water or water free from any microorganism. Hence, as per needs, the arrangements of water supply shall be provided by installing the demineralisation plant, reverse osmosis plant, distil water plant, etc. 3. There can also be a requirement for the drain lines near the equipment, the same shall be provided as per the requirement. 4. Some equipment like Invasive Ventilators may require compressed medical air for operation. The same shall be provided with either form the central medical gas pipeline system of the standalone air compressor. 5. Some of the equipment may require different gases for its operation, e.g. Invasive Ventilators require oxygen, CO2 laser or insufflators require carbon dioxide and anaesthesia workstations require nitrous oxide for their functioning. Hence, as per the requirement, the arrangement of the respective gas shall be done near the equipment.

14.7.7 Installation of the Equipment Once the hospital is ready with the installation requirement, the clearance shall be given to the manufacturer/vendor to install the equipment, who in turn shall arrange to install the equipment. During installation, the following issues shall be taken care of 1. Once the delivered packages and boxes containing the equipment and accessories are opened, the inspection is done and the material shall be moved to the location of installation safely. 2. During installation the representative of the hospital, preferrable the Biomedical Engineer shall always be present at the site throughout the installation period. 3. The Biomedical Engineer shall ensure that the equipment is placed on the foundation properly and screwed to the foundations. He/she shall ensure that there is no vibration due to inappropriate installation. 4. Biomedical Engineer shall ensure that the equipment is assembled correctly and as per the laid down standards. 5. Biomedical Engineer shall ensure that all the accessories are properly connected to the equipment. 6. Check that all the supplies like water or gases are connected to the equipment. 7. Check that all the electrical connections are done properly and proper electric/ power supply is proper and within controlled limits concerning the voltage and frequency. 8. Check the ground earthing of the equipment.

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9. Make sure to clear the area where the medical equipment is located of all packing materials and other trash. By doing this, you can guarantee that the workers who will be utilising the equipment frequently have a tidy, functional environment. It also guards against pollution and other workplace accidents.

14.7.8 Commissioning and Testing of the Equipment Next is the commissioning and testing of the equipment. The manufacturer/vendor shall carry out the testing of the equipment, as per the testing protocol of the equipment. During commissioning, in some of the equipment, the software needs to be activated and registered. The Biomedical Engineer shall ensure that all such registrations are done and the software is working properly. The medical apparatus should be functionally evaluated after assembly. Sometimes, even if everything seems to be working properly, there might be an invisible issue. Testing can reveal assembly errors in addition to equipment issues before any permanent damage occurs. During testing, the Biomedical Engineer shall ensure that all the tests are performed on the phantoms if required or on dummy patients if required. It is necessary that the number of tests shall not be limited and shall be performed till the desired results are achieved.

14.7.9 Installation and Testing Reports Once the equipment is tested, the manufacturer/vendor shall submit the installation, commissioning and testing report to the purchaser. The installation, commissioning and testing report shall be prepared by the installation team of the vendor/manufacturer. The report shall be prepared on the letter pad of the vendor/manufacturer. The installation report shall be signed by both the parties, i.e. by the hospital authorities (on the recommendation of the Biomedical Engineer) and the head of the installation team. This report is prepared in duplicate. The first and original copy shall be handed over to the hospital, and the second copy shall be retained by the installation team, later to be submitted to the vendor or manufacturer. Along with the installation report, the vendor/manufacturer shall provide the quality assurance certificates. Three such quality assurance certificates shall be provided, which are IQ, OQ and PQ. Here, IQ means—Installation Qualification (IQ) OQ means—Operational Qualification (OQ) PQ means—Performance Qualification (PQ)

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14.8 User Training and Certification Once the equipment is ready for handing over after commissioning, the manufacturer/vendor shall be asked to provide training to the actual user or the technicians who may operate the equipment. If required, the manufacturer/vendor may be asked to provide the training certificates to the users or the technicians as the case may be. To reduce the possibility of equipment malfunction, the user of the equipment shall be provided with aggressive training by the vendor/manufacturer or the authorised agency of the manufacturer. If the users are not trained properly, it may lead to the device malfunctioning. Incorrect use of medical equipment will also aggravate maintenance issues. As a result, user training shall be regularly monitored by the vendor/manufacturer to ensure that the appropriate skill level required for equipment operation is maintained. In fact, training shall include all user staff as needed, including clinical and technical personnel. 1. During training, each user must be instructed on how to use the equipment properly, especially if it is a new model that has never been used by your hospital before. 2. It is equally important that the instruction is also provided to the biomedical staff of the hospital to facilitate the trouble-free operation of the equipment. 3. First, the user shall be explained about the hardware equipment and the components of the equipment. 4. Then, the process of switching on and turning off the machine shall be explained. 5. Details of accessories and attachments have to be explained. How these accessories are also an important issue shall also be explained. 6. Then comes the software of the equipment. The user shall be explained the purpose of the software and how to use the software. Particularly, the sequences that have to be followed to operate the software shall be explained. 7. The user shall be made to operate the machine in front of the trainer so that he/ she can check if the user has any problem operating the equipment. 8. The user is required to take a deep interest in learning and shall clear all his/her doubts during the training. 9. Now the user shall be asked to perform procedures on dummy patients or the phantoms. 10. If everything goes well, the user shall perform the procedure on the actual patient. 11. The trainer shall also provide training to the user regarding the proper maintenance, cleaning and sterilizing of the equipment at the required intervals. 12. The trainer shall provide a list of Do’s and Don’ts of the equipment in writing to the user. 13. If there is any written operational manual of the equipment, the same shall be provided to the user. 14. In the end, the trainer shall issue a certificate to the user, confirming that he/she has been trained as per the standards and requirements and can operate the equipment.

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14.9 Handing Over the Equipment Now is the time to hand over the equipment to the hospital. Before transferring the ownership and signing the final equipment commissioning reports and handing over the report, the Biomedical Engineer shall inspect and test the equipment thoroughly. Check all the hardware, software and accessories that are supplied with the equipment. Compare these items with the purchase order. The Biomedical Engineer is also supposed to check the technical parameter of the equipment and compare it with the purchase order. While taking over the equipment, the issues like electrical safety inspection, radiation safety, etc. shall also be taken care of before giving the final affirmation. The Biomedical Engineer shall take charge of the equipment, its accessories, attachments, kits and consumables supplied along with the equipment. All the operational manuals, service manuals, warranty cards and any other documents must be taken into the possession of the Biomedical Engineer. The Biomedical Engineer shall take charge of all the spare parts supplied with the machine and store them carefully. All the stock entries shall be completed by the Biomedical Engineer or other concerned persons of the hospital. The handing over report shall be prepared by the authorised person of the vendor/manufacturer in duplicate. The report is supposed to be signed by the person preparing the report and the Biomedical Engineer of the hospital. The head of the department where the equipment is installed shall also countersign the handing over report. Depending on the policies of the hospital, if required the authorised higher authority of the hospital shall also countersign the handing over report. Handing over the report shall have all the details of the medical equipment that has been installed. The report shall contain, –– –– –– –– –– –– –– –– –– –– –– –– ––

Name, address and contact numbers of the equipment supplier. Name, address and contact numbers of the installer. Name, address and contact numbers of the authorised person of the hospital. Purchase order reference and date of the purchase order. Invoice number and date through which the equipment was supplied. Date of installation. Date of handing over the equipment. Make, model and serial number of the equipment. Make, model and serial number of all the attachments and accessories. A brief note about the installation procedure adopted. Details of commissioning. Details of testing that has been performed. Details of training provided and the names of persons to whom the training has been provided. –– Signature of the installer and authorised person of the hospital.

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14.10 Monitoring Performance at Regular Intervals One of the most common mistakes done by the hospital is to believe that the warranty period is covered by the vendor, so no in-house technical attention is necessary. This is absolutely wrong. Continuous monitoring of the performance of the equipment is equally important for a healthy life of the equipment and trouble-free operations. The user, Biomedical Engineer and the head of the department shall regularly monitor the machine. He/she shall ensure that: 1. The operator or the user is operating the equipment as per the standard protocols defined by the manufacturer of the equipment. 2. The desired results and output are being received from the equipment. 3. The equipment is regularly calibrated as per standards. 4. The equipment is cleaned and maintained properly. 5. The preventive maintenance of the equipment has been carried out as per schedule. 6. The electrical connection and other connections like water and gases are intact and leakproof. 7. Electrical safety shall be checked at the defined intervals. 8. Ensure that all the attachments and accessories are working properly. 9. Ensure that the approved consumable like kits, reagents, paper, etc. used and sub-standard material is not being used in the equipment. 10. Check the consumable part like lamps and electrodes of the equipment at regular intervals and ensure that they do not require replacement. If required, arrange for replacing them immediately.

14.11 Maintenance, Safety and Care of Medical Equipment Equipment maintenance, care and service activities are necessary to ensure the continued functioning of the equipment and avoid breakage or operational failures. If the equipment is maintained and cared for properly, the downtime will be reduced, the quality and accuracy of the performance will be better and the life of the equipment will increase. The primary goal of maintenance is to minimise or, if possible, eliminate the need for repairs. There are a lot of issues which shall be taken care of for proper maintenance of the equipment; they can be related to the equipment directly or other issues like infrastructural issues or cleaning issues etc. We have described a few such issues which shall be taken care of.

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First and the foremost requirement for equipment maintenance is to maintain the history and logbook of every major piece of equipment. For very small instruments like sphygmomanometers, monitors, etc., this log sheet need not be maintained. The history and the logbook can either be maintained on the electronic mode of the manual register. It is recommended that both soft and hard copies can be maintained. First coming to the historical record of the equipment. The history sheet of the equipment shall be maintained by the Biomedical Department. The history sheet shall include details like –– –– –– –– –– –– –– –– –– –– –– –– –– ––

Name of the equipment. Make, model and serial number. Purchase order detail like PO number and date of PO. Main terms and conditions of the PO. Payment details. Material receipt details with the date of receipt. Warranty clause. Maintenance contract details. Invoice number and date of invoice. Store entry details like MRN and date of receipt. Installation details with the date of installation. Equipment handing over details. User training details. Repair details like date of repairs, type of repair, spare parts used for repairs and the expenses on repairs. –– Name, address and contact number of the service provider for maintenance of equipment. Now the Logbook The logbook shall be maintained by the user and shall be placed in the department near the equipment. The logbook shall contain details like –– –– –– –– –– –– –– –– ––

Time of switching on the equipment. Time of switching off the equipment. Actual running time of the equipment. If the equipment has been provided with running exposure meters, the reading of the same shall be recorded. Date and time of breakdown of equipment. Date and time of repair of equipment. Ideal time, dead time, etc. Date and time of preventive maintenance. Date and time of breakdown maintenance. The sample format of the checklist is given in Table 14.4.

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Table 14.4  Equipment maintenance checklist Point of care Daily Weekly Bi-monthly Monthly Quarterly Biannual Annual Equipment care Preventive maintenance (PM) Check electrical wirings, sockets, plugs and switches Check the voltage of the electricity Check the ground earthing Check all the accessories and attachments Check the stock of spare parts and accessories Check audio/visual alarms Check other items like connections of any pressurised parts like gas or air cylinders Check all the seals, connectors and adapters Check the battery backup Check the battery health Check all the bulbs, heaters, etc. Check and replace oil, paper, electrodes, lamp and other consumable items Check all the rubber parts Check the vibration pads, if provided Check that all the gas, water and air supply lines are connected to the equipment Calibration of equipment Check water and waste matter in the room Has the equipment been screwed or tied up properly with the belts and straps? Is the operation manual kept near the equipment

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Table 14.4 (continued) Point of care Daily Weekly Bi-monthly Monthly Quarterly Biannual Annual Is the equipment when not in use, covered properly Check and ensure that the wheels are intact and in working condition and are freely rotatable. Check the inventory of the equipment, including accessories, attachments, kits, spares, consumables, etc. Cleaning issues Clean equipment, linen, floors, walls, etc. Cleaning and dusting of the equipment Clean print heads of the printers, if any Cleaning of all transducers, probes, connectors Cleaning of filters, if any Infrastructure-related issues Check the temperature of the room Check humidity levels in the room Check fire detection and firefighting devices Check services of pest control treatment in the room

14.11.1 Equipment Checking 1. Preventive Maintenance (PM): Preventive maintenance is performed to extend the operational life of the equipment and to detect and correct problems that are not apparent to the user. PM procedures are planned and performed by the manufacturer of the equipment based on the factors like individual experience, equipment service history, etc. The maintenance services shall include all necessary actions that should be carried out on the equipment. 2. The equipment shall be properly switched on and off as and when required. For shutting down the equipment, standards shut down procedure shall be followed

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and not by just switching off the main supply to the equipment. If done, the software of the equipment may get corrupted. 3. Check the electrical wiring, sockets, plugs and switches at regular intervals, say weekly, and ensure that everything is working fine. If anything is found to be defective or damaged, arrange for an immediate replacement. 4. Daily check the voltage of the electricity and ensure that the constant voltage is received at the equipment end. 5. At regular intervals, check the ground earthing of the equipment or the electrical sockets as the case may be. 6. Ensure that the accessories and the attachments on one piece of equipment shall not be replaced with that of other equipment, even if it is the same item, or of the same make or model. 7. Ensure that the generally required spare parts and accessories are always available in the stores for the continuous operation of the equipment. 8. The audio/visual alarms of the equipment, if any shall be taken seriously. On noticing any such alarm, immediately inform the Biomedical Department for corrective action. 9. If the equipment consists of any pressurised parts like gas or air cylinders, get the pressure testing done at regular intervals, as recommended by the manufacturers of the equipment. 10. Check all the seals, connectors and adapters at regular intervals. If the same is damaged, worn out or leaking, replace them immediately. 11. Most of the medical equipment is provided with battery backup. For hassle-free operations of the equipment, check the battery backup daily. Also, ensure that the batteries are put on continuous charging. If the equipment is not in use for a long duration, it is advised to disconnect the batteries. 12. Further check the battery health at regular intervals. If batteries are found to be worn out, replace them with new batteries. 13. Check all the bulbs, heaters, etc. of the equipment on regular basis. If any defect is noticed, inform the Biomedical Department to replace them immediately. 14. Replace oil, paper, electrodes, lamp and other consumable items as per the schedule recommended by the manufacturer of the equipment. 15. Check all the rubber parts as per the predefined schedule provided by the manufacturer. If any part is noticed to be torn, worn out or damaged, arrange for replacement from the Biomedical Department. 16. Check the vibration pads, if provided and ensure that they are in working condition. If required, the request shall be sent to the service department of the manufacturer to replace the pads. 17. At regular intervals, check that the equipment is properly screwed to the foundation. If any looseness is noticed, inform the Biomedical Department to take care of the defect. 18. Daily check that all the gas, water and air supply lines are connected to the equipment, whereever required, e.g. oxygen lines are connected to the ventilators, nitrous oxide lines to the anaesthesia work station, line for compressed air to the ventilator and pneumatic tools, CO2 line to the insufflator, etc.

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19. Calibrate the equipment on regular basis as per the schedule provided by the manufacturer of the equipment. 20. It shall be strictly ensured that only recommended regents/kits/disposable/consumables are used during the operations of the equipment. No local, substandard or non-recommended material shall be used in the equipment. 21. Then, equipment shall always be screwed or tied up properly with the belts and straps. This will prevent the equipment from falling and avoid damage to the equipment. 22. Operation manual shall be kept near the equipment so that in case of any requirement the same can be referred to immediately. 23. Please ensure that the equipment when not in use shall be properly covered with the help of a water-resistant cover to prevent equipment from dust and liquid spilling. 24. Minor breakdown shall be attended to immediately and ratified to prevent any big damage to the equipment. 25. If the equipment is a portable type, ensure that the wheels are intact and in working condition and are freely rotatable. The wheels shall be cleaned, oiled or greased at regular intervals. 26. While moving the portable equipment to another location, the movement shall be very polite. Sudden breaking, jerks and hitting shall be avoided as they may damage the equipment or any part thereof. 27. While moving, ensure that the equipment is handled strongly, to prevent dropping the equipment and getting damaged. 28. Check the inventory of the equipment, including accessories, attachments, kits, spares, consumables, etc. at regular intervals to assess any variation. 29. The instruction for handling the equipment shall be very clearly given by the management. While giving such instructions, please ensure that no unauthorised and unexperienced person shall be allowed to handle the equipment under any circumstances. 30. It is advised that every piece of equipment in the hospital shall have a maintenance checklist, which shall be placed near the equipment and shall be regularly maintained by the user and audited by the Biomedical Engineer.

14.11.2 Cleaning Issues 1. Clean equipment, linen, floors, walls, etc. to make the area and equipment relatively free from pathogenic organisms. The rooms where the equipment is installed shall be cleaned at least once a day. If required, it can be cleaned more than once also. The method of cleaning the floor depends upon the type of floor. Generally, the floors are mopped with mops. Vacuum cleaners can also be used wherever required. The floor may be washed with detergent or soap at regular intervals. The abrasives, the acids or the alkalise should be avoided to be used. If the floor stains, the stain remover should be used to clean the stain. The wooden

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floor should be kept well-polished. These should be mopped regularly. The water should be wiped off immediately to prevent staining. Cement floors can be cleaned with mild alkaline solutions such as soap, detergent, soda carb, etc. Occasionally polishing the floor keeps the floor surface glazing. For walls, the method of cleaning depends upon the type of walls. Cement or marble walls can be cleaned in the same way as floors. On the painted wall, never use acid or alkalise as it may damage the painted surface, but the usage of a damp cloth can clean the surface. 2. Due to the continuous use of the equipment, being exposed to dirt and continuous touch by the operators and the patients, it is natural that the equipment will get dirty. Either the dust will accumulate on the equipment or the body of the equipment can become black due to continuous touches. Hence, regular cleaning and dusting of the equipment is necessary. Therefore, it is suggested that at least once a week, the equipment shall be dusted with a clean cloth (if necessary, use a low-suction vacuum cleaner). Thereafter, the panel and body of the equipment shall be scrubbed with soft cleaning solutions and dry it with a dry soft cloth. Avoid using harsh chemicals. 3. As medical equipment is a very delicate and sophisticated item and may easily get damaged if handled by an unexperienced or unauthorised person. Hence, none of these persons shall be allowed to touch the equipment even for cleaning. This type of equipment shall be cleaned by the user or technician him/ herself. He/she shall clean the main equipment and all the accessories and attachments. 4. The print heads of the printers, if any, shall be regularly cleaned according to the instructions given by the manufacturers. 5. As far as the diagnostic and operative endoscopes are concerned, shall be properly rinsed, dried and disinfected by the technicians him/herself. The cleaning process, as prescribed by the manufacturer, shall be strictly adhered to. 6. All the transducers, probes and connectors shall be cleaned with non-alcoholic tissues of the cloth, after every use. 7. The filters if any shall be cleaned routinely whether by blowing air or washing, as suggested by the manufacturer of the equipment. 8. Spilling of any type of liquid on the equipment can damage the equipment and may need major repairs. Hence, it shall be ensured that the spilling of water or any type of liquid is prevented. For this, the staff shall be instructed to keep the liquids away from the equipment. Further, if the equipment is not in use, cover it with water-resistant covers. 9. Surgical instruments and tools shall be cleaned and sterilised according to the protocol for cleaning them. The surgical instruments shall be pre-washed after every surgery. After pre-wash, the same shall be sent to the sterilization department for sterilization as per the protocol. Sharp edge instruments shall not be sterilised and shall be disinfected by the chemical.

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14.11.3 Infrastructure-Related Issues 1. Nowadays, most medical equipment is an electronic circuit based, which requires a particular environmental condition to work efficiently. Further, some of the equipment may have tubes and other components which decapitate heat, which may require more cooling. Considering these issues, the environmental condition like temperature and humidity are very important (or to be said, the lifeline) of the equipment. If proper climatical conditions are provided in the room, the equipment will function efficiently and the life of the equipment may also increase. 2. As far as the temperature of the room is concerned, every piece of equipment may have a different requirement. E.g. the room temperature in the case of MRI will be different, CT scan may require a different temperature and the modular operating room may require different temperatures and air exchanges, etc. Hence, the air-conditioning system of the hospital shall be very effective and designed carefully. As far as the temperature of the equipment room is concerned, please obtain guidelines from the original manufacturer while planning the same. However, routine equipment and instruments may require a temperature ranging between 20 degrees centigrade and 24 degrees centigrade. 3. As in the case of temperature, the humidity levels are also equally important for medical equipment to operate and work efficiently. The more the humidity, the more will be the breakdowns of the equipment. Hence, the humidity control system of the hospital shall be very effective and designed carefully. Therefore, while planning the same, please obtain guidelines from the original manufacturer. However, routine equipment and instruments may require a humidity level ranging between 50%rh and 60%rh. 4. The spaces provided shall be adequately secured and shall be lockable. No unauthorised person shall be allowed to enter that space. If required, the spaces shall be properly guarded. 5. The room where the equipment is installed, shall be adequately provided with cupboards, shelves, tables, counters, etc. to safely place the equipment and to store the attachments and accessories when not in use. 6. The equipment room shall be dust and insect free. Proper doors with door springs shall be provided. If required, the air curtains can also be used. Windows of the rooms shall preferably be fixed and non-openable type. 7. Equipment room shall have all the provisions for necessary gadgets for fire detection and firefighting like smoke detectors and sprinklers (if recommended) to handle the fire in case it happens. 8. Arrangements shall be done for regular pest control treatment in the room, and the room shall be free from rodents, insects and particularly rats. 9. Sky lightning may be a cause of major damage to the equipment in the hospital. Hence, the lightning arrestors shall be installed on the rooftop of the hospital and shall be effectively ground-earthed.

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14.11.4 Other Issues 1. Ensure that regular refresher training is provided to the users of the equipment to make them aware of how to handle, operate, maintain and care for the equipment. 2. The medical equipment shall be properly insured for any such loss due to a major breakdown, fire, flood or earthquake.

14.12 Condemnation, Disposal and Replacement of the Equipment Every medical equipment in the hospital will reach a stage where the life of the equipment has ended.

14.12.1 Reasons for Replacement and Condemnation There are various reasons why the equipment may have to be discontinued from use and have to be condemned and replacement taken with a piece of new equipment. These reasons can be like –– –– –– –– –– –– –– –– –– –– –– ––

The cost–benefit ratio falls due to decreased dependability. Increased downtime. High repair costs or beyond economical repairs. Recurrent breakdowns of the equipment. Nonavailability of spare parts. Operations are hazardous and other safety issues. Compromised care. Increased operating costs. Changing regulations. Functional but obsolete. Simply obsolete technologies. The manufacturer declared the equipment as the end of life and service support is withdrawn. –– Very rare use of equipment or equipment not required at all.

14.12.2 Life Span of Medical Equipment In any hospital set-up, there are a lot of medical equipment, devices, tool and instruments and each of them has its own specific requirement and use. These can be very small and low-valued items like stethoscopes and sphygmomanometers etc.,

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medium-valued items like multipara monitors, etc. and high-valued items like linear accelerators, MRI, etc. Usually, for these low-value items, the life spans are not strictly defined or determined. Hence, these items shall be condemned and replaced as and when it is beyond repairs. Medium-valued items like monitors, ventilators, ultrasound machines and X-ray machines, usually have a defined lifespan. If we talk about developed countries, the lifespan generally is considered to be 5–7 years. However, in developing countries or underdeveloped countries, the lifespan can be up to 10 years. Few countries have their own laid-down rules, regulations and guidelines for replacement of the medical equipment, devices, tools and instruments. If we talk about surgical instruments, the replacement depends on the efficient working of the instruments, e.g. if the sharpness of the scissors has gone out, the same shall be replaced. Similarly, the forceps, if the grasping power of the forceps is not good, it shall be replaced.

14.12.3 Condemnation Process For the Condemnation of the medical equipment, devices, tools and instruments, there shall be set laid down guidelines for the hospital and everyone shall follow those set of guidelines. The general procedure to be followed shall be as: 14.12.3.1 Condemnation Committee For the condemnation of any medical equipment, device, tools or instrument, the condemnation committee shall be formed. It is this committee where the proposal for condemnation shall be placed. The committee shall then evaluate the condemnation proposal and decide whether or not an item/equipment should be condemned. The recommendation should be based on the user department’s recommendation, history/log sheet/alternative location of use and so on. The committee may be construed with the following members: • • • • • • • •

Head of the concerned department (HOD) where the equipment is being used. Designated Medical Officer. Head of the Biomedical Department. A representative from Finance Department. A representative from Procurement Department. A representative from the Stores. A representative from the Administration Department. Any other member as nominated by the competent authority of the hospital.

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14.12.3.2 Proposal and Request for Condemnation At the request of the user, the head of the department where the equipment is installed shall prepare the proposal and request for condemnation and replacement of the equipment, device, tool or instrument. While preparing the proposal, the head of the department shall check the history and life of the equipment. Also, he/she shall check the repair history of the item to be condemned. If he/she is satisfied and falls in one of the reasons for condemnation, he/she shall prepare the proposal and request letter. Copies of the proposal and request letters shall be sent to all the members of the condemnation committee well in advance so that the members of the committee can review the case before attending the committee meeting. The committee shall examine every proposal and, after a thorough assessment, shall follow the guidelines for the condemnation of equipment. The committee shall assess the life of the equipment that it has lived in. If the equipment is functioning well beyond its life shall continue to be used. However, depending upon its usage, availability of the backup of services and repairs, technology and other related factors, equipment may be continued to be used even after the end of its life of the equipment. Under the following circumstances, the medical equipment, devices, tools and instruments shall be considered for condemnation and replacement. 1. If substantial repairs have already been carried out during the lifespan of the equipment, it is expected that in future the higher costs of repairs are expected. 2. The equipment is nonfunctional, and the expected repair cost is equal to or more than 50% of the procurement cost of the equipment. 3. For equipment, which is nonfunctional and certified as non-reparable by the service agency/manufacturer due to the nonavailability of spare parts, irrespective of the asset life, the equipment can be considered for condemnation and replacement. 4. If the equipment is undergoing breakdown frequently, the dead time is more. 5. For equipment which is obsolete or hazardous or there are any other safety issues, irrespective of the equipment’s life or functionality, it shall be considered for condemnation. 6. In case, the cost of regents, kits and consumables used in that particular equipment has increased enormously and the per test has increased and is not feasible to carry out the procedure. 7. Even after the setting, calibrations etc., the equipment is not providing the expected results. 8. In case, the technology of the equipment is outdated and not useful or new advanced technology is available. 9. At the time, the regulation, rules or guidelines of the Government changes and restricts the use of a particular technology, in that case, the equipment shall be condemned. In some cases, equipment like X-ray and nuclear scan machines, which have been licensed, if condemned, has to be brought to the notice of the licensing

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authority. This equipment has to be decommissioned and information has to be sent to the licensing authority before disposal. In case, the procurement cost of the equipment is not available due to any reason, then the current cost of the same make and model or equivalent make or model can be used to assess the acceptable cost for repair. The recommendation of the Condemnation Committee shall be put up to the competent authority for final approval. Ongoing Annual Maintenance Contract/Comprehensive Maintenance Contract for such equipment, if any, shall be terminated from the effective date of condemnation. The condemnation committee shall issue a certificate certifying that the equipment is nonfunctional and irreparable, as well as the reasons for irreparability and that it has been declared condemned. 14.12.3.3 Disposal of the Equipment Once the equipment has been condemned, it has to be disposed of. There are various issues involved for disposal. The condemned medical equipment, devices, tools and instruments shall be decontaminated before disposal. Disposal of equipment must follow safety procedures to protect people and the environment. As most medical equipment, these days is electronic-based, after condemnation will generate E-waste. For the disposal of E-waste, most countries have set rules, regulations and guidelines. The hospital is bound to follow those guidelines. Disposal as scrap: If the equipment is disposed of as scrap, it shall be clear that if E-waste has been generated after condemnation, the same has to be disposed of only to the licensed and approved vendor. It shall not be otherwise disposed of by any other person. If it is normal scrap and not E-waste, it can be disposed of by any scrap dealer in the market. Returns to vendors: If the hospital is planning to purchase new equipment, the vendor of the new equipment may allow the buy back of the old and condemned equipment. This may help the hospital in saving some costs of new equipment.

14.12.4 Replacement of the Equipment After the condemnation of the equipment, the request for the replacement shall be placed by the concerned head of the department where the equipment has to be used. For replacement, the entire process of procurement, as is done in the case of new equipment shall be repeated.

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However, in case the vendor is prepared to buy back the condemned equipment at an attractive amount, the preference shall be given to that particular vendor for procurement of the new equipment.

Further Reading Garg A, Dewan A.  Manual of hospital planning and designing for medical administrators, architects, and planners. Chapter 49, Equipment Planning. India, Springer Singapore; 2022. p. 501–27.

Chapter 15

Department Wise Equipment Detailing

As stated earlier in Chap. 14 of this book, the selection of the medical equipment, instruments, machines and tools required in the hospital varies from one hospital to the other. The choice of equipment to be procured totally depends on various factors like: 1. Which all speciality and super speciality medical departments the promoters are planning to make operative in the hospital? These can be like General Medicine, General Surgery, Paediatric, Gynaecology, Urology, Cardiology, Neurology, etc. 2. Which all medical equipment is required for a particular medical speciality? 3. Which investigation departments are to be provided in the hospital, like radiological and clinical laboratory, etc.? 4. What will be the level of investigations? Will it be the routine investigations or will it be the highly specialised investigations? Some hospitals may plan only for basic investigations like X-rays, ultrasound, etc., whereas others may decide to have CT scans and MRIs also. Still further, some may like to have PET-­CT also. 5. Is the hospital planning to outsource any department like Radiology, Oncology, etc.? 6. What will be the level of the medical equipment? Will it be a low-ended machine or otherwise a high-ended machine with the latest technology? 7. The functionality of the equipment. 8. Frequency of use of the equipment. 9. The financial cost of the equipment. 10. Income likely to be generated by the equipment. 11. Period of return on investment for the equipment. 12. The useful life of the equipment. 13. Determine equipment reuse and relocation options. 14. Expected technology changes in the equipment. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_15

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Therefore, very careful and in-depth planning is required for choosing the medical equipment to be procured. Similarly, deciding the specification and configuration of the equipment is a more cumbersome process. While planning, the planner shall understand equipment preferences, concerns and priorities after conducting interviews with the departmental heads. He/she shall also review the architectural drawing and details to ensure that all the elements of the building fulfil the requirement for the efficient functioning of the equipment. Almost every medical equipment, machinery and tool to be installed in the hospital may have some specific requirements for installation of such equipment, machinery and tools. These requirements can be related to the civil infrastructure, electrical requirements, environmental conditions, cleanliness, sterility, security, etc. Mentioning all such requirements in detail is not feasible because first each manufacturer of such equipment, machinery and tools may have a different requirement and that also may vary from one country to another. However, we have tried to brief out some of the general requirements which the manufacturers normally ask for. For detailed installation requirements of any equipment, machinery and tools, it is better to contact the manufacturer of such items. With the growing technologies in the medical industry, there is a huge list of medical equipment, machinery, instruments and tools that can be installed in the hospital. It is not possible to compile a list of all the medical equipment available in the market today, but we have tried to list out a few of them along with the purpose for which it is used. The below exercise will make the task of choosing a bit easier for the planner and promoter. However, the final list of equipment to be purchased shall entirely depend on the team of experts and the users, considering the budget that has been allotted for this purpose.

15.1 Emergency and Triage See Table 15.1. Air Bed: Air bed is a mattress to prevent bed sores and also relieve pain from pressure spots, sore spots and pressure ulcers. Anaesthesia Workstation: This device is used for the administration of anaesthesia to patients before and during surgical procedures. This machine can mix and control the flow of oxygen and nitrous oxide along with the anaesthetic vapour and deliver this to the patient continuously at a safe pressure and flow. Requirements of Infrastructure for Installation, Commissioning and Testing of Anaesthesia Workstation: For details of infrastructure requirements for installation, commissioning and testing of the anaesthesia workstation, please refer to Sect. 15.22 under the heading of ‘Operating Room’ in this chapter. Analysers Blood Gas/Ph: This analyser is to determine pH levels and partial pressure of oxygen and carbon dioxide in the blood.

15.1 Emergency and Triage

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Table 15.1  Emergency and triage

Activity Air bed Anaesthesia workstation Analyser blood gas/pH Bipap machine Blood warmer Boyles machine C arm (image intensifier) Camera HD for laproscopes CT scan Defibrillator DVT pump ECG machine Echocardiogram Elec. surgical cautery Electrolyte analysers Head light Haemoglobinometer High flow nasal cannula Infusion pumps Insufflator Invasive ventilators Laparoscopic set LED monitor medical grade for laparoscopes Light source with fibre optic cable for laparoscopes Microprocessor-­ controlled electrosurgical unit Modular operation theatre with pendants MRI Multipara monitor Multipara monitor with ETCO2 Muscle stimulator OT light

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::::::::::::::::::::::::-

:-

::::::(continued)

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Table 15.1 (continued)

Activity OT Pneumatic tourniquet electric Portable OT light Recording system Scrub station two/three bay Suction machine Surgical operating instruments Syringe pumps Telescopes of laparoscope Ultrasound machines UPS 10 KW Vaporiser X-ray DR system stationery/portable

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::::::::::::-

Bipap Machine: This is a noninvasive ventilator and is used to supply pressurised air in the airway of the patient. Blood Warmer: Sometimes before transfusion to the patient, the fluids or blood needs to be heated. Blood Warmer is the machine used for this purpose. Boyles Machine: Boyles machine is a device to mix medical gases along with the accurate concentration of anaesthetic vapour and delivers this to the patient continuously at a safe pressure and flow. Requirements of Infrastructure for Installation, Commissioning and Testing of Anaesthesia Boyles Machine: For details of infrastructure requirements for installation, commissioning and testing of the Boyles machine, please refer to Sect. 15.22 under the heading of ‘Operating Room’ in this chapter. C-ARM: C-arm is an X-ray-based imaging intensifier. The CCD camera/X-ray detector and the X-ray source are mounted on the C-shaped arm in the opposite direction to each other. C-arm is used for fluoroscopic intraoperative imaging during surgeries and procedures. Requirements of Infrastructure for Installation, Commissioning and Testing of C-Arm Machine: For details of infrastructure requirements for installation, commissioning and testing of C-Arm, please refer to Sect. 15.22 under the heading of ‘Operating Room’ in this chapter.

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Camera HD: The HD camera is a part of the endoscopic set and is used to record high-resolution, full-featured, colour, multiformat images. The camera is mounted on the distal end of the endoscope to provide an unobstructed view of the surgical site. Computed Tomography (CT): CT is basically a computerised X-ray imaging machine where a narrow beam of X-rays is aimed at a patient and the gantry is rotated around the body at a high speed. These X-ray beams after passing through the body of the patient are captured by the detectors and sent to the processing unit for processing. In the processing unit, the cross-sectional images or slices of the body are generated. This is also called the spiral CT. Requirements of Infrastructure for Installation, Commissioning and Testing of CT Scan: For details of infrastructure requirements for installation, commissioning and testing of CT Scan, please refer to Sect. 15.23 under the heading of ‘Radiology’ in this chapter. Defibrillator: Defibrillator sends an electric pulse or shock to the heart which restores the normal heartbeat. The defibrillator is also used to prevent or correct arrhythmia. Defibrillators can also be useful in restoring the heart’s beating, in case the heart suddenly stops. This device is also a life-saving device. DVT Pump: DVT Pump is a pneumatic compression pump which is designed to prevent the patient from developing deep vein thrombosis (DVT). This pump delivers a set pressure resulting in increased blood flow in the venous system of the limbs, which prevents blood clotting. ECG Machine: ECG machine (electrocardiograph) is used to measure and record the electrical activity of the heart. Echocardiogram: Echocardiogram is used to see the anatomy of the heart. Echocardiography also allows monitoring of the functioning of valves of the heart. It also gives information about blood clots in the heart chambers. Elec. Surgical Cautery: Electrosurgical is used to cut and cauterise the tissue with a pencil-like probe attached to the machine. Electrolyte Analysers: Electrolyte analysers measure electrolytes in serum, plasma and urine. Head Light: Headlight is a LED light fitted with microscopic lenses and is used for microsurgery or routine examination also. Haemoglobinometer: A haemoglobinometer is used to measure haemoglobin blood concentration. High-Flow Nasal Cannula: High-Flow Nasal Cannula (HFNC) is a nasal cannula to provide very high oxygen flow rates. Requirements of Infrastructure for Installation, Commissioning and Testing of High-Flow Nasal Cannula: As HFNC is used to provide very high levels of oxygen, an oxygen port shall be provided near the HFNC machine. As the oxygen quantity required is very high, the supply source should be liquid oxygen. As a backup, it is advised to provide one spare port of oxygen, so that it can be used in case of failure of the working port.

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Infusion Pumps: An infusion pump is to deliver fluids, such as medications and nutrients, into the patient’s body in preset and controlled amounts or volumes. Insufflator: Insufflator is to blow CO2 in the stomach while performing laparoscopic surgery. Invasive Ventilators: Invasive mechanical ventilator is a life-saving device used after intervention for patients suffering from respiratory or breathing problems. The primary purpose of mechanical ventilation is to provide oxygen to the patient, remove CO2, decrease the efforts involved in breathing and reverse life-threatening conditions such as hypoxaemia, insufficient oxygenation of arterial blood, acute progressive respiratory acidosis or build-up of CO2 in the blood. Requirements of Infrastructure for Installation, Commissioning and Testing of Invasive Ventilator: The invasive ventilator with the help of compressed air mixes the oxygen and forces it into the lungs of the patient, hence providing supportive breathing. Therefore, the ventilator requires compressed air and oxygen to ventilate the patient. Hence, apart from the routine installation requirements, the ports of centralised compressed air (4  bar) and oxygen shall be provided near the ventilator. As a backup, it is advised to provide one spare port for both the air and oxygen, so that it can be used in case of failure of the working port. Laparoscopic Set: Laparoscopes are thin telescopes fitted with a cold light source and a video camera on the distal end. These scopes pass inside the body, and the image is captured by the camera under brighter conditions and displayed on the screen. The laparoscopic instruments are passed inside the body through the laparoscope, and the desired surgery is performed. LED Monitor Medical Grade: A LED medical monitor is a monitor that meets the high demands of medical imaging. Medical displays usually come with special image-enhancing technologies to ensure consistent brightness, noise-free images, ergonomic reading and automated compliance with DICOM and other medical standards. Light Source with Fibre-optic Cable: A fibre light source is to produce high-­ intensity light and transmits it to the tip of the laparoscope/endoscope through the fibre-optic cable. The light source is available with halogen bulbs or LED bulbs. Microprocessor-Controlled Electrosurgical Unit: ESU is a surgical cautery for cutting and cauterisation but is controlled by the fast microprocessor processing all operating parameters. Modular Operation Theatre with Pendants: Modular operating theatre is a theatre built-up with modules having a provision of air filtration through HEPA filters and airflow in a laminar style. It consists of a modular wall, ceiling with slanted panels, plenum, control unit, PDR and HEPA filters with a provision of laminar flow to maintain the positive pressure in the OR. The OR has the facility of electrical points and medical gas outlets along with surgical or anaesthetic pendants. Requirements of Infrastructure for Installation, Commissioning and Testing of Modular Operating room:

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For details of infrastructure requirements for installation, commissioning and testing of Modular Operating Rooms, please refer to Sect. 15.22 under the heading of ‘Operating Rooms’ in this chapter. Magnetic Resonance Imaging (MRI): Magnetic resonance imaging (MRI) is a magnetic and radio frequency-based machine. The machine uses a high-power magnetic field and computer-generated controlled radio frequency waves to create detailed images of the organs and tissues of the body. Magnetic fields align the protons of the cell in a unidirectional fashion. Then, the radiofrequency waves are fired on the protons, due to which the protons oscillate. This oscillation is captured by the machine, and an image is produced. Requirements of Infrastructure for Installation, Commissioning and Testing of MRI: For details of infrastructure requirements for installation, commissioning and testing of MRI, please refer to Sect. 15.23 under the heading of ‘Radiology’ in this chapter. Multipara Monitor: This monitor is used to keep track of the vital of the patient. Generally, the fixed parameters are blood pressure, heart rate, respiratory rate, pulse oximetry and temperature. Apart from these fixed parameters, other parameter modules can be attached to the device like EtCo2, etc. Muscle Stimulator: Muscle Stimulator machines also go by the name of EMS (electrical muscle stimulator); it is basically an electronic machine that can contract the muscles via an electrical current passed through muscles. OT Light: An operating table (OT) light is a ceiling-mounted LED light with adjustable high-lumen light used for surgery. These lights are shadowless, and no heat is generated. The light is used to aluminate the surgical field. OT: An operating table is a table where the patient is laid down for surgery. The table has a provision for multipositional adjustments and provisions to attach the required attachments to ease the surgery. The table can be operated hydraulically, electrically or a combination of both. Pneumatic Tourniquet Electric: Pneumatic tourniquet is to apply pressure on the arterial blood flow, through cuffs, in a limb to create a bloodless surgical field. The cuffs are inflatable, and the machine consists of a pressure-regulated control unit. Portable OT Light: A portable OT light unit with battery backup and the flexibility of clamping it to an OT. Recording System: A recording system is used to record the live and still images in HD format, from the endoscopes/laparoscopes during surgeries. These captured images can either be displayed on the screen or can be saved for later revival. Scrub Station: Scrub sink is used by surgeons and other surgical staff for scrubbing before surgery. Scrub sinks are normally foot-operated, sensor-operated or hand-operated. Requirements of Infrastructure for Installation, Commissioning and Testing of Scrub Station:

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For details of infrastructure requirements for installation, commissioning and testing of the Scrub Station, please refer to Sect. 15.22 under the heading of ‘Operating Room’ in this chapter. Suction Machine, Electrical: A suction machine is a tracheostomy-care device used to remove any obstruction from a patient’s airway. The machine uses the technique of suction to pull out mucus, saliva, blood, secretions or other fluids stuck up in the airway, hence clearing the airway for easy breathing. Surgical Operating Instruments: For any type of surgery, the surgeon apart from equipment needs a set of instruments to perform surgeries. The basic instruments are like scissors, artery forceps, BP handle, Babcock, retractor, needle holder, dissecting forceps, speculum, etc. Further, every item of an instrument may have different variants based on shapes and sizes. Syringe Pumps: To gradually administer specific amounts of fluids to the patient (which has been preset), the syringe pump is used. Telescopes: The telescopes transmit light coaxially through each barrel to provide converging light at the operative sight. The telescopes eliminate the need for constant realignment of loupes and headlights. Ultrasound Machine: An ultrasound machine is used to take images of organs inside the body using the technique of high-frequency ultrasound waves. This machine sends out high-frequency sound waves, in the body, which reflect off body structures. A computer receives the reflected waves and considering the time lag of receiving the waves from different tissues of the body, creates a picture. UPS 10 KW: Uninterrupted power system (UPS) is to provide power backup to the electrical devices in case of power failure. UPS shall be provided in every operating room. Depending on the factors like the electrical load of the OR, the load of the medical equipment to be connected for power backup, the duration of power backup required, etc., the rating of the UPS shall be worked out. However, it is recommended that the rating of 10 KW with 30 min backup shall be provided in the OR. Vaporiser: Vaporiser is a device used to vaporise substances for inhalation. X-Ray Machine DR systems: Digital radiography (DR) is the machine wherein the X-rays are directly received by the detectors. These X-ray photons are directly converted into a digital image and are sent to the processing unit for further management of the image. Requirements of Infrastructure for Installation, Commissioning and Testing of X-ray machine: For details of infrastructure requirements for installation, commissioning and testing of X-Ray Machine/DR Systems, please refer to Sect. 15.23 under the heading of ‘Radiology’ in this chapter.

15.2 Indoor Wards and Patient Rooms See Table 15.2. Air Bed: Air bed is a mattress to prevent bed sores and also relieve pain from sore spots, pressure spots, and pressure ulcers.

15.2 Indoor Wards and Patient Rooms

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Table 15.2  Indoor wards and patient rooms Status of works Activity Air bed Analysers blood gas/pH Bipap machine Blood warmer Defibrillator ECG machine Infusion pumps Multipara monitor Pulse oximeter Suction machine Syringe pumps X-ray DR system portable

Start date

End date

Not Responsible Complete In-progress started person

Remarks

::::::::::::-

Analysers Blood Gas/Ph: This analyser is used to determine pH levels, and partial pressure of carbon dioxide and oxygen in the blood. Bipap Machine: This is also called a non-invasive ventilator and is used to supply pressurised air into the airway of the patient. Blood Warmer: At times the blood or fluids needs to be heated before transfusion to the patient. For this, the blood warmer is used. Defibrillator: Defibrillator sends an electric pulse or shock to the heart which restores the normal heartbeat. The defibrillator is also used to prevent or correct arrhythmia. Defibrillators can also be useful in restoring the heart’s beating, in case the heart suddenly stops. This device is also a life-saving device. ECG Machine: ECG machine (electrocardiograph) is used to measure and record the electrical activity of the heart. Infusion Pumps: An infusion pump is to deliver fluids, such as medications and nutrients, into the patient’s body in preset and controlled amounts or volumes. Multipara Monitor: This monitor is used to keep track of the vital of the patient. Generally, the fixed parameters are blood pressure, heart rate, respiratory rate, pulse oximetry and temperature. Apart from these fixed parameters, other parameter modules can be attached to the device like EtCo2, etc. Pulse Oximeter: A pulse oximeter is a noninvasive equipment used to measure oxygen saturation level or the oxygen levels in the blood. Suction Machine Electrical: A suction machine is a tracheostomy-care device used to remove any obstruction from a patient’s airway. The machine uses the technique of suction to pull out mucus, saliva, blood, secretions or other fluids stuck up in the airway, hence clearing the airway for easy breathing.

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Syringe Pumps: To gradually administer specific amounts of fluids to the patient (which has been preset), the syringe pump is used. X-Ray Machine DR System Portable: Portable X-ray Digital radiography (DR) is basically an X-ray machine with lower intensity and can be easily taken from one place to another. Requirements of Infrastructure for Installation, Commissioning and Testing of X-ray Machine: For details of infrastructure requirements for installation, commissioning and testing of the X-Ray machine, please refer to Sect. 15.23 under the heading of ‘Radiology’ in this chapter.

15.3 Intensive Care Units (ICU’S) See Table 15.3. Air Bed: Air bed is a mattress to prevent bed sores and also relieve pain from sore spots, pressure spots and pressure ulcers. Table 15.3  Intensive care units (ICUs) Status of works Activity Air bed Analysers blood gas/pH Bipap machine Blood warmer Defibrillator DVT pump ECG machine Echocardiogram Electrolyte analysers High-flow nasal cannula Infusion pumps Invasive ventilators Multipara monitor Syringe pumps Ultrasound machine X-ray DR system portable

Start date ::::::::::::::::-

End date

Not Responsible Complete In-progress started person

Remarks

15.3 Intensive Care Units (ICU’S)

367

Analysers Blood Gas/Ph: This analyser is used to determine pH levels, and partial pressure of carbon dioxide and oxygen in the blood. Bipap Machine: This is also called a non-invasive ventilator and is used to supply pressurised air into the airway of the patient. Blood Warmer: Sometimes before transfusion to the patient, the fluids or blood needs to be heated. Blood warmer is the machine used for this purpose. Defibrillator: Defibrillator sends an electric pulse or shock to the heart which restores the normal heartbeat. The defibrillator is also used to prevent or correct arrhythmia. Defibrillators can also be useful in restoring the heart’s beating, in case the heart suddenly stops. This device is also a life-saving device. DVT Pump: DVT Pump is a pneumatic compression pump which is designed to prevent the patient from developing deep vein thrombosis (DVT). This pump delivers a set pressure resulting in increased blood flow in the venous system of the limbs, which prevents blood clotting. ECG Machine: ECG machine (electrocardiograph) is used to measure and record the electrical activity of the heart. Echocardiogram: Echocardiogram is used to see the anatomy of the heart. Echocardiography also allows monitoring of the functioning of valves of the heart. It also gives information about blood clots in the heart chambers. Electrolyte Analysers: Electrolyte analysers measure electrolytes in serum, plasma and urine. High-Flow Nasal Cannula: High-Flow Nasal Cannula (HFNC) is a nasal cannula to provide very high oxygen flow rates. Requirements of Infrastructure for Installation, Commissioning and Testing of High-Flow Nasal Cannula: As HFNC is used to provide very high levels of oxygen, an oxygen port shall be provided near the HFNC machine. As the oxygen quantity required is very high, the supply source should be liquid oxygen. As a backup, it is advised to provide one spare port of oxygen, so that it can be used in case of failure of the working port. Infusion Pumps: An infusion pump is to deliver fluids, such as medications and nutrients, into the patient’s body in preset and controlled amounts or volumes. Invasive Ventilators: Invasive mechanical ventilator is a life-saving device used after intervention for patients suffering from respiratory or breathing problems. The primary purpose of mechanical ventilation is to provide oxygen to the patient, remove CO2, decrease the efforts involved in breathing and reverse life-threatening conditions such as hypoxemia, insufficient oxygenation of arterial blood, acute progressive respiratory acidosis or build-up of CO2 in the blood. Requirements of Infrastructure for Installation, Commissioning and Testing of Invasive Ventilator: The invasive ventilator with the help of compressed air mixes the oxygen and forces it into the lungs of the patient, hence providing supportive breathing. Therefore, the ventilator requires compressed air and oxygen to ventilate the patient. Hence, apart from the routine installation requirements, the ports of centralised compressed air (4  bar) and oxygen shall be provided near the ventilator. As a

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backup, it is advised to provide one spare port for both the air and oxygen so that it can be used in case of failure of the working port. Multipara Monitor: This monitor is used to keep track of the vital of the patient. Generally, the fixed parameters are blood pressure, heart rate, respiratory rate, pulse oximetry and temperature. Apart from these fixed parameters, other parameter modules can be attached to the device like EtCo2, etc. Syringe Pumps: To gradually administer specific amounts of fluids to the patient (which has been preset), the syringe pump is used. Ultrasound Machine: An ultrasound machine is used to take images of organs inside the body using the technique of high-frequency ultrasound waves. This machine sends out high-frequency sound waves, in the body, which reflect off body structures. A computer receives the reflected waves and considering the time lag of receiving the waves from different tissues of the body, creates a picture. X-Ray Machine DR systems: Digital radiography (DR) is the machine wherein the X-rays are directly received by the detectors. These X-ray photons are directly converted into a digital image and are sent to the processing unit for further management of the image. Requirements of Infrastructure for Installation, Commissioning and Testing of X-ray machine: For details of infrastructure requirements for installation, commissioning and testing of the X-ray machine, please refer to Sect. 15.23 under the heading of ‘Radiology’ in this chapter.

15.4 Robotic Surgery See Table 15.4. Robotic systems are used for robotic surgery. In this technique, the patient is laid on the OT and the surgeon gives a command from the joystick from the control room and the arms of the robot, fitted with the desired surgical instruments, is to Table 15.4  Robotic surgery

Activity Surgical robot with :master control, magnified 3D HD vision, slave control, foot pedals for electrosurgery, clutch for camera and instrument control, surgical manipulator; endo wrist functionality; etc.

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

15.5 Cardiology and Interventional Cardiology

369

perform the surgery. Mainly, it is not only used for urological surgeries, but also now being used for cardiac surgeries, GI surgeries and plastic surgeries. The set-up includes surgical robot with master control, magnified 3D HD vision, slave control, foot pedals for electrosurgery, a clutch for camera and instrument control, a surgical manipulator, endowrist functionality, etc.

15.5 Cardiology and Interventional Cardiology See Table 15.5. ACT Machine: Activated clotting time (ACT) is used to monitor anticoagulation effects, after administration of an intense amount of anticoagulation medicines like heparin. ACT machine is used to monitor the activated clotting time, during and shortly after surgeries that may require higher doses of anticoagulation medicines, such as CTVS, interventional cardiology, etc. Table 15.5  Cardiology and interventional cardiology

Activity ACT machine Ambulatory ABP monitor Cath lab Defibrillator, high energy (including paddles) Electrophysiology lab Electrocardiograph (ECG) Gamma camera Holter monitoring system Hypothermia device (blanket, plumbing and heat exchanger) Instruments for Cath Lab Intra-aortic balloon pump Pacemaker temporary TEE probe with ultrasound Tilt test table TMT

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::::-

:::::-

::::::-

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Ambulatory ABP Monitor: Ambulatory blood pressure (ABP) monitor is to monitor the blood pressure continuously at specified intervals over 24 h and thus get an overall profile of blood pressure variation in a day. Cath Lab: A Cath Lab is an imaging equipment used to see the conditions of the arteries and check how well blood is flowing to and from the surface of the heart. Cath Lab helps to diagnose and treat blockages that may have occurred in the arteries. It is used to perform procedures like coronary and peripheral angioplasty, angiography, cardiac catheterisation, atherectomy, stent implantation, thrombectomy, etc. Requirements of Infrastructure for Installation, Commissioning and Testing of Cath Lab: The Cath Lab is an X-ray-based imaging machine, and a very high dose of the rays is produced when exposure is given. Hence, it requires the designing consideration according to the norms and regulations as prescribed by the regulatory authority. Proper designing has to be done to avoid radiation leakages. Before designing the Cath Lab rooms, the guidelines and norms of the controlling authority of the country must be taken into account. Like in India, the authority is Bhabha Atomic Research Institute. The main issues to be considered while designing the Cath Lab spaces are: For Cath Lab, if the machine is to be installed horizontally, a rectangular room shall be designed. If the machine is installed diagonally, a square room can also be considered. But, the suggestion is to install it horizontally in a rectangular room. The space of the room shall not be less than 42  m2. The approx. size can be 9144 mm × 4572 mm. All the walls of the room shall be at least 229 mm thick with plaster on both sides. The ideal thickness for the primary wall of an X-ray room should be at least 250 mm of solid baked clay bricks or 150 mm in the case of mortar/concrete walls. Hollow bricks, if used, should be plastered with a thickness of 6 mm barium plaster and should be protected up to 2200 mm from the floor level. The flooring shall be either tile/marble/granite. But, the flooring shall not be slippery to avoid the chances of an accident-causing injury to the patient. The door shall have a proper 2 mm thick lead lining. The lining has to be done even on the door frame. There shall be no leakage of the radiation from any place in the door. Doors should overlap by a minimum of 100 mm on each side when closed. The door should be at least 1800 mm wide and 2000 mm high. It is advised to provide air interlock spaces by providing an additional door before the Cath Lab room door. Windows are not allowed in the Cath Lab. Outside the door of the room, a warning light shall be given by providing a red colour bulb. The light must be connected to the X-ray generator in such a way that it will illuminate only during the activation of the X-ray tube. While installing the machine, care shall be taken to leave at least 1829 mm space behind the machine for easy movement of the C-Arm of the machine. The machine shall be installed in the centre of the width of the room.

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Depending on the capacity of the machine, the power load required by the machine shall be calculated and the main switch and cable shall be terminated in each Cath Lab room separately. As the weight of the machine is more and the movement of the machine is very fast, it is advised to check the weight-bearing capacity of the floor. If needed, provide a foundation for the machine as per the suggestion of the machine manufacturer. If the machine is a ceiling suspended model, care shall be taken to access the load-bearing capacity of the ceiling. If required proper treatment with the help of guarders or angles shall be done to increase the load-bearing capacity of the ceiling. The lightning in the room shall be normal LED light with sufficient lumens. No extra illumination is required in the room. The temperature in the room shall be between 17 and 21 °C, and the humidity level shall not be more than 40%. Cath Lab machine shall have proper ground earthing provisions. Inside the Cath Lab room, outlets for medical gas supply shall be given. The outlets shall be 1 for oxygen, 1 for vacuum and 1 for air. The proper two-way audio system shall be provided in the Cath Lab so that the patient can be directed by the technician from the control room itself. Position the gantry and couch in such a position that the patient is completely visible from the control console during scanning. Stand with heavy-duty hangers shall be provided outside the Cath Lab to hang the Lead Apron. Also, a cabinet shall be provided inside the Cath Lab room, for keeping other radiation safety devices like, lead gloves, lead goggles, groin guards, lead collars, etc. Attached to the Cath Lab room, a console room shall be provided. There shall be a provision of a secondary computer for the transfer of images during the procedure and reporting later on. The size of the console room shall be a minimum of 3658 mm × 3658 mm. Preferably, an online UPS shall be provided with the machine. As the UPS is usually of high rating say above 100  KVA, a lot of batteries shall be required. Definitely, for this, a separate room is required. This room shall be attached to the control room or the machine room. Some hospitals want to install all the UPS of the entire hospital in a common place away from the machine. UPS away from the Cath Lab is not recommended. Earthing of the UPS is also desirable. The size of the UPS room shall be about 3658 mm × 3658 mm with a provision of racks to install the batteries. Because of the acid in the batteries, some fumes are formed in the room, so the UPS room shall have a provision of exhaust to remove these fumes from the room from time to time. As the UPS also generates heat, the UPS room shall be air-conditioned and the temperature shall be about 17–20 °C with an RH of not more than 40%. Apart from the main machine where the tube and the detectors are fixed, other electronic parts are provided in the panels connected to the machine. These panels control the machine’s working but are not directly needed in the Cath Lab room. For

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15  Department Wise Equipment Detailing

better protection of these panels, it is suggested to install them in a different room or enclosure attached to the Cath Lab room. Hence, such an area shall be designed after consulting the equipment manufacturer. The size and temperature, etc. shall be confirmed by the manufacturer of the machine. At times, with the patient’s clothes which he/she is wearing, it becomes difficult to perform the procedure. Hence, the change rooms shall be provided near the Cath Lab, to enable the patient to remove the outside clothes and change into the hospital dress. The size of this change room shall be 3658 mm × 3658 mm with a provision of a hanger rod and shelves for keeping the hospital dress. Changing rooms shall also be provided in the Cath Lab to enable the doctors and staff to remove the outside clothes and change into the sterilised hospital dress. Different change rooms shall be provided for different categories of staff members. Also, the change rooms for males shall be separate from females. Cath Lab shall have a separate waiting area near the lab for the family members of the patient whose procedure is being performed. The number of persons that can be allowed to wait in this lobby may be limited with proper spacing between their seats. Cath Lab procedures require a lot of consumable materials like catheters, guide wires, fluid, etc. Hence, ample stock of these consumables shall be available in the lab. To stock these items, the department needs a store. This store shall be of the size of 3658 mm × 3658 mm. The store needs to have sufficient countertops, cupboards and drawers. The temperature of the room shall be between 17 and 21 °C. After the procedure, the images are generally transferred to a CD or DVD. These CDs/DVDs are marked with the patient ID and name and are kept in the record along with other registers and reports. Hence, to stock these items, the department needs a store. This store shall be of the size of 3658 mm × 3658 mm. The store shall have sufficient countertops, cupboards and drawers. The temperature of the room shall be between 17 and 21 °C. Defibrillator: Defibrillator sends an electric pulse or shock to the heart which restores the normal heartbeat. The defibrillator is also used to prevent or correct arrhythmia. Defibrillators can also be useful in restoring the heart’s beating, in case the heart suddenly stops. This device is also a life-saving device. Electrophysiology Lab: Electrophysiology (EP) lab is used for electrophysiology studies (EPSs). This is to monitor and map the electrical systems of the heart as well as treat heart rhythm problems (arrhythmias). Echocardiogram (ECHO): Echocardiogram is used to see the anatomy of the heart. Echocardiography also allows monitoring of the functioning of valves of the heart. It also gives information about blood clots in the heart chambers. Gamma Camera: The gamma camera, also called the scintillation camera, is used for imaging with nuclear medicine. It simultaneously detects radiation from the entire FOV and enables the acquisition of dynamic as well as static images of the area of interest in the human body. In cardiology, it can image the heart and help diagnose coronary artery disease, cardiomyopathy and many other heart conditions. Requirements of Infrastructure for Installation, Commissioning and Testing of Gamma Camera:

15.6 Pulmonology

373

For details of infrastructure requirements for installation, commissioning and testing of the Gamma Camera please refer to Sect. 15.23 under the heading of ‘Radiology’ in this chapter under the topic of Nuclear PET CT/PET MRI because the Gamma Camera is also a nuclear scan machine similar to that of PET CT/ PER MRI. Holter Monitoring System: Holter monitor is a portable device used to monitor the electrical activity of a cardiovascular system for at least 24 and up to 72 h. Hypothermia Device (Blanket, Plumbing and Heat Exchanger): This device is used to control the temperature of the body of the patient. After the surgery when the heart starts beating again, the body temperature of the patient needs to be lowered for a short time. Instruments for Cath Lab: To perform the procedures in Cath Lab, the Cardiologist requires a set of instruments. The basic instruments are like scissors, artery forceps, BP handle, Babcock, retractor, needle holder, speculum, etc. Depending on the requirement of the cardiologist, different variants based on shapes and sizes shall be procured. Intra-Aortic Balloon Pump: An intra-aortic balloon pump, or IABP, is to control the flow of blood through the aorta. The device uses a balloon, which gets deflated when the heart pumps blood, to give way to the blood to flow out in the body. On the other side, the balloon gets inflated when the heart relaxes to retain more blood in the heart. Pacemaker Temporary: When the patient suffering from Brady Dysrhythmia and temporary treatment has to be provided, the Temporary Pacemaker is used. Such conditions may arise when either the permanent pacemaker is not necessary or is not immediately available. TEE Probe with Ultrasound: TEE is an ultrasound probe which works on high-­ frequency sound waves to take detailed pictures of the heart and the arteries that lead to and from it, from the backside of the heart. The probe of the TEE passes to the backside of the oesophagus to capture images of heart structures and valves. Tilt Test Table: The tilt test table is to adjust the body position from horizontal to vertical for simulating standing up. The test is used to access faulty brain signals that may be causing low blood pressure. TMT: TMT is a treadmill used to make the patient run and put the heart under stress. During different phases of stress on the heart, ECGs are taken to detect any abnormal heart rhythms (arrhythmias) and also to diagnose any coronary artery disease. TMT is a treadmill used to make the patient run and put the heart under stress.

15.6 Pulmonology See Table 15.6. Body Box Diffusion: A body plethysmograph is used for a pulmonary function test which determines the quantity of air in the lungs after the patient takes in a deep

374

15  Department Wise Equipment Detailing

Table 15.6 Pulmonology

Activity Body box diffusion Broncho fiberscope adult Broncho fiberscope Paediatric Diffusion for DLCO EBUS Endobronchial ultrasonography TBNA FENO (fractional exhaled nitric oxide) PC-based spirometry PFT system with diffusion, Ros Q MEP/MIP Polysomnography (sleep lab) Rigid bronchoscope Video bronchoscope Video thoracoscope set

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

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:::-

::::-

breath. It also measures the amount of residual air left in the lungs once the patient exhales as much as he/she can. Broncho Fiberscope Adult/Paediatric: This is an endoscope which passes through the trachea to inspect the interior of the tracheobronchial tree for endobronchial diagnosis and treatment. It is also used to take specimens for culture and biopsy and removal of foreign bodies from the tracheobronchial tree. Diffusion for DLCO: DLCO is to predict abnormal gas exchange during exercise. EBUS: Endobronchial ultrasound (EBUS) is an instrument which is used to diagnose lung cancer, infections and other diseases causing enlarged lymph nodes in the chest. Endobronchial Ultrasonography TBNA: EBUS TBNA is to see inside the lungs and carry out the procedure with the help of a special kind of thin and flexible bronchoscope. FENO (Fractional Exhaled Nitric Oxide): Fractional exhaled nitric oxide (FeNO) is measured in the human breath test because of airway inflammation. PC-Based Spirometry: Spirometry is used to assess how well the lungs are working by measuring the quantity of air the patient inhales, the quantity of air exhaled and how quickly the patient can exhale. Spirometry is used for the diagnosis of diseases like asthma, chronic obstructive pulmonary disease (COPD) and other conditions affecting breathing.

15.7 Neurology

375

PFT System with Diffusion, Ros Q MEP/MIP: This is to measure maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) for maximal strength of respiratory muscles. Polysomnography (Sleep Lab): Polysomnography, also known as a sleep study, is to diagnose sleep disorders. This test records the brain waves, the oxygen level in the blood, heart rate and breathing, as well as eye and leg movements during the study. Requirements of Infrastructure for Installation, Commissioning and Testing of Polysomnography (Sleep Lab): Polysomnography (sleep study) is a test used to diagnose sleep disorders. As this investigation is done while the patient is asleep, the room has to be in a silent space where there shall be no disturbance to the patient from outside sound and light. Location wise, this room shall be located near the IPD area of the hospital. Highly clean and sterilised areas are not required for this. The room of the sleep lab shall be about 4267 mm × 4572 mm. This room shall have a glass partition in between. One part shall be as patient room and the other the technician room. The patient’s room has to be completely soundproof and with slight darkness to make the patient sleep comfortably. The door of the room shall also be air tight so that no outer sound can enter the patient’s room. The room shall have a bed for the patient. As this machine is usually portable, some hospitals prefer to use a private single-­ occupancy room to perform this procedure. This can also be done if providing a separate room is not possible. The technician room shall be a normal room with a glass window between the patient room and the technician room. This room shall have a working top below the glass window so that the technician can see the patient in the other room while the procedure is going on. The machine shall be placed on the countertop, and the technician records the findings of the patient while he/she is asleep. Proper electric and communication points shall be provided for the machines. Rigid Bronchoscope: Rigid Bronchoscopy is for accessing the patient’s airway and also allows to pass the larger airway instruments and cameras for diagnosis and treatment of airway disease. Video Bronchoscope: A video bronchoscope uses a CCD camera located at the distal tip of the bronchoscope to sense, capture and transmit images to the processor for further analysis. Video Thoracoscope Set: Thorascope is used to evaluate and treat pleural effusions in patients suffering from pulmonary tuberculosis.

15.7 Neurology See Table 15.7. Electroencephalograph (EEG): In electroencephalogram (EEG), small, metal discs (electrodes) are attached to the scalp and are used to detect electrical activity

376

15  Department Wise Equipment Detailing

Table 15.7 Neurology

Activity Digital video electroencephalograph (EEG) EMG (electromyogram)/ NCV/EP machine Gait and balance analysis Nystagmograph Ocular plethysmograph Polysomnography (PSG) Stimulator intracerebral/subcortical Stimulator nerve Stimulator neuromuscular Stimulator peripheral nerve Stimulator spinal cord Stimulator Vegus nerve Transcranial magnetic stimulation (TMS) Video electroencephalography (VEEG) VNG

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

::::::::::::-

:-

in the brain. The cells of the brain communicate via electrical impulses and are active during the procedure. This activity is recorded in the form of a wave and is then analysed. EMG (electromyogram)/NCV/EP Machine: EMG is used to measure the muscle response to nerve stimulation and evaluates electrical activity within selected muscle fibres. This test is used to differentiate between a muscle disorder and a nerve disorder. NCV is to measure the speed at which an electrical impulse travels along a nerve. Gait and Balance Analysis: As ambulatory and balance functions are important for maintaining general health, gait analysis is used to identify the parameters to be focused on when assessing balance and ambulatory functions. Nystagmograph: To measure, record or visually display the involuntary movements (nystagmus) of the eyeball, the nystagmograph is used. Plethysmograph, Ocular: Plethysmograph is used to measure changes in volume in different parts of the body. The test is to check for blood clots in the arms

15.8 Neuro Surgery

377

and legs and also to measure the capacity of the lungs as to how much air the patient can hold in the lungs. Polysomnography (Sleep Lab): Polysomnography, also known as a sleep study, is to diagnose sleep disorders. This test records the brain waves, the oxygen level in the blood, heart rate and breathing, as well as eye and leg movements during the study. Requirements of Infrastructure for Installation, Commissioning and Testing of Polysomnography (Sleep Lab): For details of infrastructure requirements for installation, commissioning and testing of Polysomnography (Sleep Lab), please refer to Sect. 15.6 under the heading of ‘Pulmonology’ in this chapter. Stimulator Intracerebral/Subcortical: Intracerebral/subcortical stimulator is implanted in the body and is used for pain relief by applying electrical current to subsurface areas of a patient’s brain. Stimulator Nerve: A nerve stimulator sends low levels of electrical impulses directly into the nerves to give relief from the pain. Nerve stimulation is used most often for nonsurgical pain treatment. Stimulator Neuromuscular: Neuromuscular electrical stimulation sends electrical impulses to nerves. Due to these electrical impulses, the muscles contract. Stimulator Peripheral Nerve: Peripheral nerve stimulation (PNS) is used to treat chronic pain. In this process, a small electrical device (a wire-like electrode) is placed next to one of the peripheral nerves by surgery, which in turn stimulates the nerves. Stimulator Spinal Cord: A spinal cord stimulator is a device which is implanted inside the body and then sends low levels of electrical impulses directly into the spinal cord to relieve pain. Stimulator Vagus Nerve: Vagus nerve stimulator sends regular, mild pulses of electrical energy to the brain via the Vagus nerve to prevent seizures in the patient. Transcranial Magnetic Stimulation (TMS): Transcranial magnetic stimulation (TMS) uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression and is a noninvasive procedure. Video Electroencephalography (VEEG): A video EEG records what the patient is experiencing or doing on video tape while the EEG test records the brainwaves. VNG: Videonystagmograph (VNG) is used to measure a type of involuntary eye movement called nystagmus.

15.8 Neuro Surgery See Table 15.8. Aversive Conditioning Device: An aversive conditioning device is used for the administration of an electrical shock or other noxious stimuli to a patient which helps in the modification of undesirable behavioural characteristics.

378

15  Department Wise Equipment Detailing

Table 15.8 Neurosurgery

Activity Aversive conditioning device Biofeedback device Electroconvulsive therapy device Evoked response auditory system Hypothermia device to treat spinal-cord injury Interferential current therapy Intracranial pressure monitoring device Neurosurgical fragmentation and aspiration device Ophthalmodynamometer Percussion hammer Physiological signal amplifier Pinwheel Radiofrequency lesion probe Skin potential measurement device Spectrum, electroencephalogram (EEG) signal analyser Stimulator intracerebral/ subcortical Stimulator nerve Stimulator neuromuscular Stimulator peripheral nerve Stimulator spinal cord Stimulator vegus nerve Tilt table test

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::::::::-

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15.8 Neuro Surgery

379

Biofeedback Device: To gain control over involuntary bodily functions such as blood flow, blood pressure and heart rate, biofeedback uses the mind–body technique that involves using visual or auditory feedback. Electroconvulsive Therapy Device: Electroconvulsive (ECT) is a device used to treat seizures in the brain which are electrically induced in patients to provide relief from mental disorders. Evoked Response Auditory System: Auditory evoked potential (AEP) machine is used to examine and determine the functional integrity of the auditory system. AEP is a type of EEG signal emanated from the brain scalp by an acoustical stimulus which reflects the auditory ability level of the patient. Hypothermia Device for Spinal-Cord Injury: Therapeutic hypothermia is used in various types of neurological injury such as stroke, traumatic brain injury and post-anoxic encephalopathy. Interferential Current Therapy: Interferential current therapy is used to provide relieve pain and accelerate the self-healing process. In this therapy, the high-­ frequency signals are penetrated by the IFC through the skin into deeper-lying muscular tissues. Intracranial Pressure Monitoring Device: The intracranial pressure monitoring device is used to monitor the intraventricular catheter inserted into the lateral ventricle through the brain. Neurosurgical Fragmentation and Aspiration Device: Cavitron ultrasonic surgical aspirator (CUSA) is to remove the tumour by fragmentation, irrigation and aspiration. Ophthalmodynamometer: This device is used for the detection of hemodynamically significant carotid stenosis. In this technique, the reliability of two pressure-­dependent methods, namely ophthalmodynamography and ophthalmodynamometry, is established to get the desired results. Percussion Hammer: The percussion hammer is used to test deep tendon reflexes. It comprises a handle, a telescopic rod, a first hammer head and a second hammer head. Physiological Signal Amplifier: A physiological signal amplifier is a general-­ purpose device used to electrically amplify signals derived from various physiological sources like electroencephalograms. Pinwheel: Pinwheel is used to measure nerve reactions when the instrument is rolled against the skin. This device consists of a 7″ SS handle with a wheel of evenly spaced sharp pins called the spur. The device is used to test the extent of neurological damage and to ensure communication of the nervous system after surgery. Radio frequency Lesion Probe: This device is used for the insertion of a probe transcutaneous into an orifice in the base of the skull under sedation. Skin Potential Measurement Device: This device is to acquire skin potential response (SPR) signals. SPR is a branch of electrodermal activity (EDA) and involves the reading of nervous electric pulses that may arise when the sympathetic nervous system activates the sweat glands due to any external stressing stimulus.

380

15  Department Wise Equipment Detailing

Spectrum, Electroencephalogram (EEG) Signal Analyser: An EEG signal spectrum analyser is a device used to display the frequency content or power spectral density of the electroencephalogram signal. Stimulator Intracerebral/Subcortical: Intracerebral/subcortical stimulator is used for pain relief after implanting in the body and by applying electrical current to subsurface areas of a patient’s brain. Stimulator Nerve: A nerve stimulator is used to give relief from pain by sending low levels of electrical impulses directly into the nerves. Nerve stimulation is often used for nonsurgical pain treatment. Stimulator Neuromuscular: Neuromuscular electrical stimulation is used for muscle contraction by sending electrical impulses to nerves. Stimulator Peripheral Nerve: Peripheral nerve stimulation (PNS) is used to treat chronic pain. In this process, a small electrical device (a wire-like electrode), which in turn stimulates the nerves, is placed next to one of the peripheral nerves by surgery. Stimulator Spinal Cord: A spinal cord stimulator is a device which is implanted inside the body and sends low levels of electrical impulses directly into the spinal cord to relieve pain. Stimulator Vagus Nerve: Vagus nerve stimulator sends mild and regular pulses of electrical energy into the brain via the Vagus nerve to prevent seizures in the patient. Tilt Table Test: The tilt table is to evaluate symptoms of syncope (fainting) by creating changes in posture from lying to standing.

15.9 Psychiatry See Table 15.9. ECT Machines: ECT machine is used to treat bipolar disorder, catatonia or a severe major depressive episode, who are treatment-resistant or who require a rapid treatment response. Electroencephalograph (EEG): In electroencephalogram (EEG) is used to detect electrical activity in the brain small. In the procedure, the metal discs (electrodes) are attached to the scalp. The cells of the brain communicate via electrical Table 15.9 Psychiatry Status of works Activity ECT (brief pulse :constant) EEG :Multibehaviour sex :therapy machine

Start date

End date

Not Responsible Complete In-progress started person

Remarks

15.10 Nephrology

381

impulses and are active during the procedure. These activities are recorded in the form of waves and are then analysed. Multi Behaviour Sex Therapy Machine: It is used for de-addiction, and sex therapy is also used for the treatment of sexual dysfunction cases.

15.10 Nephrology See Table 15.10. BN ProSpec and BN II System Nephelometer System: BN ProSpec system is used for testing kidney disease, cardiac risk assessment, iron assessment, nutritional assessment, as well as innovative markers such as Cystatin C by using reagents for reliable plasma protein. Colorimeter: Colorimeter is used to measure the concentration of a known solute in a given solution with the help of the Beer–Lambert law. Dialysis Chairs: A dialysis chair is used during the procedure of dialysis and is a recliner chair. This chair has replaced the beds which were being used earlier. In bed, it was difficult to pass time and was uneasy for the patient as the patient has to lie down ideal for 3–4 h. This chair can be positioned as per the convenience of the patient, and he/she can also watch the TV etc. Dialysis Machines: A dialysis machine with the help of an artificial kidney or so-called dialyzer is used to filter out metabolic waste products and remove excess water from the blood. Requirements of Infrastructure for Installation, Commissioning and Testing of Dialysis Machine: The purpose of the dialysis machine is to filter out metabolic waste through the process of reverse osmosis. Hence, there is a huge requirement for clean, unmineralised and sterile water. Therefore, at least one water supply point shall be provided near the dialysis machine. The source of the water supply shall be the RO water stored either in the department of dialysis or on the roof of the hospital. It shall be Table 15.10 Nephrology Status of works Activity BN ProSpec and BN II system Nephelometer system Colorimeter Dialysis chairs Dialysis machines RO plant Self-illuminating microscope

Start date :-

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End date

Not Responsible Complete In-progress started person

Remarks

382

15  Department Wise Equipment Detailing

ensured that the RO water supplied from the tank shall be free from any kind of impurity or foreign body and shall be sterile (with no micro-organism growth). Hence, it is recommended that the water shall be properly filtered through the microfilters and the UV lamp be installed in the RO water storage tank. Apart from this, one water drain point shall be provided on the floor just near the dialysis machine. RO Plant: Reverse osmosis (RO) is a machine used to purify water using the technique of reverse osmosis. The device is fitted with a permeable membrane which removes ions, larger particles and unwanted molecules from the water. Self-Illuminating Microscope: This microscope is used in understanding kidney physiology and pathophysiology.

15.11 Urology See Table 15.11. Automatic Device for Monitoring and Detecting Kidney Damage: To automatically monitor and detect kidney damage, this device is used. There is a sentinel Table 15.11 Urology

Activity Automatic device for monitoring and detecting kidney damage Columns for immunoadsorption in extracorporeal systems Cystoscope Erectile dysfunction device ESW lithotripter Green light laser Holmium or thulium laser Hydraulic cytometric device Nephoscope Uro dynamics cum uroflometer Ureteroscope Wearable, smartphone-­ controlled device for treating premature ejaculation (PE)

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

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15.11 Urology

383

device in this machine which continuously monitors and measures the urine flow rate and volume and urine output in real time. Columns for Immunoadsorption in Extracorporeal Systems: Extracorporeal Immunoadsorption (ECI) is used for selectively removing immunoglobulin’s (IgG) and circulating immune complexes (CICs) from patients, by using Protein A columns. Cystoscope: Cystoscope is used to examine the lining of your urethra and bladder. The cystoscope consisting of a lens is inserted into the urethra and slowly pushed into the bladder. Erectile Dysfunction Device: A vacuum constriction device (VCD) is for men who are suffering from erectile dysfunction. The VCD system consists of an acrylic cylinder with a pump and a constriction ring or band. The device creates a vacuum to help the penis become erect, whereas the band helps to maintain the erection. ESW Lithotripter: Extracorporeal shock wave lithotripsy (ESWL) generates shock waves and is used to break the kidney stone into small pieces. These small pieces of stone easily travel through the urinary tract and pass out from the body. With the help of X-rays or ultrasound, the exact location of the stone is determined and the shocks are delivered to the stone to break it into small fragments. Requirements of Infrastructure for Installation, Commissioning and Testing of ESW Lithotripter: ESW lithotripter basically consists of two machines. One is the lithotripter, and the other is the C-Arm. Both of these can either be integrated or can be separate units. As far as the lithotripter is concerned, there are no specific requirements for installation. However, for C-Arm, there are few requirements. Those are. C-Arm is basically a machine working with the technology of X-rays. The X-ray generates the X-ray, and the CCD camera or the flat panel above the tube captures the rays and converts the same into an image format. As the machine is X-ray-­ based, almost the same precautions shall be taken care of as in the case of an X-ray machine, like. The walls of the room shall be at least 229 mm thick, with plaster on both sides. The ideal thickness for the primary wall of an X-ray room is at least 250 mm of solid baked clay bricks, and 150  mm of mortar/concrete walls for plain radiography. Hollow bricks should be plastered with a thickness of 6  mm barium plaster and should be protected up to 2200 mm from the floor level. The door should be at least 1524 mm wide and 2000 mm high. The door and its frame need to have a 2 mm thick lead lining. There shall be no leakage of radiation from the door. Doors should overlap by a minimum of 100  mm on each side when closed. A warning light (red colour bulb) shall be provided outside the door. This light must be connected to the X-ray generator in a way that it illuminates only during the X-ray tube activation. Depending on the machine’s capacity, the power load required by the machine shall be calculated and the main switch and cable shall be separately terminated at each machine.

384

15  Department Wise Equipment Detailing

The temperature in the room shall range between 18 and 21 °C, and the humidity level shall not be more than 60%. Green Light Laser: The green light laser is used to treat enlargement of the prostate called Benign Prostatic Hyperplasia (BPH). Green light laser evaporates prostatic tissue which is blocking the outlet of the bladder. Holmium or Thulium Laser: Thulium laser (ThuLEP) and holmium laser (HoLEP) are used for endoscopic enucleation of the prostate glands. Hydraulic Cytometric Device: Cystometry is a diagnostic tool to measure the amount of urine actually in the bladder vis-a-vis how full the bladder feels. In the process, the main muscles of the bladder wall (the detrusor) or urethra (the urethral sphincter) are diagnosed. Nephoscope: Nephoscope is used to perform Percutaneous Nephrolithotomy (PCNL), wherein the kidney stones are located, viewed and removed with a minimally invasive surgery. Uro Dynamics and Uroflometer: Uro dynamic and uroflometer is a device to measure urine flow rates during micturition, including average flow rate, peak flow rate, time of voiding and voided volume. Ureteroscope: Ureteroscope is also used to locate, vies and remove kidney stones. The difference between nephoscope and ureteroscope is that a ureteroscope is passed through the urethra, bladder and up the ureter to the point where the stone is in the kidney. Wearable, smartphone-controlled device for treating premature ejaculation (PE): The device is placed on the perineum area which confuses the ejaculatory nerves before they go up to the brain. The device delivers a mild form of electrical energy through its four electrodes.

15.12 Gastroenterology, Hepatology and Pancreatology See Table 15.12. 24 h pH Impedance: Esophageal 24-h pH/impedance reflux monitor is used to measure the amount of reflux (both acidic and non-acidic) in the oesophagus during 24 h. This is also used to assess any symptoms that may be correlated with reflux. Breath Analyser: A breath analyser is used to estimate the alcohol contents in the blood (BAC) from a breath sample. Capsule Endoscope: A capsule endoscope is a small capsule which is swallowed while performing the procedure. This device consists of a tiny wireless camera. This capsule when passes through the stomach, large intestine and small intestine, and the endoscope takes images. These images are then transmitted to the recording device worn on a belt around the waist of the technician. These recorded images are finally processed in the central processing unit to get the report. C-ARM: C-Arm is an X-ray-based imaging intensifier. The CCD camera or the flat panel X-ray detector is fitted on the top end of the C-shaped Arm. On the bottom

15.12 Gastroenterology, Hepatology and Pancreatology

385

Table 15.12  Gastroenterology, hepatology and pancreatology

Activity 24 h pH impedance Breath analyser Capsule endoscopy C-arm Cholangioscope/ choledochoscope, flexible or rigid Colonoscope Duodenoscope Electrosurgical cautery with argon Endoscopic ultrasound (EUS) Enteroscope Manometry unit Upper gastrointestinal scope Upper GI endoscope PEDIA Video processor

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::::-

:::::::::-

end is the X-ray source tube. Both are placed opposite each other. C-Arm is used for intraoperative imaging during surgeries and procedures. Requirements of Infrastructure for Installation, Commissioning and Testing of C-Arm Machine: For details of infrastructure requirements for installation, commissioning and testing of C-Arm, please refer to Sect. 15.22 under the heading of ‘Operating Room’ in this chapter. Cholangioscope/Choledochoscope, Flexible or Rigid: Cholangioscope is an endoscope to visualise the inside of the bile ducts. It is used for the removal of bile duct stones. When it is coupled with the visualisation of the pancreas, it is termed cholangiopancreatoscopy. Colonoscope: The colonoscope is used for the examination of the colon, and another such device called proctosigmoidoscope is used to examine the rectum and lower colon by passing it through the anal orifice into the colon or the rectum as the case may be. Duedenoscope: Duodenoscopes are used to see the upper end of the patient’s small intestine or duodenum. It is mainly used for Endoscopic Retrograde Cholangiopancreatography (ERCP). Electrosurgical Cautery with Argon: Argon plasma coagulation (APC) is used for monitoring rates of initial hemostasis and causes recurrent bleeding. In the

386

15  Department Wise Equipment Detailing

process, controlled electrocoagulation via high-frequency monopolar energy is used through a contactless method. Endoscopic Ultrasound (EUS): Endoscopic ultrasound (EUS) is used to assess gastrointestinal and lung diseases. The machine generates high-frequency sound waves and passes the same in the body through the endoscope. When used, the EUS produces a clear and detailed image of the lining and walls of the digestive tract like the pancreas, liver and lymph nodes and chest along with other nearby organs. Enteroscope: An enteroscope is a device used to see inside the small bowel. This procedure is basically an endoscopy procedure and is used for the diagnosis and treatment of different types of digestive conditions. Manometry Unit: The manometry system is used to evaluate the motor functions of the oesophagus and for information for the diagnosis of diseases like achalasia, dysphagia and hiatal hernia. Upper Gastrointestinal Scope: An upper gastrointestinal (UGI) is used to examine the inside lining of the oesophagus, stomach and duodenum. The scope is inserted from the mouth and gently moved down the throat and finally into the oesophagus, stomach and duodenum. The camera and light mounted on the tip of the scope having a light bulb camera take the images under bright light conditions and transmit the images to the central processing unit for further processing of the images. Upper GI Endoscope PEDIA: An upper gastrointestinal (UGI) is the same as in adults but with the difference that the scope is of smaller diameter and is used for paediatric patients. Video Processor: The processor is used for processing and displaying the image received from the endoscopes.

15.13 Plastic, Cosmetic, Burn and Vascular Surgery See Table 15.13. CO2 Fractional Laser: Fractional CO2 laser is for steady rejuvenation of the neck, face, hands and chest by stimulating natural collagen production in the skin. It is also used for a neck lift or facelift by laser resurfacing combined with facial aesthetic surgery. Cryosurgical Unit and Accessories: Microfine jets of cryogen are used for various treatments like removal of skin tags, dermatofibroma, acne, viral warts, wrinkles, burns and keloids, lesions as well as scar tissue, small skin cancers, keratosis, basal cell carcinomas, abrasions, solar lentigo, etc. Diode Laser: A diode laser produces a light beam with a narrow spectrum, and it targets specific chromophores in the skin. Drill and Saw System for Microsurgery: As the plastic surgeon is also supposed to perform the microsurgeries, hence he/she requires the microsurgical bits, drills, motors, saws, reamers, etc. These tools are used for different types of plastic, cosmetic and reconstruction surgeries.

15.13 Plastic, Cosmetic, Burn and Vascular Surgery

387

Table 15.13  Plastic, cosmetic, burn and vascular surgery Status of works Activity CO2 fractional laser Cryosurgical unit and accessories Diode laser Drill and saw system for microsurgery Electric dermatome Erbium Yag laser Hair growth laser Hyper baric oxygen therapy machine KTP laser ND Yag laser long pulse ND Yag laser Q switch Osteotome Pulsed diode laser RF cautery Pneumatic tourniquet electric Varicose laser

Start date

End date

Not Responsible Complete In-progress started person

Remarks

::::-

::::-

::::::::-

Electric Dermatome: Electric dermatome is used for providing skin grafts and can adjust the thickness and width of skin. Erbium Yag Laser: Erbium laser is for the removal of surface-level and deep lines and wrinkles on the hands, face, chest or neck. Hair Growth Laser: The laser hair growth system stimulates hair follicles to grow thicker and more dense hair and is used for the treatment of hair loss for both men and women. Hyperbaric Oxygen Therapy Machine: Hyperbaric oxygen therapy is used to treat bubbles of air in the blood vessels, decompression sickness, serious infections and for wounds that may not heal due to diabetes or radiation injury. KTP Laser: A KTP laser generates a beam of the green visible spectrum, which passes through the potassium titanyl phosphate (KTP) crystal. ND Yag Laser Long Pulse: An Nd:YAG laser produces near-infrared wavelength, which penetrates deep into the skin and is easily absorbed by melanin chromophores and haemoglobin.

388

15  Department Wise Equipment Detailing

ND Yag Laser Q Switch: Q-switched mode Nd: YAG is mainly used for melisma and tattoo removal produces, as it produces a high-intensity beam in very short pulses. It generates dual wavelengths, one of the infrared ranges (1064 nm) and the second beam of 532 nm wavelength. Osteotome: An osteotome is used for cutting or preparing bone and is just like a chisel but is bevelled on both sides. Pulse Diode Laser: Pulsed lasers emit light in the form of optical pulses. However, depending on the pulse repetition rate, pulse duration, wavelength required and pulse energy, different types of pulsed lasers are used with different methods for pulse generation. RF Cautery: Radio frequency cautery generates high-frequency radio waves, which are passed through soft tissue to cut, coagulate or remove the said tissue. Pneumatic Tourniquet Electric: Pneumatic tourniquet is used on a limb to create a bloodless surgical field by applying pressure on the arterial blood flow through its cuffs. The cuffs are inflated, and the machine regulates the pressure. Varicose Laser: Varicose vein laser sends a thin beam of radiation in the form of light and is used to reduce varicose veins with heat technology.

15.14 Gynaecology and Obstetrics See Table 15.14. Baby Resuscitation Unit: Neonatal resuscitation is used for emergency procedures performed to support new-born babies who do not breathe, are gasping or have a weak heartbeat at the time of birth. Colposcope (and Colpomicroscope): With the help of a magnifying lens and bright light, the colposcope is used to examine the vulva, vagina and cervix. It depicts the abnormal epithelium to identify abnormal biopsy and evaluate the cervix. Equipment for Assisted Delivery: These are the instruments and devices that are used to assist in the delivery of a baby as an alternative to the ventouse (vacuum extraction). Obstetrical forceps are one of them. Table 15.14  Gynaecology and obstetrics

Activity Baby resuscitation unit Colposcope (and Colpomicroscope) Equipment for assisted delivery Labour table Monitor uterine contraction

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15.15 In Vitro Fertilisation (IVF)

389

Labour Table: Table used for the delivery of the babies. Monitor Uterine Contraction: This is used for the foetal heart and uterine contraction externally providing a continuous record of the mother’s contraction rate and the baby’s heart rate as labour progresses. This device can provide early warning of foetal distress.

15.15 In Vitro Fertilisation (IVF) See Table 15.15. CODA Extra Inline Filter: Coda filters are used to filter VOCs and contaminant. It improves the air quality in the laboratory and in the incubator, which helps a lot to improve embryo and cell development. Cryogenic Cans: Cryogenic storage canes are made from lightweight aluminium to hold liquid nitrogen. Cryogenic cans are used for the storage of sperm, embryos and stem cell in IVF clinics. Table 15.15  In vitro fertilisation (IVF)

Activity CODA extra inline filter Cryogenic cans Doppler ultrasound for foetal evaluation Heracell CO2 incubator Integrated vertical laminar flow with TFT monitor and FCG table Inverted research microscope with micromanipulator Intrauterine pressure recorder Makler counting chamber Neodymium Yag laser Spermfuge Trinocular stereo zoom microscope Uterine contraction monitor Vertical laminar flow for andrology

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:-

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390

15  Department Wise Equipment Detailing

Doppler Ultrasound for Foetal Evaluation: Doppler ultrasound is used in pregnancy to study blood circulation in the baby, uterus and placenta. A machine is an ultrasound machine and it uses sound waves to detect the movement of blood in vessels. Heracell CO2 Incubator: The CO2 incubator provides optimal growth conditions to enhance cell growth. Heracell CO2 incubators provide accurate, uniform and reliable culturing conditions. It provides samples with a uniform temperature, CO2 and humidity in the incubator. Requirements of Infrastructure for Installation, Commissioning and Testing of Heracell CO2 Incubator: Apart from the standard requirements, installation of the CO2 Incubator requires a connection and port for the supply of Carbon Dioxide gas. The source can either be the standalone CO2 cylinder or the centralised CO2 gas pipe line of the hospital. Integrated Vertical Laminar Flow with TFT Monitor and FCG Table: Integrated vertical laminar flow, through HEPA filters, provides unidirectional airflow over the entire surface of the work tables with effective air exchanges. Inverted Microscope with Micromanipulator: Inverted microscope is to take images of the live cell settled at the bottom and onto the coverslip for adherence. Intrauterine Pressure Recorder: Intrauterine pressure (IUP) transducer is used to record intraluminal pressure changes by responding to increase and decrease in the diameter of the uterine lumen. It is basically an electronic catheter-tipped instrument and also has one or two ultra-miniature pressure sensors at the distal end coupled to a computer with the help of a cable. Makler Counting Chamber: The Makler counting chamber is for rapid and accurate sperm count, motility and morphology evaluation, from an undiluted specimen. Neodymium-Yag Laser: Nd-YAG laser is used in gynaecology for ablating the endometrium in cases of menorrhagia. Spermfuge: Spermfuge is a temperature-regulated centrifuge. The instrument is used for regulating and maintaining the inner chamber temperature during centrifugation before or after centrifugation. Trinocular Stereo Zoom Microscope: A trinocular microscope has one extra eye tube for connecting a microscope camera, apart from the regular two eye pieces. This is basically a binocular microscope with an add-on moving prism assembly, which diverts the light to the third eye tube. Uterine Contraction Monitor: This is used for providing a continuous record of the baby’s heart rate and the mother’s contraction rate as labour progresses. Vertical Laminar Flow for Andrology: The laminar flow devices are used to maintain a clean environment and provide an aseptic environment for medical devices. Filtration, illumination, noise and vibration methods are used to meet clean air requirements. In andrology, laminar flow benches are also used to handle sperm samples.

15.16 Paediatric (Neo Natal ICU)

391

15.16 Paediatric (Neo Natal ICU) See Table 15.16. Baby Incubator: An incubator is used to provide an ideal environment with the required temperature, humidity, regulated oxygen and light, which is an ideal condition that is generally required for the infant to develop. This device is normally used for infants with pre-term delivery and is kept in this machine while their vital organs develop. Baby Resuscitation Unit: Neonatal resuscitation is used for emergency procedures performed to support new-born babies who are not able to breath after birth, are gasping or have a weak heartbeat at the time of birth. Baby Weight Machine: A baby weighing machine is used to weigh neonatal and children. The machine has a provision basket to take the weight of neonatal. Children can be weighed in sitting and standing positions. Humidifier: To add moisture content to the oxygen, the humidifier is used. Humidifier prevents dryness of the air, which may otherwise irritate different parts of the body. Table 15.16  Paediatric (Neonatal ICU) Status of works Activity Baby incubator Baby resuscitation unit Baby weight machine Humidifier ICE lined refrigerator Infantometer Infusion pumps Multipara monitor Neonatal CPAP (bubble) Oxygen hoods Paediatric ventilator Phototherapy under surface Phototherapy upper surface Radiant warmer

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15  Department Wise Equipment Detailing

ICE-lined Refrigerator: Ice-lined refrigerators are used to store vaccines in an ideal environment and to store blood bags. The temperature range of ice-lined refrigerator is from +2 °C to +8 °C. Infantometer: Infantometer is for measuring the size (Length) of infants. Infusion Pumps: An infusion pump is used to deliver medications, IV fluids and nutrients, to a patient’s body in preset and controlled volume or amount. Multipara Monitor: This monitor is used to keep track of the vital of the patient. Generally, the fixed parameters are heart rate, blood pressure, pulse oximetry, respiratory rate and temperature. Apart from these fixed parameters, the module’s other parameters can also be attached to the device like EtCo2, etc. Neonatal CPAP (Bubble): Bubble CPAP, a noninvasive ventilation device, provides positive airway pressure (CPAP) which is delivered for the spontaneous breathing of newborns to maintain lung volumes during expiration, hence, is used for newborns with infant respiratory distress syndrome (IRDS). Requirements of Infrastructure for Installation, Commissioning and Testing of Neonatal CPAP: As CPAP is used to provide oxygen to newborns, an oxygen port shall be provided near the CPAP machine. The supply source can be from the standalone oxygen cylinder or the central oxygen pipe line of the hospital. As a backup, it is advised to provide one spare port of oxygen, so that it can be used in case of failure of the working port. Oxygen Hoods: An oxygen hood is a dome or box made out of plastic-like material having the facility of being warmed and humidified oxygen inside. The oxygen hood is used for babies who can breathe on their own but still need extra oxygen. Pediatric Ventilator: Paediatric ventilator is used for critically ill children, who require total or partial assistance to maintain adequate breathing. This invasive ventilator provides breathing support to the child purely temporarily. Requirements of Infrastructure for Installation, Commissioning and Testing of Invasive Paediatric Ventilator: The invasive ventilator with the help of compressed air mixes the oxygen and forces it into the lungs of the baby at a very slow rate, hence providing supportive breathing. Therefore, the ventilator requires compressed air and oxygen to ventilate the patient. Hence, apart from the routine installation requirements, the ports of centralised compressed air (4 bar) and oxygen shall be provided near the ventilator. As a backup, it is advised to provide one spare port for both the air and oxygen, so that it can be used in case of failure of the working port. Another important issue is to attach the humidifier along with the ventilator to humidify the oxygen being given to the baby.

15.17 Orthopaedic and Rheumatology

393

Phototherapy Upper and Under Surface: Phototherapy having a special type of light with a specific wavelength is used for treating neonatal with high bilirubin levels. Radiant Warmer: Radiant warmer is to provide artificial support to keep the body temperature constant and limit the metabolism rate. It is used for babies where heat loss is rapid and to maintain the body temperature of the baby constant.

15.17 Orthopaedic and Rheumatology See Table 15.17. Dynamometer: Medical dynamometers are to measure the strength of different groups of muscle along with bones and neurons. It is used to evaluate hand dysfunction, or the patient trauma, measure the patient’s hand strength, and determine how a patient is responding to ongoing therapy and treatment. Gait Analysis Meter: Gait analysis is used to identify the required parameters for assessing balance and ambulatory functions. Goniometer: A goniometer is used to measure the permitted rotation and angle of an object to a definite position. This art and science of measuring joint ranges is called goniometry. Plaster Cutter: Plaster cutting saw is used to remove plaster and fibreglass casts from the patient by the technicians. Sensory Evoked Potential (SEP): This machine is used to study the relay of body sensations to the brain and how the brain receives those sensations. The stimulating electrode is placed on the arm or leg, which generates an electrical signal and is captured by the machine to provide the desired output. Table 15.17  Orthopaedic and rheumatology Status of works Activity Dynamometer Gait analysis meter Goniometer Plaster cutter Sensory evoked potential (SEP)

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15  Department Wise Equipment Detailing

15.18 Ophthalmology See Table 15.18. Angio O.C.T: Optical coherence tomography (OCT) angiography is a noninvasive imaging technique based on optical coherence tomography developed to Table 15.18  Ophthalmology

Activity Angio O.C.T Applanation tonometer A-scan A-scan with water immulsion Auto keratometer Auto refractometer B-scan with UBM C3R machine Contrast sensitivity chart Dynamometer Exophthalmometer Femto Lasix Fornixscope Fundus camera Humpry automated Indirect ophthalmoscope Keratometer (KMS6) Lensometer NA-Yag laser (long-pulse Yag laser) O.C.T Ocular esthesiometer Ophthalmic camera Ophthalmic refraction unit Ophthalmoscope Ophthalmic laser (green) Ophthalmic trial frame and trial box Orb’s scan

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15.18 Ophthalmology

395

Table 15.18 (continued)

Activity Pachymeter (NCT) Radiation beta unit Retinoscope Slit lamp Synapthophare Tonometer, noncontact (pachymeter) Visual acuity chart

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::::::-

:-

visualise vascular networks in the human retina. OCTA may make use of speckle variance optical coherence tomography. Applanation Tonometer: Applanation tonometer is used to measure the amount of force that is needed to flatten, or appellate, a consistent area of the cornea. This study is called IOP. This machine is also used to determine the intraocular pressure of the eye. A-Scan: A-scan ultrasound biometry is used to determine the length of the eye and is used to determine sight disorders. This machine is also used for calculating the power of intraocular lenses (IOLs) before cataract surgery. A-Scan with Water Immersion: This device is to scan the eye without compressing the cornea. For the scan, a small immersion scleral shell is placed onto the eye between the lids, filled with BSS. The probe is then immersed in the fluid without contacting the cornea. Auto Keratometer: A keratometer, also called an ophthalmometer, is used to measure the curvature of the anterior surface of the cornea and to assess the extent and axis of astigmatism. Auto Refractometer: Auto refractometer is used to measure the degree of refractive error in the eye and the suggested correction powers lenses to be used. B-Scan with UBM: B-scan is used to view the eye as well as the orbit in a two-­ dimensional cross section. B-scan also enables the view accurately the other structures of the eye like the sclera, lens, vitreous, choroid, and retina. The most important function of this machine is to diagnose retinal detachment. C3R Machine: This machine is used for the treatment of Corneal Collagen Cross-linking with Riboflavin (C3R). With the help of this device, ultraviolet light is used to promote increased cross-linking between collagen fibres within the cornea. Contrast Sensitivity Chart: This machine is used to test the details of how eyes view contrast. The test called the sine-wave grating test is a contrast sensitivity test. Dynamometer: Dynamometer is used to measure the strength of eye muscles. Exophthalmometer: To measure the degree of forward displacement of the eye in exophthalmos, the exophthalmometer is used.

396

15  Department Wise Equipment Detailing

Femto Lasix: Femto laser is used for high-precision lenticular extraction. The machine combines femtoseconds and can cut the cornea precisely without opening a large corneal area. Fornixscope: A fornix scope is used to pull back and hold open the eyelid for proper examination of the conjunctiva. Fundus Camera: This is a low-power microscope and has a camera attached to it. Humpry Automated: Humpry is used for early detection of glaucoma, neuro-­ ophthalmic conditions and general screening. The device is also used to measure 24° temporally and 30 degrees nasally at 54 points. Indirect Ophthalmoscope: The indirect ophthalmoscope is used to see the fundus or back of the eye. The device produces a stereoscopic image with magnification ranging from 2× to 5×. Keratometer: A keratometer is used for measuring the curvature of the anterior surface of the cornea and for assessing astigmatism in terms of extent and axis. Lensometer: A lensometer, also known as a vertometer or focimeter, is to verify the power of the lenses of eyeglasses. It is also used to properly orient and mark uncut lenses and ensure the correct mounting of lenses in spectacle frames. ND-Yag Laser (Long-Pulse Yag Laser): Nd:YAG lasers is used to correct posterior capsular opacification. O.C.T: OCT is used to examine patients with glaucoma by generating an image of the retina. The picture is made by precisely measuring the amount of dim red light that reflects off the retina. Ocular Esthesiometer: An ocular esthesiometer is a device used to assess corneal sensitivity, by touching the cornea with a single-hair brush. Ophthalmic Camera: This camera, also known as a retinal camera, is used to take images of the retina for diagnosis of disease in the retina or progression of the disease. These images are also used to view the central and peripheral retina, macula and optic disc. Ophthalmic Refraction Unit: Ophthalmic refraction chair unit is a compact unit with various facilities for the initial examination of the eye, and the patient is made to sit on this chair for examination. The chair has a facility to mount a slit lamp, projector and near vision holder, auto-refractometer, ophthalmoscope, etc. on the unit. Ophthalmoscope: Ophthalmoscope is to see inside the fundus of the eye and other structures of the eye. Ophthalmic Laser (Green): This laser is used for the treatment of diabetic retinopathy. The laser is focused, and a bright powerful beam of light is thrown on the retina. This beam of light scars the areas of the retina, hence stopping the formation of new blood vessels and shrinking any new vessels that may be present. Ophthalmic Trial Frame and Trial Box: Trial frame is an eyeglass frame for holding trial lenses for refraction of the patient. A trial box is a set of glasses with different powers, and these glasses are mounted in steel rings. The trial box is used for a clinical examination to determine the refractive correction of the patient. Orbscan: The Orbscan is used to evaluate the anterior and posterior corneal surface topography along with the thickness of the entire cornea.

15.19 Otorhinolaryngology (ENT)

397

Pachymeter (NCT): Pachymeter is used to measure the thickness of the cornea by gently placing a probe on the cornea to measure its thickness. Radiation Beta Unit: Beta radiation is used for the management of lesions of the anterior segment of the eye. Retinoscope: A retinoscope is used to observe the light that is reflected from the retina by illuminating the inside of the eye. Slit Lamp: A slit lamp is a microscope with a bright light used for the general examination of the eye. The device gives a closer look at the eye both from the inside and front of the eye. Synapthophare: To diagnose and treat the imbalance of eye muscles by orthoptic methods, this instrument is used. Tonometer, Noncontact (Pachymeter): A noncontact tonometer measures the pressure of the eye, with the help of a small puff of air known as pneumotonometry. Visual Acuity Chart: The visual acuity chart, also called Snellen chart, is used to determine the vision by reading it from a distance of 20 ft. (6 m).

15.19 Otorhinolaryngology (ENT) See Table 15.19. Audiometer: Audiometer is a machine used for the evaluation of the hearing acuity. It tests both the intensity and the tone of sounds, balance issues and other issues related to the function of the inner ear. The headphone connected to the machine is given to the patient to wear for examination. Requirements of Infrastructure for Installation, Commissioning and Testing of Audiometer: For the audiometry test, the specifically designed room is required. This room shall be located near the ENT OPD and in the general movement area. Clean and sterilised areas are not required for this. The room of the audiometry shall be about 4267 mm × 4572 mm. This room shall have a glass partition in between. One portion of the room shall be the patient room, and the other the technician room. The patient room shall be completely soundproof and echoproof. For making the room soundproof and echoproof, acoustic treatment shall be done on the walls and ceiling. A wooden frame shall be fixed on the wall and ceiling, and in between the frame filling of glass, and wool shall be done. On the top, fireproof cloth shall be fixed. Another alternative is to do wall panelling on the wall with specially designed sound and echo absorption panels. The flooring shall be done with wooden planks or the carpet can be provided. The door of the room shall also be airtight so that no outer sound can enter the patient’s room. The technician room shall be a normal room with a glass window between the patient room and the technician room. This room shall have a working top below the glass window so that the technician can see the patient in the other room while the

398

15  Department Wise Equipment Detailing

Table 15.19  Otorhinolaryngology (ENT)

Activity Audiometer Bronchoscope (flexible or rigid) Bronchoscope, non-rigid Electroglottograph ENT examination unit with endoscope, camera and chair ENT microsurgical carbon dioxide laser Filli form set, eustachian Impedance audio meter Laryngoscope Nasopharyngoscope (flexible) Oesophagoscope (flexible or rigid) Otodyamics otoport (DP + TE) (OAE) Otoscope Speech trainer software Strobe laryngoscope (endoskope) KS Temporal bone lab station

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procedure is going on. The machine is placed on the technician’s side just below the glass window. Bronchoscopes: A bronchoscope is an endoscope used to visualise the inside of the airways for diagnostic and treatment purposes. The bronchoscope is inserted into the airways, usually through the mouth, nose or sometimes through a tracheostomy. Some bronchoscopes are rigid, and some are flexible. Electroglottograph: A electroglottograph or EGG (laryngograph) is used to noninvasively measure the degree of contact between the vibrating vocal folds during vocalisation. ENT Examination Unit with Endoscope, Camera and Chair: The ENT examination unit consists of an adjustable electric chair and an examination unit with endoscopes and other diagnostic instruments, such as ear and nose speculum,

15.19 Otorhinolaryngology (ENT)

399

throat mirrors, etc. This unit is used for the initial examination and diagnosis of disorders of the head and neck, ears, nose and throat. ENT Microsurgical Carbon Dioxide Laser: CO2 lasers are used for minimally invasive and high-precision head and neck procedures, such as removing cancerous tissue while preserving healthy structures, nerves and tissue. Requirements of Infrastructure for Installation, Commissioning and Testing of ENT Microsurgical CO2 Laser: Apart from the standard requirements, installation of the Microsurgical CO2 Laser requires a connection and port for the supply of carbon dioxide gas. The source can either be the standalone CO2 cylinder or the centralised CO2 gas pipe line of the hospital. Filli Form Set, Eustachian: Eustachian tube catheter is a device consisting of a thread-like catheter used for probing or dilating the Eustachian tube. Impedance Audio Meter: Impedance audiometry is used for tympanometry to determine the condition of the eardrum and middle ear. It is also used to assess the acoustic reflex pathways including the cranial nerves and auditory brainstem. Laryngoscope: Laryngoscope is used to view the larynx, vocal folds and glottis. It is used during general anaesthesia, for surgical procedures of the larynx and during resuscitation for intubation of an endotracheal tube. Nasopharyngoscope (Flexible): The flexible nasopharyngoscope is used for the examination of the nose, throat and airways. Oesophagoscope (Flexible or Rigid): An oesophagoscope is used to find out the cause of abnormal throat, stomach or bowel symptoms. Taking a tissue sample (biopsy) to diagnose cancer or other conditions, such as dysphagia or gastroesophageal reflux disease (GERD). Otodyamics Otoport (DP + TE) (OAE): Otoport DP Clinical OAE Handheld is used for OAE examinations and can be easily switched between analytical clinical modes and screening modes. Otoscope: An otoscope, also called an auriscope, is used to see inside the ears. Using the bulb and lenses built into the device allows the physician to look inside the ear canal and eardrum. Speech Trainer Software: Speech Trainer 3D provides an animated 3D video and audio model for 24 consonants and 7 vowels. Strobo Laryngoscope (Endoskope): A stroboscope is used to register the frequency of the voice with the help of a strobe light connected to the scope. The stroboscope is placed on the skin of the neck over the larynx, which then flashes slightly in sync with the frequency. The video image of the vibration of the vocal folds is created for analysis. Temporal Bone Lab Station: The temporal bone lab is to learn the complex anatomy of the temporal bone and ear at the base of the skull. Requirements of Infrastructure for Installation, Commissioning and Testing of Temporal Bone Lab: For installation of the temporal bone lab stations, a separate room may be of the size 4572 × 3657 shall be provided. The temporal bone lab shall have a provision

400

15  Department Wise Equipment Detailing

for the sink of the working top with the supply of water and also the drain below the sink to drain the water.

15.20 Dermatology, Cosmetology and Venereology See Table 15.20. Cryotherapy unit: Cryotherapy, also called cold therapy, is a technique in which the body is exposed to extremely cold temperatures for several minutes. The patient must stand in a closed chamber with the head protruding from the top of the chamber, and the body is exposed to the cold temperature for the therapy.

Table 15.20  Dermatology, cosmetology and venereology Status of works Activity Cryotherapy unit Derma abrader Derma peal Dermatological ultraviolet light Dermatoscopes Diode laser pulsed Electrocautery machine Fractional CO2 laser High-freq. Radio surgery unit Iontophoresis unit Liquid nitrogen cryogenic tank MIPL laser Phototherapy lamps PUVA chamber Q switched Nd-Yag laser RF cautery Skin biopsy punches Skin ultrasound imaging systems Woods lamp

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15.20 Dermatology, Cosmetology and Venereology

401

Dermabrader: Dermabrader is used to remove the outer layers of skin that have been damaged. This exposes the new layers of skin. Derma Peel: Derma peel helps to eliminate fine lines and wrinkles, shrink enlarged pores and build collagen and elastin that tighten and firm the skin. It is also used to reduce or even eliminate hyperpigmentation and melisma. The device is also helpful in removing acne and acne scars. Dermatological Ultraviolet Lamp: The ultraviolet lamp is used to treat certain skin conditions such as eczema, acne, psoriasis and vitiligo. Dermatoscopes: The dermatoscope uses visible light like LED bulbs and is used to examine suspicious skin lesions. Pulsed Diode Laser: Pulsed lasers emit light in the form of optical pulses. However, depending on pulse duration, pulse energy, pulse repetition rate, and required wavelength, different methods of pulse generation and different types of pulsed lasers are used. Electrocautery machine: Electrosurgical cauterisation is used to cut, dissect, coagulate, ablate, fulgurate and shrink the tissue. During the process, high-­frequency DC is passed through the tissue at various voltages resulting in heat generation. Fractional CO2 Laser: Fractional CO2 laser to stimulate natural collagen production in the skin of the face, neck, chest and hands. This results in a steady rejuvenation over several months that lasts for several years. This device is also used in conjunction with facial aesthetic surgery for a facelift or neck lift. High-Frequency RF Cautery: Radiofrequency involves passing high-frequency radio waves through soft tissue to cut, coagulate or remove it. Iontophoresis Unit: Iontophoresis is used to treat bursitis, tendonitis/tendinopathy and scar tissue. The technique used is electrical stimulation, which is used to deliver medication into the body through the skin. Liquid Nitrogen Cryogenic Tank: Cold storage tubes are made of lightweight aluminium to hold liquid nitrogen. MIPL Laser: Intense pulsed light (IPL) is used for various skin treatments such as hair removal and photo rejuvenation such as skin pigmentation, sun damage and thread veins. Phototherapy Lamps: Phototherapy lamps are ultraviolet light therapy that can effectively treat some types of skin diseases such as psoriasis, eczema and vitiligo. If the affected skin cells are regularly exposed to light, their growth can be slowed down. PUVA Chamber: PUVA (psoralen and ultraviolet A) is an ultraviolet light therapy used to treat skin diseases such as psoriasis, eczema, vitiligo, graft-versus-host disease, mycosis fungoides, large plaque psoriasis and cutaneous T-cell lymphoma. Q-Switched ND-Yag Laser: The Q-switched mode ND-YAG produces two wavelengths, one in the infrared range (1064 nm) and a second beam with a wavelength of 532 nm. These waves are suitable for superficial skin lesions. It is mainly used for the removal of melisma and tattoos, as it produces a high-intensity beam in very short pulses. RF Cautery: Radio frequency is used to cut, coagulate or remove soft tissue by passing radio frequency radio waves through the tissue.

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15  Department Wise Equipment Detailing

Skin biopsy punches: The skin biopsy punch is used to collect full-thickness skin samples. To the pencil-like handle of the device attached is the circular blade or trephine. Skin Ultrasound Imaging Systems: High-resolution ultrasound (HRUS) is used for the noninvasive evaluation of skin nodules and skin diseases. Woods Lamp: A Woods lamp uses long-wavelength ultraviolet light and is used to diagnose diseases such as tinea (a type of ringworm). When viewed with Woods light, the fungus lights up to reveal the fungal infection of the scalp or skin.

15.21 Oncology See Table 15.21. Brachytherapy: Brachytherapy involves the induction of a radioactive substance into the patient’s body. Brachytherapy is a form of radiation therapy used to treat cancer. Brachytherapy is a method of radiating tumours in which radioactive sources are placed either in the tumour tissue or close to the tumour. Brachytherapy is also referred to as internal radiation. Requirements of Infrastructure for Installation, Commissioning and Testing of Brachytherapy Machine: While designing the Brachytherapy Unit, the following issues shall be considered: 1. The brachytherapy treatment room is used to deliver a radiation source through a tube or applicator implanted during surgery. 2. The brachytherapy room is similar to that of the external beam irradiation unit, i.e., a bunker must be provided for brachytherapy. Therefore, all issues related to the bunkers must be addressed as mentioned above at LINAC. 3. In addition to the brachytherapy unit, there must be an equipped operating room with other facilities such as an anaesthesia induction room, washroom, recovery room, clean room, etc. 4. C-arm shall be provided in the brachytherapy unit for the placement of the applicator, which shall be installed either in the procedure room or in the treatment room, depending on local practises. 5. The brachytherapy bunker shall have a wall and ceiling thickness of at least 1000 mm. Table 15.21 Oncology Status of works Activity Brachytherapy :Cyber knife 6MV :Linac linear :accelerators

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15.21 Oncology

403

6. The illustrated labyrinth is 1800 mm wide to allow easy access in case of emergency, and the illustrated structure has no door. 7. The internal dimensions of the room are 4000 mm × 4000 mm × 3600 mm high (ceiling height 3000 mm) to allow sufficient space around the unit for manoeuvring a C-Arm and treatment cart when preparing the patient in the treatment room. 8. Since the radiation source emits isotopic radiation, a shielded roof is required. 9. Apart from the wall thickness and dimensions of the brachytherapy bunkers, all other aspects of the LINAC bunkers must be considered when designing the bunkers for brachytherapy. Cyber Knife 6MV: Cyber Knife is a system for Stereotactic Radio Surgery (SRS). SRS is a combination of principles of stereotactic or three-dimensional target radiation. In this procedure, beams from multiple directions strike the tumour at the exact location of interest. Because of its high precision, it is possible to direct higher doses of radiation to the target area with minimal damage to normal tissue and structures surrounding the tumour. Requirements of Infrastructure for Installation, Commissioning and Testing of Cyber Knife: As the Cyber Knife is also a high radiation machine, the infrastructure for installation, commissioning and testing shall be the same as that of the Linear Accelerator as mentioned under the head liner accelerator below. Linac Linear Accelerators: A linear accelerator, also known as LINAC, is a device used to deliver external beam radiation to cancer patients. A linear accelerator is a type of particle accelerator that accelerates charged subatomic particles or ions to a high velocity by exposing them to a series of oscillating electrical potentials along a linear beam path. Requirements of Infrastructure for Installation, Commissioning and Testing of Linear accelerator: While designing the external beam radiation unit, the following issues shall be considered: 1. External beam radiotherapy LINAC shall be installed in bunkers. The bunkers shall be constructed of high-density RCC materials such as concrete or steel. 2. The wall thickness of the bunker is usually 2400 mm in primary areas. The roof also has a thickness of 2400 mm in the primary area. 3. The bunkers have a maze-like structure. 4. The interior space of the bunkers has a size of 7000 mm × 7000 mm, with the iso-centre approximately in the middle of the space. 5. The bunkers shall offer an area for the shape of the LINAC unit and the most longitudinal extension of a standard patient treatment desk. 6. The gantry and the patient treatment table shall be engineered to rotate round an iso-centre. 7. The width shall allow comfortable access around the gantry and the patient for all angles of rotation.

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15  Department Wise Equipment Detailing

8. The plane of gantry rotation shall be parallel to the treatment control panel vicinity. 9. At the same time as designing the orientation of the bunkers, the issues of excessive occupancy areas shall be taken into consideration. 10. The minimal structural room height shall be four meters, together with the maze. This height is vital for ease of getting admission while equipment is installed to offer the air conditioning, heating, exhaust and air flow device design, and for installing extra electrical deliver cabling. 11. A maze width of 2000 mm–2200 mm shall be provided to ensure an adequate turning circle for gadget shipping. 12. LINAC is a very heavy machine weighing about 8–9 tonnes. As a result, the flooring needs to be very strong to endure this type of weight. 13. While installing LINAC for the first time, provision for the base-frame shall be provided. This base frame shall be measured from the centre to the back and shall be 6000 mm × 2000 mm × 610 mm deep excavation. 14. Two or more bunkers shall be designed adjoining each other to lessen costs by sharing the primary shielding. 15. The door shall be provided at the end of the maze, i.e. access to the bunkers, just to avoid unintentional entry inside the bunkers at the same time as the radiation is in progress. This door need not have shielding as this door is not for protection from radiation, but to offer a physical barrier and restrict access in the bunkers. 16. Getting admission to all through radiation shall be averted with an aggregate of mild sensors and/or push gates or barriers which might be interlocked to the control panel. 17. Usually, the bunker occupies 1.5 floors till the top of the bunker. Access to the roof of the bunkers shall be confined and cordoned off, with a security entrance, interlocked to the machine. 18. The equipment like the water chillier and the air-conditioning plants can be placed on the roof, as these varieties of the system require controlled access. 19. Linear accelerator bunkers require radiation protection that could include leading protection and concrete partitions, floors and ceilings to distinctive thicknesses. A neutron door can also be required relying on the type of linear accelerator used. 20. The radiation protection needs of the unit shall be assessed by using a licensed physicist or suitable agency. This assessment is to specify the sort, place and quantity of protection to be installed according to the final permitted layout and system choice. The radiation safety necessities shall be incorporated into the final plans and specs. An early session with the producers of radiotherapy equipment is usually recommended. 21. For LINAC with a maximum power of 10 MV, neutron defence is not always required. 22. The lifespan of the facility and the need to improve technology ought to be taken into consideration while specifying the radiation shielding required. It is far possible that the machines might be upgraded and more recent machines may or may not emit more potent radiation. Consequently, it is sensible to permit the highest energy system and widest beam that is likely to be used in the future.

15.22 Operating Rooms

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23. The bunker shall be supplied with plumbing and electric provisions. The underground conduits for these lines shall now not be straight but should be angulated on the attitude of 45 tiers. 24. The bunker shall be provided with the provision of power being delivered to the LINAC according to the requirement of the machine. Therefore, the manufacturer of the gadget shall be contacted in advance even before designing the bunkers. 25. Provisions for joints, ducting and sleeves should not comply with the divergence of the number one beam, and this is effortlessly executed by setting those in the secondary defensive and using a curved path. 26. The provisions of the mechanical, electric and safety shall all be taken into consideration like supplying dimmable lighting inside the room, emergency switches and the provision of standby lights. 27. Provision for ducting shall be provided in the bunker for connection between the gantry structure and the treatment control panel. 28. Further, isolated ducts should be provided for dosimeter cables and connectivity to the chiller system. 29. After the installation of the gadget, false ceilings shall be furnished within the bunkers. 30. Each bunker shall be furnished with control rooms. Those regions shall be positioned outdoors in the maze of the bunker. 31. The bunkers shall be supplied with a patient intercommunication tool and at least two closed-circuit tv monitors, to speak with the patient whilst the therapy is in development. 32. The working top within the control area shall be of adequate length to provide spaces to set up all of the video display units and other control devices in conjunction with the patient information documents, sheets and images to be used at the same time as therapy is in progress. 33. Electric power outlets shall be provided alongside the whole length of the worktop to allow a connection of devices to be powered, consisting of extra emergency switches. 34. The X-ray viewing box with ambient lighting fixtures shall be provided inside the control room. 35. The area shall be provided alongside the control room for a networked imager or printer. This facility can also be shared with brachytherapy.

15.22 Operating Rooms 15.22.1 General Items in All Operating Rooms See Table 15.22. Anaesthesia Workstation: The device is used to administer anaesthesia to the patients before and all through surgery. It is far designed in such a fashion that can

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Table 15.22  General items in all operating rooms

Activity Anaesthesia workstation Boyles machine Camera HD C-ARM Cryogun Defibrillator EES generator (harmonic) Elec. Surgical cautery Head light Heavy duty OT Hyperthermia system, extracorporeal Insufflator Laparoscopy set Laser scalpel LED monitor medical grade Light source with fibreoptic cable Microprocessor-­ controlled electrosurgical unit Mobile ultrasound system Modular operation theatre with pendants Morcellator Multipara monitor with ETCo2 OT light OT Pneumatic tourniquet electric Portable OT light Recording system Scrub station Suction machine electrical

Status of works Start End Not Responsible date date Complete In-progress started person :::::::::::-

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Table 15.22 (continued)

Activity Surgical loupe Surgical operating instruments for all departments Telescopes Uninterrupted power system (UPS) Vaporiser

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

::-

:::-

mix and control the drift of nitrous oxide and oxygen. This device also consists of an invasive ventilator and the gases are delivered with the assistance of this ventilator. Requirements of Infrastructure for Installation, Commissioning and Testing of Anaesthesia Workstation: The anaesthesia workstation also consisting of the ventilator mixes the flow of Nitrous Oxide and Oxygen to anaesthetise the patient. Therefore, apart from the routine installation requirements, the ports of centralised nitrous oxide and oxygen shall be provided near the workstation. As a backup, it is advised to provide one spare port for both gases, so that it can be used in case of failure of the working port. Boyles Machine: Boyle device is a device to combine medical gases along with the accurate concentration of anaesthetic vapour, and delivers this to the patient continuously at a secure pressure and flow. Requirements of Infrastructure for Installation, Commissioning and Testing of Anesthesia Boyles Machine: As the Boyles machine works in a similar pattern as the anaesthesia workstation and mixes the flow of nitrous oxide and oxygen, therefore apart from the routine installation requirements, the ports of centralised nitrous oxide and oxygen shall be provided near the workstation. As a backup, it is advised to provide one spare port for both gases, so that it can be used in case of failure of the working port. Camera HD: The HD digital camera is one part of the laparoscopic surgical operation and is used to record the high-resolution, full-featured, coloured, multi-­ layout photographs. The digital camera is mounted on the distal end of the endoscope to provide an unobstructed view of the surgical site. C-ARM: C-Arm is an X-ray-based imaging intensifier. The CCD digital camera/ X-ray detector and the X-ray source are provided on the C-fashioned arm opposite to each other. C-Arm is used for fluoroscopic intraoperative imaging during surgeries and invasive procedures. Requirements of Infrastructure for Installation, Commissioning and Testing of C-Arm, or so-called Image Intensifier: C-Arm is a machine working with the technology of X-rays. The X-rays are generated by the X-ray tube and the CCD camera or the flat panel above the tube

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15  Department Wise Equipment Detailing

captures the rays and converts the same in an image format. As the machine is X-ray-based, almost the same precautions shall be taken care of as in the case of an X-ray machine, like. The walls of the room shall be at least 229 mm thick, with plaster on both sides. The ideal thickness for the primary wall of an X-ray room is at least 250 mm of solid baked clay bricks, and 150  mm of mortar/concrete walls for plain radiography. Hollow bricks should be plastered with a thickness of 6  mm barium plaster and should be protected up to 2200 mm from the floor level. The door should be at least 1500 mm wide and 2000 mm high. The door and its frame need to have a 2 mm thick lead lining. There shall be no leakage of radiation from the door. Doors should overlap by a minimum of 100  mm on each side when closed. A warning light (red colour bulb) shall be provided outside the door. This light must be connected to the X-ray generator in a way that it illuminates only during the tube activation. Depending on the machine’s capacity, the power load required by the machine shall be calculated and the main switch and cable shall be separately terminated in each radiography room. The temperature in the room shall range between 18 and 21 °C, and the humidity level shall not be more than 60%. Cryogun: The patented cryogun permits works in situ for the maximum accurate sample collection. The patented cryogun assures of the fine-frozen and/or vitrified samples. Defibrillator: Defibrillator sends an electric pulse or shocks to the coronary heart which restores the heartbeat. The defibrillator is likewise used to prevent or correct arrhythmia. Defibrillators can also be useful in restoring the heart’s beating, in case the coronary heart unexpectedly stops. This device is also a life-saving device. EES Generator (Harmonic): The harmonic scalpel is similar to surgical cautery but more advances and is used to cut and cauterise tissue concurrently. Elec. Surgical Cautery: Electrosurgical cautery is used to cut and cauterise the tissue with a pencil-like probe connected to the device. With this pencil probe technique, the tissue is heated by using a high-voltage DC and is heated up. Headlight: A headlight is a LED light equipped with microscopic lenses and is used for microsurgery or routine exam additionally. Heavy Duty OT: Heavy duty tables are the tables which have more weight-­ bearing capacities and are generally used for Bariatric patients. Hyperthermia System, Extracorporeal: The hyperthermia system is to raise the overall core body temperature as much as 107–108 °F which helps in killing the malignant cells, that is often carried out by using hot water blankets or thermal chambers, which resemble massive, human-sized incubators. Insufflator: Insufflator is to blow CO2 in the belly while performing the laparoscopic surgery. Laparoscopy Set: Laparoscopes are thin telescopes fitted with a cold light source and a video digital camera on the distal end. These scopes pass inside the body, and the image is captured by digicam underneath brighter situations and

15.22 Operating Rooms

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displayed on the screen. The laparoscopic gadgets are passed inside the body of the patient through the laparoscope, and the favoured surgical operation is accomplished. Laser Scalpel: The light scalpel is a CO2 laser which produces a concentrated beam of light. The particularly focused CO2 laser beam vaporises and seals the blood vessels concurrently very cleanly and exactly. LED Monitor Medical Grade: A LED scientific monitor is a display that meets the high needs of clinical imaging. Medical monitor normally includes unique picture-­enhancing technologies to make sure constant brightness, ergonomic reading, noise-free photographs and automated compliance with DICOM and different medical standards. Light Source with Fiber-optic Cable: A light source is to provide high-­intensity light and transmits it to the end of the endoscope through the fibre-optic cable. The light source is available with halogen bulbs or LED bulbs. Microprocessor-Controlled Electrosurgical Unit: ESU is a surgical cautery for cutting and cauterisation. However, it is managed through the fast microprocessor for processing all operating parameters. Mobile Ultrasound System: Transportable ultrasound is a small and light device and is largely used within the OR or the patient’s bed for an ultrasound. The gadget operates with a battery power backup. Modular Operation Theatre with Pendants: Modular running theatre is a theatre constructed with modules having a provision of air filtration through HEPA filters and air waft in a laminar fashion. It includes a modular wall, ceiling with slanted panels, control unit, plenum, PDR and HEPA filters with a provision of laminar float to maintain the effective positive air pressure inside the OR. The OR has facility of electrical outlets and medical gas outlets alongside the surgical or anaesthetic pendants. Requirements of Infrastructure for Installation, Commissioning and Testing of Modular Operating Rooms: There are extraordinary styles of OR as follows: There are different types of OR as follows: 1. 2. 3. 4. 5.

Simple room OR. Prefabricated modular OR. Semimodular OR. Modular OR. Hybrid OR.

Simple Room OR: These are the simplest type of operating rooms without a precise provision of sterility, no environment consideration and no air exchanges. In these OR: 1. There is no specific size of such OR and are purely built-up as per the requirement of the promotor. 2. The walls of the OR are all just simply plastered. 3. On the walls, either washable paint or glazed tiles are affixed. 4. The ceiling is normally plastered or at the maximum POP false ceiling is used.

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15  Department Wise Equipment Detailing

5. The flooring may be of everyday marble stone or glazed tiles. 6. The doorways can be of normal wood door or aluminium. 7. The OT is just placed in the centre of the room. 8. OT light is fixed at the ceiling in the centre of the room. 9. A proper pipeline for medical gases is not laid down. 10. For air conditioning, generally, split air conditioners are used. Prefabricated Modular OR: These are the most commonly used type of operating room. They are evolved inside a room having partitions. These ORs fulfil the maximum needs of an ideal OR like sterility, environment, temperature, humidity, air exchanges, cleanliness, air flow, internal pressure, etc. The details of these ORs are as follows: Size of the OR: Standard size of these ORs shall be 6096 mm × 6096 mm, i.e. 37.16 m2. But, for specialised surgeries such as Neuro, Cardiac, Robotic Surgery, etc., the size has to be bigger and shall be about 46.45 m2. Still further, for transplant surgical procedures like renal, liver and coronary transplants, the area shall be about 74.32 m2. Walls of the OR: Walls of these types of ORs are artificially created in front of the pre-built brick walls. Initially, the prefabricated panels are fixed on the wall. These panels are then arranged on the walls and fixed with rod fasteners about 152 mm–254 mm far from the wall, hence creating a vacuum between the wall and the panel to further reduce the thermal losses. These sets of panels are now welded to each other so that no space is left between the panels. The extra welding spots are grinded to smoothen the panel surface. These panels have to be arranged in such a fashion that there are no sharp 90° corners because corners are not allowed in the ORs. Instead, the panels are laid and welded in such a fashion so that the angle of the corners are at 45° instead of 90°. The ceiling of the OR: The ceiling of these ORs is likewise fabricated from the puff panel similar to that of the wall panels. In the centre of the OR, a Plenum is hung from the ceiling with the help of screw rod fasteners. Just in the centre of the Plenum, a round cut-out is given to hang the OT light from the ceiling. As no sharp corners are allowed in the ceiling also, slanted panels are provided on the vertical panels, which shall ultimately be jointed and welded to the ceiling panels. Corners of OR: All four corners of the OR shall be covered and protected. First of all, the return air duct, which is a vertical duct fabricated from an aluminium sheet, is fixed with clamps screwed to the wall on all four corners of the OR. The leftover spaces in the corners, where the wall panels were not fixed earlier, are covered with the same type of puff panel as was fixed to the wall. These corner panels shall also be installed at a 45° angle to avoid corners. Door of the OR: A prefabricated puff door shall be installed. The width of the door shall not be less than 1524 mm. This door shall be a hermetically sealed door, which enables sealing of all the surfaces of the door and wall and shall not permit any leakage of air in or out of OR. These doors can either be manually operated with a handle or can be motor-driven.

15.22 Operating Rooms

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Window in OR: The window in the OR is fixed on the outer wall of the OR. The size of the window may be 610 mm–1000 mm in width and approximately 610 mm in height. The windows shall be a fixed type and not openable. The glass of the windows shall be double-glazed glass with a vacuum in between. In the vacuum space, between two layers of glass, vanishing blinds can be provided, which shall be motorised and controlled by a switch button or remote. Pass-Through Windows/Hatch Boxes: These are provided in the OR to pass clean supplies and material inside the OR without opening the doors of the OR. This window has two doors opening on both sides. While designing these windows, unique attention shall be paid that at any moment, only one door can be opened. If the material has to be passed from the outside of the OR, the outer door shall be opened and the inner door on the OR side shall be automatically locked. Once the outer door is closed, the inner door shall be opened and the outer shall automatically be locked. This shall be applicable visa-versa also. Plenum: As stated earlier, the plenum is a box-type structure hung from the ceiling. Its main purpose is to fix HEPA filters for air filtration and form a unidirectional glide of air. The plenum is closed from the bottom end either by fixing a framed silken fabric or by way of a stainless steel sheet which has multiple holes for the passage of the air. Control Panel: The control panel is recessed in the panelled wall next to the entrance of the OR. This panel is used to control and govern the functioning of the entire OR. Normally, the control panel can manage the functions like OT light, plenum lights, peripheral lights, clock, time elapsed, hand-free intercom, temperature meter, medical gases pressure, humidity meter and the music system (if provided). Writing Board: A magnetic white writing board is also recessed in the panelled wall adjoining the view box located in front of the surgeon. View Box: The LED view box is recessed in the panelled wall which shall be located in front of the surgeon for easy visibility, while the surgeon is operating. Pressure Relief Damper (PRD): To reduce the excess pressure in the OR, the PRD is installed. PRD is a set of stainless-steel fins connected at a specific distance, and a stainless-steel weight is welded on one of the fins. The PDR is fitted at the bottom in the cut-out of a wall of the OR. This PDR automatically opens in case the pressure in the OR increases and automatically closes once the pressured reaches with in the normal limits in the OR. Flooring: The OR shall have anti-static flooring, i.e. they have adequate earthing properties. It is PVC flooring with a layer of carbon coating at the bottom. As soon as the tile or roll is glued, the joints are thermowelded with a PVC twine to fill any gaps in the flooring. Painting: All surfaces (walls and ceiling) of the OR shall be painted. First of all, a coat of primer is applied. Then, the metal putty is applied to fill any gaps. After scrubbing the surfaces with sandpaper, at least two coats of washable antibacterial and anti-fungal paint shall be applied. Peripheral Lights: In the straight panel of the ceiling of the OR, peripheral lights are recessed. The peripheral lights are LED lights packed in a unit and have

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15  Department Wise Equipment Detailing

the facility of a dimmer. Usually, 8 such lights are fixed in the OR, two on each facet of the OR. These lights have a provision for dimming or switching off as per the choice of the surgeon. Plenum Lights: Plenum lights are usually a set of about 15–30 LED tube lights fixed in the plenum. These lights have a provision for dimming or switching off as per the choice of the surgeon. These lights give an excellent look, and the OR brightens up when these lights are switched on. Anaesthetist Pendant: At the left-hand side of the patient, an anaesthetist pendant shall be hung from the ceiling. The pendants can either be single-arm or double-­arm pendants. The pendant ends up with a square or rectangular box-type structure. On the back wall of the pendant box, the outlets of medical gases shall be fixed. Two outlets of each supply, i.e. oxygen, suction, compressed air and vacuum shall be provided. On both, sidewalls of the box of pendant, electric and communication ports shall be provided. On the front wall of the pendant box, a service tray and drawers shall be provided. Surgeon Pendant: On the right-hand side of the patient, a surgeon pendant can be given, if required. This is generally a fixed arm pendant which can simply revolve on its axis. This pendant is especially utilised by the surgeon and has electrical outlets on the sidewalls and a couple of of-three trays. Air Conditioning and Environment of ORs: The OR shall be fully air-­ conditioned, allowing manipulation of temperature, humidity and air exchanges. Suitable and safe air quality must always be maintained in the OR. Special Air Requirements for OR: Based on the biological load and the area of the OR, the minimum total air changes shall be 20. Out of 20 air changes, the fresh air component of the air change shall be a minimum of 4. The airflow needs to be downwards on the OR table and shall be unidirectional. It is suggested that the velocity of the air shall be 25–35 FPM (feet per minute) from a non-aspirating unidirectional laminar flow diffuser/ceiling array. The minimum positive pressure recommended is 2.5 Pascal (0.01 inches of water). Air shall be supplied through terminal HEPA filters installed in the plenum suspended from the ceiling. The HEPA filters can be at the AHU level or the terminal level inside the OR. AHU is the air purification and filtration unit. There shall be two sets of washable flange-type filters of efficiency 90% down to 10 microns and 99% down to 5 microns with aluminium/stainless steel 304 frames within the AHU. The temperature inside the OR shall be maintained at 21 °C ± 3 °C (except for joint replacement where it shall be 18 °C ± 2 °C). Similarly, the relative humidity shall be between 20 and 60%, though the ideal relative humidity is considered to be 55%. Electrical Outlets: Sufficient number of electrical outlets shall be provided in the OR for connecting the medical/electrical appliances. It is recommended that at least two dual sets of 6/16 amp (it means 4 outlets) switch/sockets shall be provided on each wall of the OR. Importantly, all these electrical outlets shall have a supply through the UPS for an uninterrupted supply of power. Other Communication Points in OR: R.J. 45 points for computer networking, R.J. 11 for Intercom and extension line shall be provided in each OR.

15.22 Operating Rooms

413

Modular OR: These types of OR are such where the complete structure is fabricated using angles, sheets and channels, and other specialised sections made of either mild steel or stainless steel. These fabricated structures then are assembled, at a particular location demarked for OR, to give it a shape of a room-like structure. Henceforth, the prefabricated wall panels and ceiling panels are fixed in these fabricated structures to make them a room. Hybrid OR: It is an OR where multidisciplinary integration is done by combining advanced imaging diagnostics and surgery to the operating table, which allows surgeons, radiologists and other health care providers to use real-time images for guidance and assessment during complex surgeries. As different types of procedures such as cardiac, vascular and neurosurgery are performed in a hybrid OR, it requires a variety of imaging equipment to be used. Some examples of commonly installed imaging equipment in a hybrid OR are Angiography Equipment (Cathlab), Computed Tomography (CT) Scanners, Magnetic Resonance Imaging (MRI) Scanners, C-arm, X-ray, and Digital Subtraction Angiography Systems (DSA). A hybrid OR shall be at least 1.5 times larger than a normal OR. Morcellator: A power morcellator is usually used during laparoscopic surgery to cut bigger chunks of tissue into smaller ones. Multipara Monitor with ETCO2: The machine is used to monitor the CO2 levels of intubated and non-intubated patients. This monitor is used in the ORs when the patient is in an anaesthesia workstation. At times, this monitor is also used to monitor the vital parameters of sick patients in the ICU. OT Light: An OT light is a ceiling-mounted LED/Halogen light used for surgery in the OR to aluminate the surgical field. This light is a high-lumen light and facility to adjust the lumens as per the requirement of the surgeon. These lights are shadow less and cool lights and do not generate heat. OT: An operating table is a table used to lay down the patient for surgery. The table is a multipositional adjustment table and has a provision to fix the required attachments to ease specialised surgeries like the spine and orthopaedic etc. Tables with different operating mechanisms are available like hydraulically operated, electrically operated or a combination of both. Pneumatic Tourniquet Electric: Pneumatic tourniquet is to apply and hold a pre-determined pressure on the arterial blood flow, through cuffs. This is required to create an environment for a bloodless surgical field. The machine consists of a pressure-­regulated control unit with inflatable cuffs. Requirements of Infrastructure for Installation, Commissioning and Testing of Pneumatic Tourniquet: This machine works on the pressurised air supply. Hence, a port for air supply shall be provided in the operating room. The supply shall be from the centralised medical pipeline system. Portable OT Light: A portable OT light unit is again a LED/Halogen light used for surgery in the OR to aluminate the surgical field. This light comes with a battery backup and the flexibility of clamping it to the OT. Recording System: A recording system is used to record the live and still images of the surgeries and procedures in HD format. These recording systems are

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15  Department Wise Equipment Detailing

generally attached to the endoscopes/laparoscopes during surgeries. The images or videos captured by these recording systems can either be displayed on the screen or can be saved for later retrieval. Scrub Station: Scrub sink is generally a pedestal SS sinks fitted with sensors and the foot paddle and is used for scrubbing before surgery by surgeons and other surgical staff. Scrub sinks are normally sensor-operated, foot-operated or hand-­ operated. These sinks shall have a provision of being connected to the hot and cold water supply lines. Requirements of Infrastructure for Installation, Commissioning and Testing of Scrub Station: Scrub Station requires clean water under high pressure to facilitate hand washing and scrubbing. Therefore, apart from the routine installation requirements, the water outlet shall be provided near the scrub station. Also, the provision for hot water shall be done near the scrub station. The hot water source can be like standalone geysers or the central hot water supply system. A proper drain point shall also be provided near the scrub station to drain the used water into the sewerage lines. Suction Machine Electrical: The suction machine is used to remove any obstruction from a patient’s airway and is a tracheostomy-care device. By the technique of negative pressure, the machine help to create suction to pull out mucus, blood, secretions, saliva or other fluids stuck up in the airway, thereby clearing the airway for easy breathing. Surgical Loupe: Surgical loupe is a device to enhance and magnify the field of surgery and is generally head wearable. Surgical Operating Instruments: For any type of surgery, the surgeon apart from equipment needs a set of instruments to perform surgeries. The basic instruments are like scissors, artery forceps, BP handle, Babcock, retractor, needle holder, dissecting forceps, speculum, etc. Further, every item of an instrument may have different variants based on shapes and sizes. The instruments shall be procured as per the recommendation of the surgeon. Telescopes: The telescopes are used for incisive surgeries, procedures or examinations inside the body. The telescope is a tube-like device which can either be flexible or rigid. Some of the telescopes can be semiflexible also. The telescope has a light bulb at the distal end to transmit light coaxially through each barrel, to provide converging light at the operative sight. The telescopes also have a camera mounted on the distal end to capture the images and transmit them to the processing unit which in turn displays the images on the screen or can be the recorder. Uninterrupted Power System UPS: UPS shall be provided in every operating room. Depending on the factors like the electrical load of the OR, the load of the medical equipment to be connected for power backup; the duration of power backup required etc., the rating of the UPS shall be worked out. However, it is recommended that the rating of 10  KW with 30  min backup shall be provided in the OR. Vaporiser: Vaporiser is a device used for vaporizing anaesthetic reagents for easy inhalation.

15.22 Operating Rooms

415

15.22.2 Operative Room CTVS See Table 15.23. Cardiopulmonary Bypass Blood Pump (Heart Lung Machine): Cardiopulmonary bypass blood pumping machine (CPB) also called a Heart Lung machine is used during cardiac surgeries to stop the heart from beating whereever required to perform the surgery. The machine takes over the function of the heart and the lungs and helps in maintaining the circulation of blood and the oxygen content of the body. Requirements of Infrastructure for Installation, Commissioning and Testing of Heart Lung Machine: As Heart Lung Machine requires oxygen for working. Hence, an oxygen port shall be provided near the Heart Lung Machine. It is advised that the supply source shall be from the central medical pipeline system. As a backup, it is advised to provide one spare port of oxygen, so that it can be used in case of failure of the working port. Hypothermia Device (Blanket, Plumbing and Heat Exchanger): This device is used for controlling the temperature of the patient’s body. Intra-Aortic Balloon Pump: An intra-aortic balloon pump, shortly called IABP, is used to control the flow of blood through the aorta. The device is fitted with the aortic balloon, which gets deflated when the heart pumps blood, to give way to the blood to flow out in the body, and gets inflated when the heart relaxes to retain more blood in the heart. Table 15.23  Operative room CTVS

Activity Cardiopulmonary bypass blood pump (heart lung machine) Hyperthermia device (blanket, Plumbing and heat exchanger) Intra-aortic balloon pump Patient warming system Sternum saw Sternum saw battery Sternum saw battery charger Sternum saw blade guard Vacuum stabiliser system octopus

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

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15  Department Wise Equipment Detailing

Patient Warming System: A patient warming system (PWS) is used to provide heat to the patient before, during or after the surgical procedures. The device uses either the heated surgical table pad or over-body blanket immediately upon transfer to the surgical table. Sternum saw with Battery, Battery Charger and Blade Guard—A sternum saw is a bone cutter and is used to cut the sternum bones to open the patient’s chest to perform surgery. The saw resembles a jigsaw in appearance and has a reciprocating type of blade. Vacuum Stabiliser System Octopus: The Octopus tissue stabiliser is used for cardiac surgeries on the beating heart. The device immobilises the target site of the coronary artery of the heart while performing bypass cardiac surgery.

15.22.3 Operating Room ENT See Table 15.24. Drill and Saw System: Bone drill is used to drill holes through the bones or cut the bones to fix implants during orthopaedic and ENT surgeries. The device either be electrically operated or pneumatically operated. Requirements of Infrastructure for Installation, Commissioning and Testing of ENT Drill and Saw System: The ENT drills and saws are either electrically operated or can be pneumatically operated. If electrically operated, nothing much has to be done except providing the electrical points. If pneumatically operated, a port for the supply of air (7 bar) shall be provided in the OT or near the OT. It is advised that the supply source shall be from the central medical pipeline system. As a backup, it is advised to provide one spare port of air so that it can be used in case of failure of the working port. ENT Operating Microscope: Microscope is used to carry out complex invasive ENT surgical procedures with a high level of precision to enable the best possible clinical outcomes.

Table 15.24  Operating room ENT Status of works Activity ENT drill and saw system ENT operating microscope

Start date ::-

End date

Not Responsible Complete In-progress started person

Remarks

15.22 Operating Rooms

417

15.22.4 Operating Room Eye See Table 15.25. Cryophthalmic Unit: A cryophthalmic unit is a device that is used to remove cataracts by the formation of an adherent ice ball in the lens. It is also used to freeze the eye and adjunct parts for the surgical removal of scars. The device consists of a small tip mounted on the probe which becomes extremely cold through the controlled use of a refrigerant or gas. Ophthalmic Operating Loupe: Surgical loupe is used to enhance and magnify the field of surgery and is a head wearable device. These loupes are used in strabismus and retinal cases or for oculoplastic procedures. Ophthalmic Operating Microscope for Cataract and Vitrectomy: Operating microscope is a device used for ophthalmic surgeries having small structures. For magnification, the device is fitted with light- and high-powered lenses. Ophthalmic Laser (Green): This laser is an argon laser which emits blue-green wavelengths. The red haemoglobin cells in the blood under the retina absorb these waves for procedures. Photofragmentation Unit: Photofragmentation is used during refractive and cataract surgery for the removal of the eye lens. With this device, the lens is removed from the eye in the pieces through a 4 mm–5 mm incision once the lens has manually deteriorated after crystallisation. Vitreous Aspiration and Cutting: A vitreous aspiration is an ultrasound-based device and is used for removing the vitreous matter from the vitreous cavity or removing a crystalline lens from the eye. Table 15.25  Operating room eye

Activity Cryophthalmic unit Ophthalmic operating loupe Ophthalmic operating microscope for cataract Ophthalmic operating microscope for vitrectomy Ophthalmic laser (green) Photofragmentation unit Vitreous aspiration and cutting

Status of works Not Start End Responsible date date Complete In-progress started person Remarks :::-

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15  Department Wise Equipment Detailing

15.22.5 Operating Room Gynaecology See Table 15.26. Culdoscope: Culdoscope is a kind of endoscope is used to visualise female pelvic organs by introducing the scope through the vagina into the cul-de-sac. Fetal Doppler: A Doppler fetal monitor is a handheld ultrasound transducer used to detect fetal heartbeat for prenatal care. Hysteroscope and Hysteroscope Pump: Hysteroscope assisted by hysteroscopy pump is a thin device used for the examination inside of the cervix and uterus by inserting it through the vagina. Hysteroscopes are also used to take a biopsy sample or for the removal of polyps or fibroid tumours.

15.22.6 Operating Room Neurosurgery See Table 15.27. CUSA: Ultrasonic cavitation device is an ultrasound probe (acoustic vibrator) combined with an aspirator device and uses the technology of low-frequency ultrasound energy to dissect or fragment tissues with low-fibre content. Neurosurgeons Table 15.26  Operating room gynaecology Status of works Activity Culdoscope Fetal Doppler Hysteroscope Hysteroscopy pump

Start date

End date

Not Complete In-progress started

Responsible person

Remarks

::::-

Table 15.27  Operating room neurosurgery Status of works Activity CUSA Drill and saw system Neuro endoscopes Neurosurgical operating microscope and spine drill O-arm navigation—spine Stereotactic frame

Start date ::::-

::-

End date

Not Responsible Complete In-progress started person

Remarks

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use this device to ‘cut out’ brain tumours without adversely affecting the surrounding healthy tissue. Drill and Saw System: Bone drill is used to drill holes through the skull bones or cut the bones to perform neurosurgeries. This device is either electrically operated or pneumatically operated. The attachments to the device are drills, saws, reamers, blades, etc. Requirements of Infrastructure for Installation, Commissioning and Testing of Drill and Saw System: The drills and saws are either electrically operated or can be pneumatically operated. If electrically operated, nothing much has to be done except providing the electrical points. If pneumatically operated, a port for the supply of air (7 bar) shall be provided in the OT or near the OT. It is advised that the supply source shall be from the central medical pipeline system. As a backup, it is advised to provide one spare port of air, so that it can be used in case of failure of the working port. Neuroendoscopes: Neuroendoscope is an endoscope to perform minimally invasive surgeries on the brain and is generally used to remove the tumour from the brain through small holes in the skull or the mouth or nose. This device enables to reach such regions of the brain which are otherwise difficult to reach by traditional open surgeries. Neurosurgical Operating Microscope and Spine drill: This operating microscope like other microscopes has a provision for higher magnification under illumination and provides a better and enlarged view of the field of surgery. The microscope also has a facility of connecting the camera in the third eyepiece of the microscope for recording purposes. O-Arm navigation: Spine: The O-arm navigation allows visualisation in real-­ time of the surgical site and is generally used for spine surgeries. The beauty of the machine is its mobility, lower doses of X-ray images and speedy image processing, which provides live 3D navigation during surgery. Stereotactic Frame: A stereotactic head frame is used for targeting surgery by tracing out the reference points. In the process, the frame is fixed at the patient’s head using local anaesthesia to numb the scalp to perform surgeries.

15.22.7 Operating Room Urology See Table 15.28. Cystourethroscope: Cystoscope, or so-called cystourethroscope, is used to have an inside view of the bladder and urethra in detail for diagnosis or surgery. Flexible Fiber Urotero Renoscope: The Flexible Uretero-Renoscope is an endoscope used to have better access and ability to perform surgeries on the upper urinary tract. The device is mounted with a light bulb and high-resolution camera at the distal end, which provides clear, sharp images.

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Table 15.28  Operating room urology

Activity Cystourethroscope Flexible fibre urotero-renoscope 270° Holmium/thulium Yag laser Nephoscope Paediatric cystoscope Resectoscope Urethrotome

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

::-

:::::-

Holmium/Thulium Yag Laser: Holmium YAG laser is the desired laser for lithotripsy and is used in urology. The Holmium laser operates at 2120 nm and provides energy via optical fibres with core diameters starting from 200 μm to1000 μm. Nephroscope: Nephroscope is used for a procedure called PCNL wherein small kidney stones and small tumours is removed from the kidney. In the process, through a small cut, the nephroscope is inserted inside the kidney to remove stones up to about 1 cm. Paediatric Cystoscope: Paediatric cystoscope is slim in design as compared to the adult cystoscope. Cystoscopes varying different sizes and types like straight or angled channels and angled or straight ocular, both with 70o direction of view and 4.2 Fr channel. Resectoscope: Resectoscope is used to cut, remove or destroy tissue and control bleeding and also used to remove tissue from the body. Urethrotome: Urethrotome is an endoscopic device and is used to treat urethral stricture under direct visualisation. This instrument consists of a knife blade that is deployed by the surgeon during surgeries.

15.22.8 Operating Rooms Orthopaedic See Table 15.29. Arthroscope Set with Accessories for Knee and Shoulder: Arthroscope is an endoscope-like instrument which is smaller in size. It is just about the size of a pencil and is used for arthroscopic surgeries of joints like the knee and shoulder. An arthroscope consists of a lighting bulb, camera and lens mounted on the distal end of the arthroscope, which allows a surgeon to view inside a joint. The surgeries with the help of an arthroscope are performed through small incisions and the joint need not be fully opened.

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Table 15.29  Operating room orthopaedic Status of works Activity Arthroscope set with accessories for knee and shoulder Bit, drill, micro motors, saw reamers, etc Navigator for hip replacement Navigator for knee replacement

Start date

End date

Not Responsible Complete In-progress started person

Remarks

:-

:-

::-

Bit, Drill, Micro Motors, Saw Reamers, etc.: These tools are used for cutting and drilling the bones. These items are used in different types of orthopaedic surgeries starting from simple surgeries like intramedullary nailing of long bone fractures to complex surgeries like total joint arthroplasty. Requirements of Infrastructure for Installation, Commissioning and Testing of Drill, Micro motors, Reamers and Saw System: The Drill, Micro motors, Reamers and Saw Systems are either electrically operated or can be pneumatically operated. If electrically operated, nothing much has to be done except providing the electrical points. If pneumatically operated, a port for the supply of air (7 bar) shall be provided in the OT or near the OT. It is advised that the supply source shall be from the central medical pipeline system. As a backup, it is advised to provide one spare port of air, so that it can be used in case of failure of the working port. Navigator for Hip Replacement: Navigation helps to minimise errors during surgery. This device provides real-time visual information about the surgical field and also provides precise information about the accuracy of the bone cuts, positioning of the implant, ligament balancing and final alignment of the limb. Navigator for Knee Replacement: Knee navigation is an infrared based real-­ time tool used during surgery of total knee replacement. This device provides precise information about the accuracy of the bone cuts, positioning of the implant, ligament balancing and final alignment of the limb.

15.23 Radiology See Table 15.30. Camera Scintillation (Gamma): A gamma camera catches gamma rays emitted by radio pharmaceutical material injected into the patient. These gamma rays are then converted into a visible light photon (Scintillation).

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Table 15.30 Radiology

Activity Camera scintillation (gamma) Computed tomography (CT) Cyclotron/radio pharmacy Densitometer, bone Digital subtraction angiography (DSA) Laser imager camera Leakage tester Magnetic resonance imaging (MRI) with spectroscopy Mammographic machine digital MRI fibre optic pulse oximeter Nuclear computed tomography (PET CT) Nuclear magnetic resonance imaging system (PET MRI) Picture archiving and communications system PACS Portable X-ray machine DR Pressure die injector Rebreathing systems, radionuclide Ultrasound machine Vascular Doppler X-ray machine DR systems 800/500/300 MA with fluoroscopy

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

::::::::-

:::-

:-

:-

::::::-

Requirements of Infrastructure for Installation, Commissioning and Testing of Gamma Camera machine: For details of infrastructure requirements for installation, commissioning and testing of the Gamma Camera please refer to Sect. 15.23 under the heading of ‘Radiology’ in this chapter under the topic of Nuclear PET CT/PET MRI, because the Gamma Camera is also a nuclear scan similar to that of PET CT/PER MRI.

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Computed Tomography (CT): CT is a computerised X-ray imaging-based machine consisting of the X-ray tube and the detectors opposite to each other and is placed in a single circular gantry. The patient is laid down between the gantry and the narrow beam of X-rays is aimed at the patient and the gantry is rotated around the body at a high speed. These X-ray beams after passing through the body of the patient are captured by the detectors on the other end of the gantry. The X-rays detected by the detectors are sent to the processing unit for processing. The processing unit generates the cross-sectional images or slices of the body and displays the same on the screen. This is also called the spiral CT. Requirements of Infrastructure for Installation, Commissioning and Testing of CT Scan Rooms: A separate zone for the CT Scan shall be created in the department of radiology. As this machine is also X-ra- based and when exposure is given, a very high dose of X-rays is produced. Therefore, special care needs to be taken while designing the CT room. Before designing the CT scan room, the guidelines and norms of the controlling authority of the country shall be taken into account. Like in India, Baba Atomic Research Institute issues all such norms and guidelines. CT Scan Machine Room: There shall be a separate room for each machine. If the machine has to be installed horizontally, a rectangular room shall be designed. If the machine is to be installed diagonally, a square room design would be better. The space of the room shall not be less than 42 m2, and the room size, if rectangular, shall be 9144 mm × 4572 mm. The ideal thickness for the primary wall of a CT scan room shall be at least 250 mm solid baked clay bricks, and 150 mm mortar/concrete walls for plain radiography. All the walls of the room shall be plastered from both sides. Hollow bricks if used for the walls, shall be plastered with a 6 mm thick barium plaster and shall be protected up to 2200 mm from the floor level. Flooring inside the CT scan room can be of tiles/marble/granite, but it shall not be slippery to avoid accidents and injury to the patient. Air interlocks are suggested to be provided by placing an additional door before the CT room door. The door of the CT scan room shall be at least 1500 mm wide and 2000 mm high. Doors should overlap by a minimum of 100  mm on each side when closed. The doors shall have a proper 2 mm thick lead lining. This lead lining is also required even on the door frame. Once the door is ready, it shall be tested for any leakage of radiation and ensured that there is no leakage of the radiation from any place in the door. In the CT scan room, windows are not allowed. Outside the door of the CT room, a warning light (red colour bulb) shall be provided. This warning light must be connected to the X-ray generator of the CT scan in such a fashion, that it illuminates only during the tube activation. While installing the machine, ensure to leave at least 1829 mm space behind the machine for the Gantry of the CT scan to tilt. This space shall also help in the easy

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maintenance of the machine. Try to install the CT scan in the centre of the room width-wise. Depending on the electric load required by the CT scan, the power load shall be calculated and the supply cable and main switch shall be terminated in each CT scan room separately for each machine. CT scan being heavier in weight and the movement of the gantry of the machine is very fast, weight-bearing capacity of the floor shall be checked. If required, a foundation for the CT scan shall be provided as per the suggestions of the original manufacturer of the machine. For mounting the machine on the floor or foundation, a base plate with desired mounting anchor fasteners, as specified by the original manufacturer of the machine, shall be provided. For lighting in the CT scan room, provide normal LED, with the sufficient lumen. Extra illumination in the room shall be avoided. The temperature inside the CT scan room shall range between 18 and 21 °C. The humidity level shall be less than 60%. Proper ground earthing provision shall be provided in the room. As far as the piped medical gas supply in the CT scan room is concerned, provide 1 outlet for oxygen, 1 for vacuum and 1 for air. An effective two-way audio system shall be provided in the CT room, so that the technician sitting in the control room can direct the patient, without entering the CT room. While positioning the gantry and couch in the room, position them in such a fashion that the patient is completely visible to the technician from the control console during scanning. To hang the lead aprons, a stand with heavy-duty hangers shall be provided outside each room of the CT Scan. To safely keep other radiation safety devices like lead goggles, lead collars, lead gloves, groin guards, etc., a cabinet shall be provided in each CT scan room. A control room attached to the CT scan room needs to be provided. Strictly ensure that no person shall be allowed to enter the machine room while the scan is in progress. All controls shall be carried out only from the control room. The size of the control room shall be 3658  mm  ×  3658  mm. In the control room, a table to install the Control Unit of the machine shall be provided. Also, the provision shall be made to provide a secondary computer for transferring the CT images for preparing reports. To ensure no leakage of the radiation from the CT scan room to the control room, a lead glass (provided with the machine) of about 1200 mm × 1000 mm shall be provided between the CT scan room and the control room. To install the lead glass, the glass shall be fixed in a wooden frame with 2 mm lead lining and fixed in the opening of the wall, provided for this purpose. To print CT films, a camera (printer) shall also be provided in the control room. CT scan is an electronic machine that requires a continuous power supply. Therefore, consider providing the UPS room attached to the CT room. The size of this room shall be about 3658 mm × 3658 mm with several racks to install batteries. Because of the acid in the batteries, sometimes fumes are formed in the UPS room.

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Therefore, an exhaust shall be provided in the UPS room. Similarly, the UPS also generates a large amount of heat; thus, the room shall be properly air-conditioned and the temperature of about 17–20 °C shall be maintained with a relative humidity of not more than 40%. Earthing of this UPS is essential. The CT scan machine consists of the main gantry where the X-ray tube and detectors are fixed. All other electronic parts are provided in the panels connected to the gantry. It is recommended that for better protection of these electronic panels, these panels shall be installed in a different room or enclosure, attached to the CT scan room. A change room shall be provided near the CT scan room to enable the patient to remove all outside clothes and change into a hospital dress. The size of the change room shall be approximately 3048 mm × 3048 mm. the change room shall have a provision of personal lockers to keep patient belongings. Also, hooks, hanger rods and hangers shall be provided to hang clothes. A cabinet to keep sterilised dresses shall also be provided. Cyclotron/Radio Pharmacy: A cyclotron is used to manufacture short-lived radioactive isotopes that can be used for medical imaging. Densitometer, Bone (Dexa Scan): To measure the mineral density of the bone, bone densitometer is used. To perform the procedure, a small dose of ionizing radiation is used to produce pictures of organs like the lower spine or hips to measure bone loss. Requirements of Infrastructure for Installation, Commissioning and Testing of Dexa Scan Machine: DEXA Scan Machine Room: Dexa Scan room is an area where there is an exposure of X-rays to the patient. Before designing the radiography rooms, the guidelines and norms of the controlling authority of the country must be taken into account. Like in India, Baba Atomic Research Institute issues all such norms and guidelines. Some of the important points related to the designing of the radiography rooms are as follows: For each Dexa Scan, a separate room shall be provided. The room can either be square room or rectangular, depending on the design of the designer. Size wise the room shall not be less than 10 m2. The ideal thickness for the primary wall of a Dexa Scan room shall be at least 250 mm solid baked clay bricks, and 150 mm mortar/concrete walls for plain radiography. All the walls of the room shall be plastered from both sides. Hollow bricks if used for the walls shall be plastered with a 6 mm thick barium plaster and shall be protected up to 2200 mm from the floor level. Flooring inside the Dexa Scan room can be of tiles/marble/granite, but it shall not be slippery to avoid accidents and injury to the patient. Air Interlocks are suggested to be provided by placing an additional door before the Dexa room door. The door of the Dexa Scan room shall be at least 1000 mm wide and 2000 mm high. Doors should overlap by a minimum of 100 mm on each side when closed. The doors shall have a proper 2 mm thick lead lining. This lead lining is also required

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even on the door frame. Once the door is ready, it shall be tested for any leakage of radiation and ensured that there is no leakage of the radiation from any place in the door. In the Dexa Scan room, windows are not allowed. Outside the door of the Dexa Scan Room, a warning light (red colour bulb) shall be provided. This warning light must be connected to the X-ray generator of the Dexa Scan in such a fashion, that it illuminates only during the tube activation. To protect the staff from radiation exposure, a shielded barrier should be placed at the DEXA scan control console. Depending on the electric load required by the Dexa Scan, the power load shall be calculated and the supply cable and main switch shall be terminated in each Dexa Scan room separately for each machine. For lighting in the Dexa Scan room, provide normal LED, with the sufficient lumen. Extra illumination in the room shall be avoided. The temperature inside the Dexa Scan room shall range between 18 and 21 °C. The humidity level shall be less than 60%. Proper ground earthing provision shall be provided in the room. To hang the lead aprons, a stand with heavy-duty hangers shall be provided outside each room of Dexa Scan. To safely keep other radiation safety devices like lead goggles, lead collars, lead gloves, groin guards, etc., a cabinet shall be provided in each Dexa Scan room. Digital Subtraction Angiography (DSA): Digital subtraction angiography (DSA) is a fluoroscopic technique and is used to visualise the soft tissues and the blood vessels inside the human body. This machine being X-ray-based, while performing the procedure captures radiopaque structures such as bones. Subsequently, with the help of software in the DSA machine, these radiopaque substances are eliminated (‘subtracted’) digitally from these captured images, thus providing an accurate depiction of the opacified soft tissues and blood vessels. Requirements of Infrastructure for Installation, Commissioning and Testing of DSA Unit: As the DSA is more or less like the Cath lab and also a kind of X-ray-based machine with high doses of X-ray radiation, hence the requirements for installation, commissioning and testing will be more or less the same as for Cath Lab. Please refer to the topic of Cath Lab under the earlier heading in para number ‘9.5’ in ‘Cardiology and Interventional Cardiology’ in this chapter. Laser Imager Camera: These are dry imaging laser printers and are used to print multiformat images of digital radiology on the emulation coted X-ray films. Leakage Tester: Leakage tester is used for checking ant unwanted radiation leakage from within the source assembly except for the useful beam. Magnetic Resonance Imaging (MRI) with Spectroscopy: Magnetic resonance imaging (MRI) is a magnetic and radio frequency-based machine. The machine uses a high-power magnetic field and computer-generated controlled radio frequency waves to create detailed images of the tissues and organs of the human body. These strong magnetic fields align the protons of the cell in a unidirectional fashion. Thereafter, the radio frequency waves are fired on the protons, due to which the

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protons oscillate. This oscillation is captured by the machine and after processing the image is produced. Requirements of Infrastructure for Installation, Commissioning and Testing of MRI Machine: MRI Machine Room: Some of the important issues related to the designing of the MRI rooms are as follows: For each MRI, a separate room shall be provided. As MRI creates a very high magnetic field, safety factors need to be considered when the installation of the MRI. The most crucial factor is to shield the magnet and procedure room from any external magnetic interferences, to ensure that the specified magnetic fields are not exceeded. RF Shielding: As the MRI systems are highly sensitive to radio frequencies, the MRI machine shall be enclosed in a radio frequency (RF) shield. RF shield is essentially a 6-sided copper-lined box around the room called a ‘Faraday Cage’ which protects the MRI system from exterior radio frequencies for the clarity of the scan. Though RF shielding can also be done with sheets made out of aluminium and galvanised steel, copper is considered to be the best out of all the metals. Therefore, the wall of the MRI room shall often have three partitions, first is the parent wall made out of clay brick, the second is RF shield fixed on the wall and the third is the interior finishing of the wall. RF Shield is the actual metallic sheet, and the inner finishing is the artificial decorative interior. The inner interior can be done using PVC panels, wooden panels or wallpapers etc. The floor in the MRI exam room often has three layers. First is the structural subfloor, the second is the RF shielding and the third is the protective layer made out of finishing materials. Subfloor is the originally constructed floor, RF shield is the metallic cage, and then the protective layer. The protective layer can be made of wood, as it does not affect the magnetic field. Another important factor while installing the MRI is to protect the public from a high magnetic field. From the designing of protective, provisions shall be made to keep the public away from the most dangerous magnetic fields. The areas which are affected by the magnetic field from the magnet’s iso-centre are called the Gauss Field. All the areas within the 5-Gauss line from the iso-centre are dangerous for anyone wearing ferrous metal or for any metal objects. Any metal object within the 5-Gauss line will essentially become a part of the magnet and the magnet will forcefully pull that metal object towards the iso-centre of the magnet. To avoid this and keep everyone safe, the designers shall design barriers to deter people from getting too close. Pacemakers, cell phones and credit cards are severely damaged when inside the 5-Gauss line. MRI being heavier in weight, the weight-bearing capacity of the floor shall be checked. If required, a foundation for the MRI shall be provided as per the suggestions of the original manufacturer of the machine. For mounting the machine on the floor or foundation, a base plate with desired mounting anchor fasteners, as specified by the original manufacturer of the machine, shall be provided. Proper ground earthing provision shall be provided in the room.

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While positioning the gantry and couch in the MRI room, position them in such a fashion that the patient is completely visible to the technician from the control console during the scanning. Attached to the MRI scan room, a control room shall be provided. No person shall be allowed to enter the scan room while the procedure is going on. All controls shall be carried out from the control room only. The size of the control room shall be 3658  mm  ×  3658  mm. A meshed glass (provided with the machine) of about 1200  mm  ×  1000  mm shall be fixed in a wooden frame with 2  mm lead lining between the MRI room and the control room to ensure no leakage of the radiation. To print MRI films, a camera (printer) shall also be provided in the control room. An effective two-way audio system shall be provided in the MRI room, so that the technician sitting in the control room can direct the patient, without entering the MRI room. To safely keep other devices like phantoms, coils and other accessories of MRI etc., a cabinet shall be provided in each MRI Scan room. MRI is an electronic machine that requires a continuous power supply. It is more essential, as the cold head of the machine shall always be on, failing which the Helium gas filled in the magnet will boil, resulting in a potential lost. As UPS attached to the MRI is usually of high rating (above 150 KVA), a lot of batteries shall be required. Therefore, a separate room shall be provided for UPS of MRI. This room shall be attached to the MRI control room or the machine room. The size of this room shall be about 3658 mm ×3658 mm with several racks to install batteries. Because of the acid in the batteries, sometimes fumes are formed in the UPS room. Therefore, an exhaust shall be provided in the UPS room. Similarly, the UPS also generates a large amount of heat; thus, the room shall be properly air-conditioned, and the temperature of about 17–20 °C shall be maintained with a relative humidity of not more than 40%. Earthing of this UPS is essential. The MRI machine consists of the main gantry where the magnet and RF devices are fixed. All other electronic parts are provided in the panels connected to the magnet. These panels control the working of the machine but are not directly needed in the MRI room. It is recommended that for better protection of these electronic panels, these panels shall be installed in a different room or enclosure, attached to the MRI room. While positioning the gantry and couch in the room, position them in such a fashion that the patient is completely visible to the technician from the control console during scanning. Depending on the electric load required by the MRI, the power load shall be calculated and the supply cable and main switch shall be terminated in each MRI room separately for each machine. The temperature inside the MRI scan room shall range between 16 and 20 °C. The humidity level shall be less than 60%. For lighting in the MRI room, provide normal LED, with sufficient lumen. Extra illumination in the room shall be avoided. Along with the MRI, a water chiller is required to cool down the gradient coil and liquid helium compressor. The whole refrigeration system of MRI is composed

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of a chiller, a helium compressor and a cold head. Through their joint work, the temperature inside the magnet is controlled at −269 °C, to maintain the superconducting state of the coil. To maintain this temperature inside the magnet, the heat of the superconducting coil is taken away by the vaporisation of liquid helium, which will cause the pressure inside the magnet to rise and thus the loss of liquid helium. If the MRI chiller fails, the entire refrigeration system will stop working; thus, it shall also be connected to the UPS for its continuous working. The chiller is usually installed outside the hospital building to keep it cool. It is provided with a water tank, from where the chiller takes the water, cools it and then sends it to the machine through a connected pipeline. This water cools the machine and returns to the chiller through a separate pipeline and is cooled again. Change rooms shall be provided in the department to enable the patient to remove all outside clothes and change into a hospital dress. The room shall be approximately 3048 mm × 3048 mm in size. It shall have an adequate provision of personal lockers to keep patient belongings. Also, hooks, hanger rods and hangers shall be provided to hang clothes. There shall be a cabinet to keep sterilised dresses. As far as the piped medical gas supply in the MRI room is concerned, provide 1 outlet for oxygen, 1 for vacuum and 1 for air. The outlets of these medical gases shall be fixed on the wall outside the RF shield. From these outlets, the medical gases are supplied through the HP rubber hoses. Mammographic Machine: Mammography is used for X-ray imaging of the breasts of female patients. Requirements of Infrastructure for Installation, Commissioning and Testing of Mammographic machine: Mammography Room: The mammography room is the actual room where the mammography machine is installed, and the exposure of X-rays is given to the patient. Before designing the radiography rooms, the guidelines and norms of the controlling authority of the country must be taken into account. Like in India, Baba Atomic Research Institute issues all such norms and guidelines. Some of the important points related to the designing of the mammography rooms are as follows: There shall be a separate room for each machine. The room can either be a square room or rectangular ss designed by the designer, and the size of a room shall not be less than 10 m2. The ideal thickness for the primary wall of a mammography room shall be at least 250 mm of solid baked clay bricks and 150 mm mortar/concrete walls for plain radiography. All the walls of the room shall be plastered from both sides. Hollow bricks if used for the walls shall be plastered with a 6 mm thick barium plaster and shall be protected up to 2200 mm from the floor level. No single wall dimension of the mammography room shall be less than 3000 mm. Flooring inside the mammography room can be of tiles/marble/granite, but it shall not be slippery to avoid accidents and injury to the patient. The door of the mammography room shall be at least 1000 mm wide and 2000 mm high. Doors should overlap by a minimum of 100 mm on each side when closed. The doors shall have a proper 2 mm thick lead lining. This lead lining is also required

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even on the door frame. Once the door is ready, it shall be tested for any leakage of radiation and ensured that there is no leakage of the radiation from any place in the door. In the mammography room, windows are not allowed. Outside the door of the mammography, a warning light (red colour bulb) shall be provided. This warning light must be connected to the X-ray generator of the mammography in such a fashion that it illuminates only during the tube activation. A shielded barrier should be placed at the mammography control console to protect the staff from radiation exposure. Depending on the electric load required by the mammography, the power load shall be calculated and the supply cable and main switch shall be terminated in each mammography room separately for each machine. If a digital type of machine is planned, then a separate small control room, adjoining the mammography room shall be provided. Between the two rooms, a lead glass shall be fixed in a wooden frame with a 2 mm lead lining. Proper ground earthing provision shall be provided in the room. For lighting in the mammography room, provide normal LED, with the sufficient lumen. Extra illumination in the room shall be avoided. The temperature inside the mammography room shall range between 18 and 21 °C. The humidity level shall be less than 60%. To hang the lead aprons, a stand with heavy-duty hangers shall be provided outside each room of the mammography room. To safely keep other radiation safety devices like lead goggles, lead collars, lead gloves, groin guards, etc., a cabinet shall be provided in each mammography room. For mammography, generally, the upper body clothes have to be changed to a simple cotton gown. A change room shall be provided near the mammography room to enable the patient to remove outside clothes and change into a hospital dress. The size of the change room shall be approximately 3048 mm × 3048 mm. The change room shall have a provision of personal lockers to keep patient belongings. Also, hooks, hanger rods and hangers shall be provided to hang clothes. A cabinet to keep sterilised dresses shall also be provided. CR system of the main radiology department can be used for mammography. Just the cassette needs to be carried from the mammography room to the radiology CR room. Other processes will remain the same. MRI Fiber-Optic Pulse Oximeter: MRI pulse oximeter is designed in such a fashion that the magnetic fields do not affect the working of the pulse oximeter. This device is used to monitor a patient’s pulse and blood oxygen saturation during MRI scans. As MRI is a magnetic device, a normal pulse oximeter cannot be used inside the MRI room. Nuclear Computed Tomography (PET-CT): Positron emission tomography– computed tomography (PET-CT) is a combination of a positron emission tomography (PET) scanner and computed tomography (CT) scanner in the same gantry of the machine. Both of these scanners capture sequential images in the same session, which when combined produces a single superimposed image. To perform the procedure, nuclear medicine is administered to the patient and the scan is performed.

15.23 Radiology

431

Requirements of Infrastructure for Installation, Commissioning and Testing of PET CT Machine: PET CT Scan Machine Room: The infrastructure of the machine room shall be the same as a normal CT scan machine room. The only difference is that the wall shall be made out of 300 mm thick RCC. The nuclear scan zone shall have two areas, i.e. the low-risk areas or cold areas and the high-risk areas or radiation exposure hot areas. Let us explain each of them. Low-Risk Areas or Cold Areas. Reception shall be located at the entrance of this low-risk zone, usually on the front side. The secretarial room, for administrative jobs like accounts, etc. can also be placed in the rear of the reception. Roughly a space of about 15–20 m2 shall be sufficient for both these utilities. Sub-waiting area with utility rooms. Physicians’ consulting room for analysing, interviewing and physically examining the patient before undertaking the patient for investigation is also placed in this zone. The size of this room shall be about 4267 mm× 4572 mm. To store the materials like QC phantoms, consumables, disposables, etc., a small store of size 3658 mm× 3658 mm shall also be provided in this zone. The room shall be provided with worktops, cabinets and drawers for storage. For planning the investigation and arranging resources for the department, a technologist room cum office shall be located near or opposite to the physician consultation room. High-Risk Areas or Radiation Exposure Hot Areas. Hot lab cum Radiopharmacy Room where the department has its production unit (cyclotron An injection room is constructed with a 220-mm-thick RCC wall. An aperture is provided in this room which opens in the radiopharmacy. Through this aperture, the radiopharmaceutical is injected into the patient. This room shall roughly be 12–16 m2 for each PET CT/PET MRI/SPECT CT installed. Post-dose waiting area where the injected patient is then made to wait, where he/ she can rest comfortably during the uptake period. The walls of the post-dose waiting area are made up of 300-mm-thick RCC, resulting in an exposure rate of about 1.22 uSv/h (for a patient injected with 300 MBq of  18F radiopharmaceutical at a distance of about 1000 mm). After injection and an uptake period depending on the protocol, patients are asked to void their bladder before starting the actual PET scan procedure. Hence, a toilet must be located adjacent to the preparation rooms. This is a specialised toilet called active toilet. The discharge of this toilet is taken in a separate settlement tank where it is allowed to settle down and the effects of isotopes are neutralised before dropping the discharge in the main sewerage line. The control and scanning room is the core of the facility. The scanning room shall be easily reached from the preparation rooms and the toilet. Post-examination waiting room for patients to wait while their scans are checked. It is advised to provide a separate exit gate so that these patients do not mix with others.

432

15  Department Wise Equipment Detailing

The waste disposal room for dispensing FDG and anything which could be contaminated (clothes, linen, etc.) should be stored in a dedicated area to let the radioactivity decay before being disposed of. Nuclear Magnetic Resonance Imaging System (PET/MRI): A PET/MRI machine is a combination of a positron emission tomography (PET) scanner and an MRI scanner in the same machine. Both of these scanners capture sequential images in the same session, which when combined produces a single superimposed image. To perform the procedure, nuclear medicine is administered to the patient and the scan is performed. Requirements of Infrastructure for Installation, Commissioning and Testing of PET MRI machine: PET MRI Machine Room: The infrastructure of the machine room shall be the same as a normal MRI machine room. The only difference is that the wall shall be made out of 300 mm thick RCC. The nuclear scan zone shall have. Low-Risk Areas or Cold Areas. Reception shall be located at the entrance of the zone, usually in the front. Also, a secretarial room shall be provided in the rear of the reception for administrative jobs like accounts, etc. Roughly a space of about 15–20 m2 shall be sufficient for both these utilities. Subwaiting area with utility rooms. Physicians’ consulting room for analysing, interviewing and physically examining the patient before undertaking the patient for investigation. The outlets for the supply of oxygen and vacuum shall be provided. The size of this room shall be about 4267 mm × 4572 mm. A small store of size 3658 mm × 3658 mm shall be provided to store the materials like QC phantoms, consumables, disposables, etc. The room shall be provided with worktops, cabinets and drawers for storage. A technologist room cum office shall be located near or opposite the physician consultation room for planning the investigation and arranging resources for the department. High-Risk Areas or Radiation Exposure Hot Areas. Hot lab cum Radiopharmacy Room where the department has its production unit (cyclotron and radiochemistry lab). This allows for mono-dose syringes to be delivered to each injecting room in lead containers. The walls of the room shall be 300 mm thick RCC. An injection room is constructed with a 220-mm-thick RCC wall. An aperture is provided in this room which opens in the radiopharmacy. Through this aperture, the radiopharmaceutical is injected into the patient. This room shall roughly be 12–16 m2 for each PET CT/PET MRI/SPECT CT installed. Post-dose waiting area where the injected patient is then made to wait, where he/ she can rest comfortably during the uptake period. The walls of the post-dose waiting area are made up of 300-mm-thick RCC, resulting in an exposure rate of about 1.22 uSv/h (for a patient injected with 300 MBq of  18F radiopharmaceutical at a distance of about 1000 mm)

15.23 Radiology

433

After injection and an uptake period depending on the protocol, patients are asked to void their bladder before starting the actual PET scan procedure. Hence, a toilet must be located adjacent to the preparation rooms. The discharge of this toilet is taken in a separate settlement tank where it is allowed to settle down and the effects of isotopes are neutralised before dropping the discharge in the main sewerage line. The control and scanning room is the core of the facility. The scanning room must be easily reached from the preparation rooms and the toilet. Post-examination waiting room for patients to wait while their scans are checked. It is advised to provide a separate exit gate so that these patients do not mix with others. The waste disposal room for dispensing FDG and anything which could be contaminated (clothes, linen, etc.) should be stored in a dedicated area to let the radioactivity decay before being disposed of. Picture Archiving and Communication System (PACS): PACS is a system to electronically push, store, retrieve and transmit images, cines and reports. The images can also be transmitted electronically through Wifi or the internet. Requirements of Infrastructure for Installation, Commissioning and Testing of PACS: Installation of the PACS software requires a high-end server because the images to be stored on the server are generally very heavy and consume a lot of space. For installing PACS, a server room is required and all the machines in radiology shall be connected to the separate server through interphase. Apart from this, the computer networking shall be laid down in the hospital and outlets shall be provided to the computers points where ever the images have to be viewed. Portable X-Ray Machine DR: Portable X-ray digital radiography (DR) is an X-ray machine with low Machine and can be easily taken from one place to another. Pressure Die Injector: A pressure injector is used to administer the contrast media to the patient, in a precalibrated fashion, for performing the procedure. The device consists of an injector head for placing the syringes filled with contrast material. It has a piston plunger which delivers the contrast from the syringes to the pressure tubing connected to the syringe, and the tubing in turn delivers contrast material into the vascular system of the patient. Rebreathing Systems, Radionuclide: The radionuclide rebreathing system is a device meant to be used to contain a gaseous or volatile radionuclide or a radionuclide-­labelled aerosol and allow it to be respired by the patient during nuclear medicine ventilatory tests. Ultrasound Machines: An ultrasound device is used to take images of organs inside the human body using the technique of high-frequency ultrasound waves. The transducers attached to the machine, when placed on the body surface, send out high-frequency sound waves, in the body, which reflect off from the body structures. It is just like the sound reflecting if loudly spoken in the hills creating an echo. A computer receives these reflected waves and considering the time lag of receiving the waves from different tissues of the body, creates a picture.

434

15  Department Wise Equipment Detailing

Vascular Doppler: A Doppler ultrasound is a pencil-like thin ultrasound probe to send ultrasound waves at the précised small points and is used to estimate the blood flow through blood vessels by receiving back the bounced high-frequency sound waves by the red blood cells in the vessels. X-Ray Machine DR systems 800/500/300 MA with Fluoroscopy: Digital radiography (DR) is the X-ray system, with the difference that no cassettes are required to capture the images and process them further. Instead, the detector panel place placed opposite to the X-ray tube captures the image as photons. These X-ray photons are then directly converted into a digital image and are sent to the processing unit for further management of the image. Requirements of Infrastructure for Installation, Commissioning and Testing of X-Ray Machine: Radiography Rooms: These are the rooms where the X-ray machine is installed, and the exposure of X-rays is given to the patient. Before designing the radiography rooms, the guidelines and norms of the controlling authority of the country must be taken into account. Like in India, Bhabha Atomic Research Institute issues all such norms and guidelines. There shall be a separate room for each machine. Irrespective of the types of machines and tables, the size of the radiography rooms remains the same. For radiography, a rectangular room is suggested and the size of the room shall not be less than 25 m2. The ideal thickness for the primary wall of the radiography room shall be at least 250 mm of solid baked clay bricks, and 150 mm mortar/concrete walls for plain radiography. All the walls of the room shall be plastered from both sides. Hollow bricks if used for the walls shall be plastered with a 6 mm thick barium plaster and shall be protected up to 2200 mm from the floor level. No single wall dimension of the radiography room shall be less than 4 m. Flooring inside the radiography room can be of tiles/marble/granite, but it shall not be slippery to avoid accidents and injury to the patient. The door of the radiography room shall be at least 1000 mm wide and 2000 mm high. Doors should overlap by a minimum of 100 mm on each side when closed. The doors shall have a proper 2 mm thick lead lining. This lead lining is also required even on the door frame. Once the door is ready, it shall be tested for any leakage of radiation and ensured that there is no leakage of the radiation from any place in the door. In the radiography room, windows are not allowed. Outside the door of the radiography, a warning light (red colour bulb) shall be provided. This warning light must be connected to the X-ray generator of the X-ray machine in such a fashion that it illuminates only during the tube activation. The chest stand or the chest frame can be fixed on the wall opposite the entrance door and the control console. A shielded barrier should be placed at the X-ray control console to protect the staff from radiation exposure.

15.24 Pathology

435

Depending on the electric load required by the X-ray machine, the power load shall be calculated and the supply cable and main switch shall be terminated in each X-ray room separately for each machine. If a DR type of machine is planned, then a separate small control room, adjoining the DR room shall be provided. Between the two rooms, a lead glass shall be fixed in a wooden frame with a 2 mm lead lining. For lighting in the X-ray room, provide normal LED, with the sufficient lumen. Extra illumination in the room shall be avoided. The temperature inside the X-ray room shall range between 18 and 21 °C. The humidity level shall be less than 60%. Proper ground earthing provision shall be provided in the room. To hang the lead aprons, a stand with heavy-duty hangers shall be provided outside each room of the X-ray room. To safely keep other radiation safety devices like lead goggles, lead collars, lead gloves, groin guards, etc., a cabinet shall be provided in each X-ray room. A change room shall be provided near the X-ray room to enable the patient to remove outside clothes and change into a hospital dress. The size of the change room shall be approximately 3048 mm × 3048 mm. the change room shall have a provision of personal lockers to keep patient belongings. Also, hooks, hanger rods and hangers shall be provided to hang clothes. A cabinet to keep sterilised dresses shall also be provided. A room shall be provided along with the X-ray unit for preparing patients before specific imaging like barium sallow through. The size of the room can be 3658 mm × 3658 mm with an examination couch and chair. Computerised Radiography (CR) Room: For processing the X-ray cassette, a CR room shall be provided near the X-ray room. The size of the CR room shall be about 4267 mm × 3658 mm. The temperature in the room shall be about 18–21 °C, and the RH shall be 40–50%. Lighting shall be normal as in other rooms.

15.24 Pathology See Table 15.31. Automated Blood Cell Diluting Apparatus: An automated blood cell diluting apparatus is a fully automated or semiautomated machine used to make appropriate dilutions of a blood sample for further investigations. Automated Cell Counter: Automated cell counter is used to automatically differentiate and count the number and types of cells present in the sample like blood or urine. Automated Chromosome Analyser: Chromosome analysis is used in the cytogenetics lab to diagnose cytogeneticists and their abnormalities. Automated Coagulator: A coagulation analyser is used to measure blood platelet levels. It is also used for measuring the coagulation pathway speed, as well as thrombin and thromboplastin levels.

436

15  Department Wise Equipment Detailing

Table 15.31 Pathology

Activity Automated blood cell diluting apparatus Automated cell counter Automated chromosome analyser Automated coagulator Automated platelet counting Automated tissue processor Binocular research microscope Cell counter, normal and abnormal Cell culture suspension system Cell-freezing apparatus and reagents Centrifuge machine high speed Chromatograph Chromatograph (GAS) Chromatograph for bacterial identification Clinitek status analyser Cytocentrifuge Cytospin Electrolyte analyser Electronic precision balance Electrophoretic haemoglobin analysis system Fibrometer Gas–solid/liquid chromatograph column supports Haematology analyser

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15.24 Pathology

437

Table 15.31 (continued)

Activity Haemocytometer Ion-exchange chromatograph Laminar air flow horizontal Magnetic stirrer Mass spectrometer Micrometres, microscope Microscope binocular Microscope fluorescence/UV Microscope inverted stage, tissue culture Microtome Photocalorimeter digital Platelet aggregation automated system Platelet aggregometer Projection microscope Radioimmunoassay Refrigerated centrifuge Rotary microtome Serological water bath Slide strainer, immersion type Spectrophotometer digital Stereoscopic microscopes Thin-layer methadone chromatograph Vacuum oven Water bath

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::::::::::::::::::::::::-

Automated Platelet Counter: To study the distinction among platelets, small debris and erythrocytes, an automated platelet counter is used. Automated Tissue Processor: The tissue processor is used for the diffusion of various substances into and out of porous tissues.

438

15  Department Wise Equipment Detailing

Binocular Research Microscope: Binocular research microscope consists flat-­ field achromatic objectives and high-performance eyepieces and the lenses which are coated hard for anti-reflection, anti-fungal and reduced light. Cell Counter, Normal and Abnormal: The cell counter is used to count different types of cells in the blood like RBC, WBC, platelet, etc. Cell Culture Suspension System: A cell suspension or suspension culture is to grow single cells or small aggregates of cells and allowed them to function and multiply in an agitated growth medium, thus forming a suspension. Cell-Freezing Apparatus and Reagents: Cell Freezing is used to freeze cells and resuscitate them from liquid nitrogen storage. Centrifuge Machine High Speed: Centrifuge is a device used to separate mixtures made up of different densities. In the laboratory, centrifuge is used to separate plasma from the blood. Chromatograph: A chromatograph is used for the separation of a mixture into its components. The mixture when dissolved in a fluid solvent called the mobile phase carries it through a system on which a material called the stationary phase is fixed. Chromatograph (GAS): A gas chromatograph (GC) is used to analyse tissue homogenates and body fluids for detecting chemical compounds that may serve as markers of infection. Chromatograph for Bacterial Identification: Gas chromatography-vacuum ultraviolet spectroscopy (GC-VUV) is used to determine fatty acid methyl esters (FAMEs) of bacteria, to identify and discriminate different environmental bacteria based on their fatty acid profile. Clinitek Status Analyser: The Clinitek Status Analyser is for urinalysis to read urine test strips and Clinitest hCG cassettes. Cytocentrifuge/Cytospin: A cytocentrifuge, or cytospin, is a centrifuge used to concentrate on cells in liquid specimens onto a microscope slide to enable stain and examination. Electrolyte Analyser: The electrolyte analyser is a device for measuring the electrolytes in serum, plasma and urine. They are primarily used in the quantitative measurement of sodium, potassium, calcium, chlorine and lithium. Electronic Precision Balance: Electronic balance is used for the accurate measurement of the weight of materials. Electronic balance is mainly used in laboratories for precise measurement of chemicals which are used in various testing. It provides the digital result of measurement. Electrophoretic Haemoglobin Analysis System: To measure and identify the different types of haemoglobin in the bloodstream, haemoglobin electrophoresis is used. Fibrometer: Fibrometer is used for blood testing for the evaluation and management of liver fibrosis. This test was specifically for patients with chronic viral hepatitis. Gas–Solid/Liquid Chromatograph Column Supports: Gas chromatography is used for the separation and identification of volatile compounds of liquid

15.24 Pathology

439

mixtures and gases. There are two types of methods one is Gas–Solid chromatography (GSC) and other is Gas–Liquid chromatography (GLC). Hematology Analyser: A haematology analyser is used to perform a complete blood count (CBC) or hemogram. It performs a quantitative and qualitative analysis of the formed elements of the blood: white blood cells, red blood cells, platelets, etc. Haemocytometer: The haemocytometer is a counting-chamber device originally designed and mainly used for counting blood cells. Ion-Exchange Chromatograph: Ion chromatography is for separating ions and polar molecules based on their affinity to the ion exchanger. It can work on almost all kinds of charged molecules including large proteins, small nucleotides and amino acids. Laminar Air Flow Horizontal: Horizontal laminar flow systems due to the continuous flushing of the working area utilizing a unidirectional horizontal ultra-­ filtered air flow allow operation in sterile and particle-free conditions. The positive pressure inside the cabinet prevents the inflow of ambient air from the surrounding environment into the work area. Magnetic Stirrer: A magnetic stirrer is a device used to make a stir bar, immerse in a liquid, quickly spin, or stir or mix a solution in laboratories through the technique of rotating magnet or a stationary electromagnet that creates a rotating magnetic field. Mass Spectrometer: Mass spectrometry is used to measure the mass-to-charge ratio (m/z) of one or more molecules in a sample. These measurements are used to calculate the exact molecular weight of the sample components. Micrometres, Microscope: Microscope micrometres are used for counting or measuring specimens. Eyepiece micrometres (reticles) are small glass discs with markings on them. The micrometre is mounted in one of the two eyepieces and superimposes an image of the markings over the image of the specimen. Microscope Binocular: A binocular microscope is an optical microscope with two eyepieces to significantly ease viewing and cut down on eye strain. Microscope Fluorescence/UV: A fluorescence microscope is used for studying the dynamic behaviour exhibited in live-cell imaging. Microscope Inverted Stage, Tissue Culture: In an inverted microscope, the light source of light and the condenser are placed on the top of the stage, pointing down towards the stage. The objectives are placed below the stage pointing upwards. Microtome: A microtome is used to cut thin slices of the tissue to be examined. The cut tissues are made to float on the surface of the water bath to eliminate wrinkles and distortion in the tissue. Thereafter, the tissue is taken on the slide for examination. Photocalorimeter Digital: This instrument is used to measure the absorbance of wavelengths of light at a particular frequency (colour) by a sample. Platelet Aggregation Automated System: An automated platelet aggregation system is a device used to determine changes in platelet shape and platelet aggregation following the addition of an aggregating reagent to a platelet-rich plasma. Platelet Aggregometer: A platelet aggregometer is used to check how well the platelets clump together to form blood clots.

440

15  Department Wise Equipment Detailing

Projection Microscope: The projection microscope has an added feature to the microscope to project the microscopic image to a wall or projecting screen. Radioimmunoassay: Radio Immunoassay is used to check the specificity of an antigen–antibody reaction to detect and quantify target molecules in biological samples. Refrigerated Centrifuge: A refrigerated centrifuge is used for the separation of microliter temperature-sensitive heterogeneous mixtures or samples. This device works by spinning the samples loaded in a rotor at high speed. Rotary Microtome: The rotary microtome is to reduce vibration during microtomy, in which stability is important during sectioning to prevent undulations in the paraffin sections. Serological Water Bath: Serology Water Bath or Thermostatic Water Bath is a container filled with heated water that is used to incubate samples at a constant temperature for long periods. Slide Stainer, Immersion Type: Automated slide strainers are devices that automatically stain the peripheral blood and other hematologic smears to facilitate laboratory microscope differential counts using Wright’s stain. Spectrophotometer Digital: Digital spectrophotometer is for spectrophotometric analysis of any concentration. Stereoscopic Microscopes: Stereomicroscopes are for 3D viewing of specimens visible to the naked eye. They are also known as Low Power or Dissecting Microscopes. Thin-Layer Methadone Chromatograph: A thin-layer chromatograph is used for simultaneous screening and confirmation of methadone and its primary metabolite in urine specimens. Vacuum Oven: A vacuum oven is generally used for drying substances which are hygroscopic and heat-sensitive and is based on the principle of creating a vacuum to decrease the chamber pressure below the vapour pressure of the water causing it to boil. It can be filled with inert gases, especially for the rapid drying of some compound materials. The low-pressure environment also minimises oxidation during drying. Water Bath: A water bath is used to incubate samples in water at a constant temperature over a long period. It is also used to enable certain chemical reactions to occur at high temperatures.

15.25 Microbiology See Table 15.32. Bact Alert System: BacT/Alert is used for growing microorganisms based on the colorimetric detection of CO2 in an automated microbial detection system. Bacteriological Incubator: Bacteriological Incubator is used for storage of bacteria plate and bacterial culture growth at 37 °C. These incubators are also known as heated incubators as they are fitted with the heating temperature only.

15.25 Microbiology

441

Table 15.32 Microbiology

Activity Bact alert system Bacteriological incubator Binocular microscope Biosafety cabinet BOD incubator CD4 counter Deep freezer Distilled water plant Egg incubator Electronic colony counter Electrophoresis instrumentation Elisa reader with washer Fluorometer Gene expert High-performance liquid chromatograph (HPLC) Homogeniser Hot air oven Immunofluorescent microscope Lab incubator Laminar air flow MGIT 960 Microscope binocular LED Microscope fluorescence/UV QBC microscope (malaria) Refrigerated centrifuge RT-PCR Shaking water bath T.B. culture Bact/alert 3D Thermocycler Ultracentrifuge Vitek

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442

15  Department Wise Equipment Detailing

Binocular Microscope: A binocular microscope is an optical microscope with two eyepieces to significantly ease viewing and cut down on eye strain. Biosafety Cabinet: This cabinet is used to protect the laboratory worker and the surrounding environment from harmful pathogens. The cabinet is provided with a system to exhaust the air through HEPA filters. The cabinet is also provided with ultraviolet lights for killing harmful bacteria and viruses within the working space of the cabinet. These cabinet’s containment range is from the lowest biosafety level 1 (BSL-1) to the highest at level 4 (BSL-4). BOD Incubator: BOD Incubator (Bio-Oxygen Demand) is used for culture growth where a high degree of constant temperature accuracy is required to maintain the temperature of the test tissue for culture growth, storage of bacterial cultures and incubation. CD4 Counter: CD4 cell counter is used to count the CD4 cells (also known as CD4+ T cells) in the blood. Deep Freezer: Deep Freezer is used to store the kits and reagents which are generally used in the department under low temperatures. Distilled Water Plant: This plant is used to prepare the distilled water by boiling the water until it evaporated and condensed. EGG Incubator: The egg incubator is to simulate avian incubation by keeping eggs warm at a particular temperature range (37.5 °C for chicken eggs) and in the correct humidity with a turning mechanism to hatch them. Electronic Colony Counter: Colony counter is used for quick and accurate counting of bacterial and mould colonies in Petri dishes. Electrophoresis Instrumentation: Electrophoresis instrument is used to separate nucleic acids and proteins based on their size and charge. ELISA Reader with Washer: ELISA Plate Reader is used to detect and process biological and chemical data. The ELISA reader uses the technology of absorbance, fluorescence detection modes and luminescence, including intensity, TRF and polarisation. Fluorometer: Fluorometer is used to identify the presence and the number of specific molecules in a medium measure parameters of visible spectrum fluorescence, its intensity and wavelength distribution of emission spectrum after excitation by a certain spectrum of light. Gene Expert: Gene-Xpert, a CBNAAT (cartridge-based nucleic acid amplification test) is used for a diagnostic test of tuberculosis. This test is a rapid diagnostic test for tuberculosis detection as well as Rifampicin resistance in direct smear-­ negative cases. High-Performance Liquid Chromatography (HPLC): High-performance liquid chromatograph (HPLC) uses the technique of analytical high-pressure liquid chromatography to separate, identify and quantify each component. Homogeniser: A homogeniser is used for the homogenisation of various types of material, such as tissue, food, plant, soil and many others. Hot Air Oven: Hot air ovens use extremely high temperatures over several hours to destroy microorganisms and bacterial spores. The ovens use conduction to

15.25 Microbiology

443

sterilise items by heating the outside surfaces of the item, which then absorbs the heat and moves it towards the centre of the item. Immunofluorescent Microscope: Immunofluorescence microscope is used for tissue sections, individual cells or cultured cells that are fixed using various methods. Lab Incubator: Lab incubator is used in the laboratory to provide a temperature-­ controlled environment for supporting the growth of microbiological cultures. Laminar Air Flow: Laminar airflow is used to improve the quality of air in the workplace by providing unidirectional air at the same speed with no or minimal cross-over of air streams. MGIT 960: The BACTEC MGIT 960 is a fully automated system used to detect the growth of mycobacteria in culture and works on the technology of exploitation of fluorescence of an oxygen sensor. Microscope Binocular: A binocular microscope is a microscope with two eyepieces, one for each eye, to significantly ease viewing and cut down on eye strain by viewing the object with both eyes. Microscope Fluorescence/UV: UV microscopes are used in fluorescent microscopy. In this case, the UV light reflects the image of the sample stains to the fluorescence to create an image that can be viewed. QBC Microscope (Malaria): The QBC Microscope enables fluorescence microscopy at a fraction of the cost for the detection of Malaria, TB, Trypanosomes and other blood-borne parasites. Refrigerated Centrifuge: Refrigerated centrifuge works on the principle of sedimentation, by holding the sample tubes for rotation at a high speed around a fixed axis. Due to the centripetal force, the denser substances separate at the bottom of the centrifuge tube. RT- PCR: Real-time polymerase chain reaction (real-time PCR) is used to detect and quantify the gene expression from DNA and RNA. Requirements of Infrastructure for Installation, Commissioning and Testing of RT-PCR Lab: As the PCR laboratory is intended to perform tests on dangerous viruses, proper planning has to be done to avoid any cross-infection in the PCR Lab. The requirements for the polymerase chain reaction (PCR) diagnostic laboratory should include facilities such as specimen receiving, sample processing, nucleic acid extraction room, PCR procedure room and post-PCR room for electrophoresis, visualisation and data recording. One of the main problems in PCR work is contamination which can lead to false negative/false positive results. Hence, the entire PCR work should be divided and performed in three different locations with physical barriers for each of the activities such as Pre-PCR, PCR and Post-PCR.  All three areas must be preferably in isolated rooms (size can be small, as required). For a simple PCR laboratory, the flow of work shall be in the order: Pre-PCR → PCR → Post-PCR. All three areas shall be arranged in a total area of about 6096 mm × 4572 mm room with partitions to provide required cabins.

444

15  Department Wise Equipment Detailing

Pre-PCR Area: Pre-PCR area shall receive samples, and the samples will be processed for diagnosis. This step involves dissection, microscopy and DNA/RNA extraction. PCR Area: The PCR part will involve setting up the PCR reaction and amplifying the nucleic acids in a thermocycler. This will involve the use of molecular biological reagents. Extreme care should be taken not to contaminate any of these components. Post-PCR area: Post-PCR will involve electrophoresis of amplified PCR products and visualisation/detection of the PCR products. Shaking Water Bath: The water bath shaker is used to steadily shake and mix samples while maintaining a constant temperature. They are used for applications such as hybridisation, culturing cells and molecular biology assays. T.B. Culture Bact/Alert 3D: BacT Alert 3D system is used for mycobacterial culture from sputum samples. The machine is an automatic liquid culture machine to continuously monitor the mycobacterial growth. Thermocycler: Thermocycler is used to amplify DNA and RNA samples by the polymerase chain reaction. The thermocycler, in discrete, pre-programmed steps raises and lowers the temperature of samples in a holding block, allowing for denaturation and reannealing of samples with various reagents. Ultracentrifuge: Ultracentrifuge is used for the separation of small particles such as viruses, viral particles, lipoproteins, proteins and/or protein complexes, plasmid DNA and RNA. Vitek: VITEK is used to performing bacterial identification and antibiotic susceptibility testing.

15.26 Biochemistry See Table 15.33. Analytical Balance: Analytical balances being highly sensitive is used to accurately measure mass. Their range is between 0.1 mg and 0.01 mg. These balances have a draft shield or weighing chamber which prevents very small samples from being affected by air currents. Automated Clinical Chemistry Systems: The automated biochemistry analyser is used to quantitatively measure different chemicals and other characteristics of biological samples, with minimum human interference and assistance. Automated Urinalysis System: This is used to automatically analyse the urine. Blender/Mixer: This unit is used for rapid mixing and dry blending, of all types of free-flowing granules and powders, mixing of lubrication and homogenizing the powder and granules. Block Heating: A heating block, also known as a dry bath incubator, is used to heat samples in the tube, flasks and vials, to obtain consistent results and precise temperature stability. The machine is a microprocessor-controlled heating block with heater technology.

15.26 Biochemistry

445

Table 15.33 Biochemistry

Activity Analytical balance Automated clinical chemistry systems Automated urinalysis system Blender/mixer Block heating Carbon dioxide analyser Centrifugal chemistry analyser Centrifuge Chemistry analyser (photometric, discrete) Colorimeter, photometer, spectrophotometer Counter for clinical use Densitometer/scanner (integrating, reflectance, TLC, radio chromate) Drying unit E.S.R analyser Electrolyte analyser Enzyme analyser Flame photometer Freezer Fully auto. analyser (immunoassay) Gamma counter General use balance Glass ware Liquid scintillation counter Membrane filter unit Micromixer Micropipette Microplate washer Microscope binocular LED

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446

15  Department Wise Equipment Detailing

Table 15.33 (continued)

Activity Microscope fluorescence/UV Monochromator Nephelometer Osmometers Plasma viscometer Polarimeter Radioimmunoassay Refractometer Semiauto analyser Shaker/stirrer Water purifier (reverse osmosis)

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::::::::::-

Carbon Dioxide Analyser: Carbon dioxide analyser is used to detect and quantify the amount of carbon dioxide in the sample. Centrifugal Chemistry Analyser: A centrifugal chemistry analyser is used for centrifugally mixing a sample and a reagent and spectrophotometrically measuring concentrations of the sample. Centrifuge Machine: Centrifuge is a device used to separate mixtures made up of different densities. In the laboratory, centrifuge is used to separate plasma from the blood. Chemistry Analyser (Photometric, Discrete): Clinical chemistry analysers, also known as a biochemistry analyser, are used to test for analytes such as enzymes, proteins and electrolytes. The technique includes photometric and colorimetric testing, latex agglutination and ion-selective potentiometry, to analyse the samples such as blood serum, plasma and urine. Colorimeter, Photometer, Spectrophotometer: Colorimeter is to ascertain the concentration of a known solute. A spectrophotometer is a photometer to measure intensity as a function of colour, the wavelength of light. Counter for Clinical Use: A cell counter is used to determine the number and types of cells present or to check the viability of a cultured cell line in blood or urine samples. Densitometer/Scanner (Integrating, Reflectance, TLC, Radiochromate): A densitometer measures the degree of darkness (the optical density) of a photographic or semitransparent material or a reflecting surface. It is a light source aimed at a photoelectric cell. The machine determines the density of a sample placed between the light source and the photoelectric cell from differences in the readings. Drying Unit: Laboratory dryers or ovens are used for the washing and drying of glassware and plastic in the laboratory.

15.26 Biochemistry

447

E.S.R Analyser: The ESR analyser is used to measure erythrocyte sedimentation rate, which measures the rate at which red blood cells in whole blood descend into a standardised tube, reported as mm per hour. Electrolyte Analyser: The Electrolyte analyser is used for measuring the quantitative measurement of sodium, chloride and potassium, in whole blood, plasma electrolytes or serum, in the human body. Enzyme Analyser: The enzyme analyser is to study enzyme catalytic mechanisms. They are vital for the study of enzyme kinetics and enzyme inhibition. Flame Photometer: A flame photometer is an instrument used for determining sodium, potassium, calcium and lithium ions in body fluids. Freezer: Laboratory freezers are refrigerated cabinets useful for storing biological specimens and reagents at temperatures ranging between −40 °C and 10 °C. Fully Auto. Immunoassay Analyser: Immunoassay analysers are used to test substances like anticonvulsant, antiarrhythmic; cardiac markers; antibiotic and cardiac glycoside drug concentration determination; allergy testing; endocrine hormone testing; infectious diseases and protein, viral or bacterial toxin determinations etc. Gamma Counter: Gamma counters are used in radiobinding assays, radioimmunoassays (RIA) and nuclear medicine measurements such as GFR and haematocrit. General Use Balance: A laboratory balance is used to obtain the mass of various objects. It has units in centigrams (0.00). Glassware: Laboratory glassware is used for high-precision volumetric measurements. Liquid Scintillation Counter: Liquid scintillation counter is used for counting beta-emitting elements (3H, 14C, N, O, P, and S) because their radiation (charged particles) has a short range in solids and liquids. Membrane Filter Unit: Membrane filter units are used to test samples for microbial contamination. These are usually disposable, with reusable funnels. Micromixer: Micromixer is used for mixing for converting heterogeneous substances, which are distinctly nonuniform in some of their physical characteristics into one, homogeneous substance, that is uniform in its composition. Micropipette: A micropipette is used to transfer volumes of liquid in the microliter range accurately and precisely. Microplate Washer: Microplate washer is to control the procedure of washing experimental samples arranged in plate-based formats. In the process, the plate is loaded and the program is selected. Microplate washers then dispense, soak and aspirate liquids from the plate in seconds. Microscope Fluorescence/UV: UV microscopes are used in fluorescent microscopy. In this case, the UV light reflects the image of the sample stains to the fluorescence to create an image that can be viewed. Monochromator: The monochromator is used to automatically record spectra. Nephelometer: Nephelometer is to measure the concentration of immunoglobulin isotypes (IgG, IgA, IgM and IgE) as well as other serum proteins including haemoglobin, C-reactive protein, albumin, haptoglobin and others.

448

15  Department Wise Equipment Detailing

Osmometers: Osmometers determine osmotic pressure by methods such as the measurement of the freezing point. Plasma Viscometer: Plasma viscometer is for measuring the viscosity of whole blood, serum and plasma and its application to the diagnosis of hyperviscosity syndrome. Polarimeter: Polarimeters are used for the determination of the purity and concentration of ingredients in pharmaceuticals. Radioimmunoassay: Radioimmunoassay is used to test hormones (e.g. Adrenaline, Noradrenaline and more), hepatitis B surface antigen, drugs and anti-­ DNA antibodies in systemic lupus (SLE). Refractometer: A refractometer is used for measuring the refractive index of liquids, gases and translucent solids thereby determining the chemical composition of substances. Semiauto Analyser: Semiautomated analysers are used to perform tests on whole blood, serum, plasma, urine and cerebrospinal fluid and samples. These are faster, cheap and more compact, as compared to fully automated analysers. Shaker/Stirrer: A shaker to mix, blend or agitate substances in a tube or flask by shaking them. A shaker contains an oscillating board on which the test tubes, beakers, flasks, etc. are placed. Water Purifier (Reverse Osmosis): Reverse osmosis (RO) water purifier plant is used to produce purified water for clinical and biomedical laboratories.

15.27 Pain Clinic See Table 15.34. Manujet III Transtracheal Jet: The Manujet III is a kit which consists of an injector and jet ventilation catheters. Jet ventilation catheters allow trans tracheal access for oxygenation/ventilation with a manual jet or an automatic high-frequency jet ventilator.

Table 15.34  Pain clinic Status of works Activity Manujet III Transtracheal jet Microsurgical bipolar coagulator Radio-frequency generator Spine jet discectomy unit

Start date ::::-

End date

Not Responsible Complete In-progress started person

Remarks

15.28 Blood Bank

449

Microsurgical Bipolar Coagulator: Bipolar coagulator is mini solid-state diathermy for controlling bleeding during surgical procedures and eliminating tissue trauma. Radio Frequency Generator: RF generator is used to reduce the pain signals to the brain. Technology-wise, the machine transmits a small radio frequency current through the insulated needle to deactivate the nerve that is responsible for sending the pain signal to the brain. Spine Jet Discectomy Unit: The spine jet hydrosurgery system uses the power of water in surgery. In this machine, a controlled hair-thin supersonic stream of water is used which is capable of an effective cutting, ablation and collection.

15.28 Blood Bank See Table 15.35. Apheresis Machine: An apheresis machine is used to separate the donor’s blood into its various components like plasma, white blood cells, platelets and red blood cells. Blood Bag Tube Sealer: The blood tube sealer is to seal the tube of the blood bag without causing leakage of blood and hemolysis. Blood Bank Refrigerator: The blood bank refrigerator is used for the storage of whole blood, blood components (e.g., blood cells, plasma) and reagents in a safe and convenient environment. Blood Collection Monitor: A blood collection monitor is used to monitor the collection of blood during the donation to protect against the over or under-bleeding of the patient. Blood Donor Couch (Mobile): The blood donor couch is used during the blood donation process to provide a comfortable position to the donor. The chair has features for adjustment of height and position of the arm. Blood Mixing and Blood Weighting Device: A blood mixing device is used to mix blood or blood components by agitation. Cryo Bath Unit: Cryo baths are to control the temperature by microcontroller base PID controller up to an accuracy of 1 °C. To ensure uniform temperature, the bath unit is provided with a circulating pump. Deep Freezer −40 °C and −80 °C: Deep freezer is used for the storage of blood components like plasma in the blood bank. Dielectric Sealer: Dielectric sealer is used for joining thermoplastic films with the help of radio frequency (RF) energy. ELISA Reader with Washer: ELISA plate reader is used to detect and process biological and chemical data. The ELISA reader uses the technology of absorbance, fluorescence detection modes and luminescence, including intensity, TRF and polarisation. HB Meter: A haemoglobinometer is to measure haemoglobin blood concentration with the help of a spectrophotometric measurement technique.

450

15  Department Wise Equipment Detailing

Table 15.35  Blood bank Status of works Activity Apheresis machine Blood bag tube sealer Blood bank refrigerator Blood collection monitor Blood donor couch (mobile) Blood mixing and blood weighting device Cryo Bath unit Deep freezer −40 °C Deep freezer −80 °C Dielectric sealer Elisa reader with washer HB meter ID centrifuge Mechanical shaker Plasma extractor Platelet agitator Platelet incubator Refrigerated centrifuge Thawing bath Water bath serological

Start date

End date

Not Responsible Complete In-progress started person

Remarks

::::::-

::::::::::::::-

ID Centrifuge: ID centrifuge is an automatic balance-controlled silent centrifuge machine with a capacity of up to 12 ID cards. Mechanical Shaker: A shaker to mix, blend or agitate substances in a tube or flask by shaking them. A shaker contains an oscillating board on which the test tubes, beakers, flasks, etc. are placed. Plasma Extractor: Plasma extractor with the help of applying pressure on the collection bag through a spring-loaded front panel is used to extract plasma from the centrifuged bags of blood. Platelet Agitator: Platelet agitator is to store platelet concentrates and provides continuous gentle horizontal motion to the packs, at a fixed speed and temperature of 20–24 °C.

15.29 CSSD

451

Platelet Incubator: Platelet incubator provides accurate and stable storage conditions for platelets and small cell fragments. Refrigerated Centrifuge: Refrigerated centrifuge works on the principle of sedimentation, by holding the sample tubes for rotation at a high speed around a fixed axis. Due to the centripetal force, the denser substances separate at the bottom of the centrifuge tube. Thawing Bath: Plasma thawing bath is for rapid and uniform thawing of fresh frozen plasma (FFP) bags at 37 °C. Water Bath Serological: Serology water bath is used to incubate samples in water at a constant temperature over a long period.

15.29 CSSD See Table 15.36. Brushes for Cleaning Instruments: Cleaning brushes are used for cleaning, processing and sterilising all types of instruments and surgical equipment. These brushes are used on bone files, needle holder jaws, burrs, reamers, vascular instrument serrations and stubborn stains. Cleaner, Ultrasonic, Medical Instrument: Ultrasonic surgical instrument cleaner is used for cleaning plastic or metallic or surgical instruments, endoscopic surgical instruments including suction tips, ET tubes, sharp instruments, etc. Dry Heat Steriliser: Dry heat ovens are used to sterilise items that might be damaged by moist heat or that are impenetrable to moist heat. Table 15.36 CSSD Status of works Activity Brushes for cleaning instrument Cleaner, ultrasonic, medical instrument Dry heat steriliser Ethylene oxide gas steriliser Infectious waste burner (incinerator) Plasma steriliser Pressure sterilisers (instruments, dressings, utensils, etc.) Steriliser (autoclave)

Start date :::::::-

:-

End date

Not Responsible Complete In-progress started person

Remarks

452

15  Department Wise Equipment Detailing

Ethylene Oxide Gas Steriliser: Ethylene oxide sterilisers are used to sterilise heat and moisture-sensitive instruments, and consumables like plastic or rubber items. These items are generally prone to be damaged by pure steam or liquid chemical. For sterilisation, the items are packed in specialised paper and the sterilisation process is completed with the help of ethylene oxide gas. Requirements of Infrastructure for Installation, Commissioning and Testing of ETO Steriliser: While installing the ETO Steriliser, a separate room shall be provided in the central sterilisation department along with a separate enclosure for packing the material, which needs to be sterilised. ETO sterilisers require ethylene oxide gas for sterilisation. Some of the ETO sterilisers have to provision to fit the single-use ethylene oxide gas cylinders within the steriliser. Other may require the connection with the bulk ethylene oxide gas cylinder. In that case, the provision shall be made to provide space for the bulk cylinder. For exhaust of the used ethylene oxide gas, the SS/Copper pipe is connected to the ETO steriliser and this pipe is terminated at about 5 ft. height over and above the building height. Infectious Waste burner (Incinerator): To transform medical wastes into inorganic, incombustible matter with the help of an Incinerator. With the help of an incinerator, the waste becomes noninfectious and leads to a reduction in the volume and weight of the waste. Plasma Steriliser: Plasma steriliser is a steriliser which works on the technique called oxidation. When the plasma is used, it produces a chemical reaction due to which all microorganisms are deactivated. Further, the high heat turns the molecules of the hydrogen peroxide into highly unstable free radicals. Pressure Sterilisers: To autoclave the item at an elevated temperature and pressure of the steam, the pressure steriliser is used. Requirements of Infrastructure for Installation, Commissioning and Testing of Pressure Sterilisers: Pressure sterilisers use high-pressure steam to sterilise the material in the steriliser. Hence, the water supply is needed for the steriliser. Therefore, the water outlet shall be provided near the steriliser to supply the water with minimum hardness. Along with this, the water drain shall also be provided to clean the water tank of the steriliser. Steriliser (Autoclave): Autoclaves are also known as steam sterilisers, and this is a device which uses steam under pre-determined pressure to destroy harmful bacteria, viruses, fungi and spores on items that are placed inside the steriliser.

15.30 Dental See Table 15.37. AC-Powered Bone Saw: Power reciprocating bone saws are used in surgical procedures to cut bone.

15.30 Dental

453

Table 15.37 Dental

Activity AC-powered bone saw CBCT Cephalometer Dental accessories Dental Burr Dental chairs with unit Dental instruments Dental intraoral drill Dental operative unit Electro surgical unit and accessories, dental Electromagnetic bone growth stimulator Fibreoptic dental light Jet injector gas-­ powered/ mechanical-powered Operative burnisher OPG Pantograph Pulp tester Surgical haemostat Surgical headlight Ultraviolet activator for polymerisation X-ray unit, extraoral with timer X-ray unit, intraoral

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::::::::::::-

:::::::::-

CBCT: To produce three-dimensional (3-D) images of teeth, soft tissues, nerve pathways and bone in a single scan, the dentists use the dental cone beam computed tomography (CT). Requirements of Infrastructure for Installation, Commissioning and Testing of CBCT machine: As the CBCT is an X-ray-based machine, the requirements of infrastructure for installation, commissioning and testing of the CBCT are similar to that of an X-Ray machine room. For details of the X-Ray machine, please refer to Sect. 15.23 under the heading of ‘Radiology’. Cephalometer: The cephalometer is for cephalometry. It is to analyse both the dental and skeletal relationships found in the human skull.

454

15  Department Wise Equipment Detailing

Dental Accessories: For dental manipulation, treatment, restoration, and removal of teeth and surrounding oral structures, these instruments and tools are used. Dental Burr: For cutting hard tissues: teeth or bone, dental burrs are used. These burrs are made out of steel, stainless steel, tungsten carbide and diamond grit. Dental Chairs with Unit: A dental chair is to lay down and support a patient’s body whenever a dental procedure is being performed on a patient. This is an electric chair and is fitted with a water line; compressed air; and micro motor, and the instrument tray is retractable as per the requirements of the dentists. The unit also consists of a seat for the dentist to sit and perform the procedure. Dental unit consists of operator lights, an X-ray viewer, air–water syringe, a foot control motor, a spittoon bowl, glass holder, etc. Dental Instruments: Dental instruments are tools used for examination, manipulation, treatment, restoration and removal of teeth and surrounding oral structures. Dental Intraoral Drill: Dental drill or handpiece is a hand-held, mechanical instrument used to perform dental procedures like, removing the decay, performing cosmetic dentistry, polishing fillings and altering prostheses. Dental Operative Unit: Dental operative units are used to serve as a base for other dental devices, such as dental handpieces and other dental accessories. Electrosurgical Unit and Accessories, Dental: Dental electrosurgical unit is used for the sculpture of living tissue without pressure, controlling bleeding and inducing heat in fluids. Electromagnetic Bone-Growth Stimulator: This intra-oral device is used for the promotion of bone growth after dental implantation. The device generates a pulsed electromagnetic field (PEMF) covering the bone interface of the titanium implant. Fibre-Optic Dental Light: Fibre-optics dental light is to transilluminate the teeth and other oral structures and is used for the detection of caries, calculus and soft tissue lesions. Jet Injector Gas-Powered/Mechanical-Powered: The jet injection instrument works on the principle that small quantities of liquids forced through very small openings under high pressure can penetrate mucous membranes or skin without causing excessive tissue trauma. Operative Burnisher: Burnishers are dental hand instruments, used at the end of dental restoration procedures or operations. They are used for polishing and contouring amalgam fillings and polishing composite fillings. OPG: To obtain a flattened two-dimensional view of a half-circle from ear to ear, the OPG (Orthopantomagram) is used. It is an X-ray machine which has a provision to scan the upper and lower jaw in a panoramic view. Requirements of Infrastructure for Installation, Commissioning and Testing of OPG machine:

15.31 Physiotherapy

455

As the OPG is an X-ray-based machine, the requirements of infrastructure for installation, commissioning and testing of the OPG are similar to that of an X-ray machine room. For details of the X-ray machine, please refer to Sect. 15.23 under the heading of ‘Radiology.’ Pantograph: Pantograph is used for recording the patient’s mandibular border movement and programming an articulator so that the movements of the articulator simulate the border movements of the patient. Pulp Tester: A pulp tester is for pulp sensibility tests including thermal and electric tests, which extrapolate pulp health from the sensory response. Surgical Haemostat: Surgical Haemostat are used for wound protection and for control of oozing or bleeding from clean oral wounds. Surgical Headlight: The surgical headlight is used by surgeons for providing proper illumination to the desired local area or the surgical spot. Ultraviolet Activator for Polymerisation: An ultraviolet activator for polymerisation produces ultraviolet radiation and is used to polymerise (set) resinous dental pit and fissure sealants or restorative materials by the transmission of light through a rod. X-Ray Unit, Extraoral with Timer: Extraoral X-rays are made with the film outside the mouth. This type of X-ray not only shows the teeth but can also provide important information about the jaw and skull. Requirements of Infrastructure for Installation, Commissioning and Testing of X-ray Unit: For requirements of infrastructure requirements for installation, commissioning and testing of the X-ray machine room, please refer to Sect. 15.23 under the heading of ‘Radiology’. X-Ray Unit, Intraoral: The intraoral X-ray unit is used for getting precise positioning, straightforward imaging and good-quality images in high resolution. Requirements of Infrastructure for Installation, Commissioning and Testing of X-ray Unit: For requirements of infrastructure requirements for installation, commissioning and testing of the X-ray machine room, please refer to Sect. 15.23 under the heading of ‘Radiology’.

15.31 Physiotherapy See Table 15.38. For the Physiotherapy department, the above items can be procured. The equipment are electrotherapy, magnetotherapy, thermotherapy, cryotherapy and exercise therapy.

456

15  Department Wise Equipment Detailing

Table 15.38 Physiotherapy

Activity Ankle exerciser Balance trainer Bath Sitz, nonpowered Bath hydromassage Bath paraffin wax Bath Sitz powered Bed air flotation therapy, powered Bed air fluidised Cane Cold pack Combination therapy system (ultrasound +  stimulation) Compression therapy system CPM device for knee and hip Cryotherapy system Decompression therapy system Electromyograph EMG biofeedback system Ergometer, treadmill Finger ladder Hand exercise table High–low couches/ Bobath tables High-power laser therapy Hot pack Hydrocollator Infrared lamp Iontophoresis device, other uses Isokinetic testing and evaluation system Long wave Microwave diathermy Neurorehablitation robotics machine Other sensory products Parallel bars Physiotherapy gun

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::::::::::-

::::::::::::::::::::::-

15.32 Occupational Therapy

457

Table 15.38 (continued)

Activity Pressure applying device Quadriceps table Shockwave therapy system Shortwave diathermy Shoulder wheel Static cycle Stimulator muscle Therapy device, direct current, low intensity Traction equipment, powered Transfer aid Treadmill, powered Ultraviolet lamp Ultrasonic diathermy Unweighing harness system Wireless electrotherapy

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::::::::::::::-

15.32 Occupational Therapy See Table 15.39.

458

15  Department Wise Equipment Detailing

Table 15.39  Occupational therapy

Activity Activity mattress Aluminium sheet Ankle exercise Armeo robotic hand Audio–visual toys Ball pool Bean bag Bed with therapy mats of different sizes from ground Bench grinder with stone Bench vice Bolster roller (different sizes) Box and blocks Building blocks Buttoning hook Carousel spinning chair Cerebral palsy chair Cervical air traction Corner chair/floor sitter Counting and colour sorting beads set Cosy caterpillar Crash pad Crawler for CP Crawling tunnel Crutch Dendrite/fevicol Different types of peg boards Door latch frame set Dressing frame Dumbbells Eating aid with utensils Electrical drill machine Electro equipment frame set Envil Equilibrium board/ balance board/wobble board

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::::::::-

::::::::::::::::::::::::::-

15.32 Occupational Therapy

459

Table 15.39 (continued)

Activity Ergometer Exercise staircase Fidget set Figure eight balance beam set Filler (different types) Fingerboard Finger climbing board Finger dexterity test (100 holes + tweezer) Finger extension remedial Finger prehension device Fluido therapy dry heat therapy unit Foam adventure set, foam gymnasium Foot placement ladder Footprints Foot roller Footstool double step Full-length mirror Gel ball set Geometric puzzle board Goniometre (full circle, half circle, finger) Grip exercises Gross motor skill development set Gymnic multiactivity stone Hammer Hand dynamometer Hand exerciser power web combo Hand gym kit board Heat bath Heat gun Hilltops—set of 5

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::::::::::::::::::::-

::::::::::(continued)

460

15  Department Wise Equipment Detailing

Table 15.39 (continued)

Activity Hole punch HPEE synthetic leather occupational therapy tumble roller Inclined and horizontal sandboard Inclined tapered balance beam Indoor and outdoor play equipment like plastic balls, softballs in small and big sizes, basketball indoor kits for kids and movable toys with light and sound Jigsaw Keyhole test board Linear motion steadiness test apparatus electrical Locomat Long-handled brushes and comb Low-temperature plastic LTT sheet cutter Medicine ball Nirmal hand exerciser table Oral motor equipment Ortho wheelchair Overhead shoulder pulley Paediatric gaiters Parallel bar adult Parallel bar paediatric Paediatric walker/ relater adjustable Pegboards of different types and sizes Pencil grips Pencil maze test board Percussion hammer Physic gym ball set (different sizes), peanut shape therapy ball

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::-

:::-

:::-

::::::::::::::::::-

15.32 Occupational Therapy

461

Table 15.39 (continued)

Activity Pinch tree Poly poplin sheet Power stretch band (different level) Prone crawling board Prone sander Puzzle program set Pyramid round and pyramid square Quadriceps board Rainbow river stone Reached Rhythm instrument Rabbit Rocking horse Rope ladder Round nose pliers Sanding unit reciprocal exert with incline Sanding unit semicircular table model Sensory brush/ vibrating brush Sensory brushes Sensory motor/ perceptual motor-­ activity indoor fun gym Sensory stimulation activities kit Sewing machine Shoulder pulley Shoulder wheel/ multipurpose wheel Sorting matching posting box set Sound discrimination set Standing frame Standing table with frame Static bicycle

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::::::::::::::::-

:::-

:::::::::(continued)

462

15  Department Wise Equipment Detailing

Table 15.39 (continued)

Activity Steel scissors Strong scissors Supinator and pronator (rainbow and zig-zag type) Supine sander Tape measuring Target game Texture mat Therapeutic putty (different colours according to hardness) Therapy mat/activity mattress Tilt table Trampoline Trimming knife Velcro Vestibular/swing system, on-the-go swing, air walker therapy swing, cocoon swing Vibrator machine or toys Vise group pliers Walker Wavy tactile path Wax bath Wedge (different sizes according to need) Weight cuff (different weights) Weighted blanket Wheelchair detachable Wheelchair paediatric Wiggle seat Wire cutter Wrist circumductor Wrist rollator Wrist rotation rehabilitation

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::-

:::::-

::::::-

:::::::::::::::-

15.33 Furniture and Fixtures

463

15.33 Furniture and Fixtures 15.33.1 Patient Furniture See Table 15.40. Table 15.40  Patient furniture Status of works Activity Attendants stool Attendants couch Bed screens Bed side locker deluxe Bed side locker general Beds deluxe Beds general Beds ICU motorised Beds semi-­ fowler motorised Cribs Cylinder trollies Dressing trollies I.V. stand I.V. rod Instrument trolley Mattress Over bed table Patient stool Pillows Step stool (double) Stretcher trolley Wheel chairs

Start date ::::::::::::::::::::::-

End date

Not Responsible Complete In-progress started person

Remarks

464

15  Department Wise Equipment Detailing

15.33.2 Civil Furniture See Table 15.41. Table 15.41  Civil furniture Status of works Activity Examination table wooden with a mattress File Almirah (4 drawers) File racks Lockers large Office chairs Office chairs (deluxe) Office chairs (executive) OPD/waiting chairs Steel Almirah large Steel Almirah small Visitors chairs Visitors chairs (executive)

Start date :-

:::::::::::-

End date

Not Responsible Complete In-progress started person

Remarks

15.34 Backup Services

465

15.34 Backup Services See Table 15.42. Table 15.42  Backup services Status of works Activity Ambulance Autoclaves Bed partitions Cleaning equipment Computers with printers and UPS Fridges Hospital operating software Oxygen cylinders ‘A’ type Oxygen cylinders ‘B’ type Televisions Water coolers

Start date :::::::-

::::-

End date

Not Responsible Complete In-progress started person

Remarks

466

15  Department Wise Equipment Detailing

15.35 Hospital Laundry See Table 15.43. Table 15.43  Hospital laundry Status of works Activity Washer cum dryer Hydro extractor Calendar for pressing Iron press Automatic folding machines Sewing machines

Start date :::::-

:-

End date

Not Responsible Complete In-progress started person

Remarks

15.36 Miscellaneous Small Instruments

467

15.36 Miscellaneous Small Instruments See Table 15.44. Table 15.44  Miscellaneous small instruments Status of works Activity B.P. apparatus Baby weighing machine Chetal forceps Cidex trays 222 × 82 × 41 Cidex trays 400 × 70 × 50 Ear specular Examination lamps Formalin chamber medium Fumigator 5 L Hammer small Height scale Humidifiers Laryngoscopes Mortuary cabinets (cooled) Nasal forceps Needle holder Nebuliser heavy duty Otoscopes Splints and tourniquets Sponge holder Syringe needle destroyer Stethoscope adult Stethoscope Paed Suction machine baby Torch Tongue depressor

Start date

End date

Not Responsible Complete In-progress started person

Remarks

::::::::::::::::::::::::::(continued)

468

15  Department Wise Equipment Detailing

Table 15.44 (continued) Status of works Activity Trauma packs and kits Weight machine adult X-ray view box double X-ray view box single

Start date

End date

Not Responsible Complete In-progress started person

Remarks

::::-

Further Reading Bhawan P, Road CIG. Medical Equipment Maintenance Policy; 2012. p. 27. Biomedical Equipment List [Internet]. MedShare. [cited 2021 Jul 15]. https://www.medshare.org/ biomedical-­equipment/ Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. Chapter 49, Equipment Planning. India: Springer Singapore; 2022. p. 501–27.

Chapter 16

Manpower Planning, Hospital Committees and Staff Policies

The organisation of the hospitals helps in delivering the optimal and the best service to the patients and thus fulfils the aims of the institution. To achieve this objective, control and coordination of hospital service are essential. In turn, better control and coordination will depend on a suitable organisational structure and adequate supervision. Activities to be performed and personnel needed shall be grouped in such a way as to achieve smooth functioning. An organisation chart is a working tool for the orderly arrangement of work and people. Through its design, it shall indicate the grouping of persons concerning one another and bring out the lines of authority. The chart shall fit the individual hospital. While human elements shall be taken into consideration, adjustments on this basis shall not violate the basic principles underlying lines of authority. The medical staff is the chief agency through which the hospital achieves its prime objective, which is the proper care of patients who are sick or injured. Here, the doctor is the decision-maker on the major part of treatment whether as an out-­ patient or in-patient. Hence, the proper choice and retention of doctors are extremely important for the smooth and competent functioning of the hospital. The management philosophy of the hospital administrator will determine the philosophy of personnel management in each department and the relationship among the department heads. In most hospitals, patient care is the main objective. There can be other objectives in the hospital, which depend upon the size and the scope of the hospital, e.g. the training programme, the education programme, community health and the research activities, etc. Human endeavour in this twentieth century has become so complex that the administration of any activity offers problems unknown in the simple enterprises of an earlier civilisation. Any organisation can only provide efficient service with a combined effort of men and materials and efforts made to prevent negligence of any duty or duplication of work, and thus to produce the required results. All this can be efficiently achieved with the help of the predefined and designed ORGANISATIONAL

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_16

469

470

16  Manpower Planning, Hospital Committees and Staff Policies

CHART, where all the duties and responsibilities of the individual are predefined and elaborated. The Governing Body shall release that the medical staff of the hospital must be appointed with utmost care and only capable staff to be appointed so that the maximum care can be provided to the sick patient. While preparing the organisational chart, it shall be made clear that all the duties are defined and there shall be no overlapping of duties, i.e. every individual shall have a predefined set of duties. Waste of effort and extravagance in the use of men and materials prevent the economy. In the organisational chart, the authority shall be centralised, responsibilities fixed and duties and interrelationships clearly defined. First of all, department-wise and category-wise staff requirements shall be worked out based on factors like the number of beds; clinical departments; services provided; the number of patients; duty hours and availability of staff. As a guide in selecting the medical staff and as a safeguard for preventing the appointment of those who are not desirable, certain minimum qualifications shall be adopted and rigidly enforced. The working of present days of most organisations is through committees. If carried out properly, it can be of great help. It brings out the combined wisdom of knowledge of the people who discuss matters concerning the organisation. The committee views the problem from various angles, and finally, a consensus emerges which is, hopefully, the best alternative. The committees elected from the staff appointed by the Governing Body may perform much of the work of the hospital. These committees are, normally, of two types (a) standing committees and (b) special committees. A good hospital runs just like a well-lubricated machine. Excellent and safe patient care can be achieved if all the pieces and processes work together. This result can only be achieved if the hospital has all of those systems, manpower and processes in place. Staff members shall be made very clear as to what they have to do and what is expected from them. It is equally important that the staff shall be given an effective set of rules, regulations and procedures which shall guide them in their day-to-day tasks. In a hospital where the staff diverts from the defined, rules, regulations, procedures and standards, it can be detrimental to the hospital. Inconsistency can deteriorate the quality of patient care and could be detrimental to the patient and can spoil the reputation of the hospital. This is the reason why the set of rules, regulations, systems, policies and procedures are important for hospitals. Therefore, there is a strong need to develop a good and time-tested set of rules, regulation, systems, policies and procedures, to ease the staff to function effectively and efficiently and ensures the safety of the patients and staff. Hospital policies and procedures guide day-to-day operations and make sure that everything is running as it was expected. The policies and procedures define the expectations and standards of staff, set guidelines for operations and improvements, and streamline processes. To summarise, we can say that the main purpose of having these policies and procedures is to establish a high degree of understanding, efficiency, cooperation

16.1 Staff Requirement

471

and unity among the employees of the hospital. It also helps to provide uniform policies for all employees of the hospital, so that there are no discrepancies. The enclosed checklist shall help the planner and designer to work out the staff requirement, appointment, form committees and framing of staff policies.

16.1 Staff Requirement 16.1.1 Administration See Table 16.1. Governing Body: For any hospital, the head is the Governing Body, by whatever name it may be called, either the ‘Board of Trustees’ or the ‘Board of Directors,’ etc. The duties of the Governing Body are to see that the services to be provided to the sick are efficient and at the lowest cost. For fulfilling these objectives of the hospital, the Governing Body appoints the executives and delegates all the powers to them, to achieve the objective of the hospital. Such a person may be called the Administrator, the Medical Director or anything else, depending upon the need of the individual hospital. Practically, it is this person who will be responsible to the Governing Body and for fulfilling his/her duties. Therefore, he/she may have the persons below his/her line reporting to him/her. Table 16.1 Administration Status of works Activity Details of Governing Body Size of the body Main members of the Body Chairman Vice Chairman Meeting schedule of the body Director Administrator Asstt. Administrator Medical Superintendent Asstt. Medical Superintendent Secretary

Start date

End date

Complete In-progress

Not Responsible started person

Remarks

:::::::- Yes :- Yes

No No

Qualification Qualification

Experience Experience

No.____ No.____

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

472

16  Manpower Planning, Hospital Committees and Staff Policies

In a hospital, there are two divisions, one dealing with patient care and the other with business management. These two divisions are again subdivided into different departments. The Governing Body is the supreme authority in the hospital, and its selection shall be made from the representatives of the community to which it serves. While selecting, it shall be ensured that the members do justice with their position and give an uplift to the functioning. Because the Governing Body has this duty and responsibility, it shall have the power to control. This power to control is derived from the charter of articles of incorporation of the hospital, its bylaws and its rules and regulations. Size and the members of the Governing Body: The Governing Body shall ideally consist of 8–15 members from the different sections of the society. All the members of the Governing Body shall either be the learned professional, the businessman, the representative of the labour or the influential class of the society. The members of the Governing Body shall be such that the hospital can have the advantage from their natural talents, special training, experience, etc. The Governing Body is expected to take a genuine interest in the hospital's work; devote a great deal of time to the hospital’s affairs; shall think of the hospital plans and for its uplift; shall be regular in attending the meetings; shall actively discuss the new policies being formulated and shall review the working results of the hospital and give his comments on the same. As the members of the Governing Body are not full-time employees, they need assistance in fulfilling their objectives. For this, they appoint the Director. Officers of the Governing Body: Governing Body shall consist of Chairman: The Chairman or President who shall be the head of the Governing Body and shall preside over the meeting of the Governing Body. Vice Chairman: He shall be below the Chairman and acts as a Chairman in the absence of the latter. Secretary: The Secretary keeps the record of the meetings, arranges for the meetings and presents the reports along with other facts and figures. Treasurer: The treasurer shall be for keeping the records of the funds, receipts and disbursements. For efficient day-to-day working of the hospital, Governing Body shall appoint the following officials: CEO/Managing Director: The CEO/Managing Director shall be a person responsible for the overall management of the day-to-day affairs of the hospital. As the CEO/Managing Director cannot be available all the time and it is difficult for handling all the jobs by himself/herself, he/she requires assistance for which he/she shall appoint the Medical Superintendent/Medical Director to look after the affairs of the medical administration and the medical care and the Administrator/ Director Administration for looking after the non-medical administrator or the business management. Medical Superintendent/Medical Director: In a hospital, the overall in-charge of Professional/Medical care shall be the Medical Superintendent/Medical Director. For all the departments under the control of the Medical Superintendent/Medical

16.1 Staff Requirement

473

Director, he/she shall be responsible, but depending on the size of the hospital and the workload, he/she may have one or more Deputy Medical Superintendent/Dy. Medical Director. Generally, the Medical Superintendent/Medical Director along with the help of the Deputy Medical Superintendent/Dy. Medical Director shall be directly responsible to manage and control the department like Medical Care of Indoor and OPD Patients, Radiology, Laboratory, Emergency Department, Medical Items Purchases, Medical Stores, Pharmacy, Nursing Care, Supporting Departments like Dietary services, Library and Social Service, etc. Administrator/Director Administration: The Administrator/Director Administration in a hospital shall be responsible for Business Management and Non-Medical Administration. For all the departments under the control of the Administrator/Director Administration, he/she shall be responsible, but depending on the size of the hospital and the workload, he/she may have one or more Asst. Administrator/Deputy Director Administration. Administrator/Director Administration with the help of Asst. Administrator/Dy. Director Administration shall be responsible to manage and control the departments like Information Technology, Reception and Information, Accounts & Finance, Repair & Maintenance, House Keeping, Linen Supply Department, Non-Medical Purchases, Non-Medical Stores, Admission & Discharge, Transport, Medical Records, Security, Personnel department, Public relations, Volunteer department, etc.

16.1.2 Medical Care See Table 16.2. For efficient and effective medical care in the hospital, the medical staff shall be the chief agency through which the hospital achieves its prime objectives. The medical staff consists of Physicians or so-called Doctors. They are the persons who decide on the major part of treatment whether as an out-patient or in-patient. It is the doctor who decides whether a patient is to be admitted or not, what investigations and treatments are to be carried out and when the patient is to be discharged. Hence, the proper choice and retention of doctors are extremely important for the smooth and competent functioning of the hospital. For the achievement of the objectives, the medical staff of the hospital must be appointed with utmost care and only capable staff to be appointed so that the maximum care can be provided to the sick patient. This department shall be under the direct control of the Medical Superintendent/ Medical Director. Below the line shall be the Heads of the Departments, the Medical Officers, the House Surgeons, the Senior Residents and the Interns. The Heads of the Departments shall be generally the Specialists of various departments, or the Super Specialists, Pathologist, Biochemist, Microbiologist, Histopathologist, Radiologist and Anaesthetist. The departments of the Laboratory, the Radiology and the Operation Theatre shall be assisted by the Technicians. Apart from this, there can be a few

474

16  Manpower Planning, Hospital Committees and Staff Policies

Table 16.2  Medical care Status of works Activity Specialists What will be the mode of payment Super specialists What will be the mode of payment Emergency medical officer Medical officers Floor officers Senior residents Do you want to keep Honorary Doctors What will be the mode of payment Associate doctors What will be the mode of payment Courtesy doctors What will be the mode of payment Visiting doctors What will be the mode of payment

Start date :- Yes :-

End date No

Not Responsible Complete In-progress started person Qualification Experience

:- Yes :-

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

::::-

Yes Yes Yes Yes

No No No No

Qualification Qualification Qualification Qualification

Experience Experience Experience Experience

No.____ No.____ No.____ No.____

:- Yes :-

No

Qualification

Experience

No.____

:- Yes :-

No

Qualification

Experience

No.____

:- Yes :-

No

Qualification

Experience

No.____

Remarks No.____

:-

departments where Technicians are required like Eye, ENT, Cardiology, Surgery, Orthopaedics, etc. Qualification of the Medical Staff: As a guide in selecting the medical staff and as a safeguard for preventing the appointment of those who are not desirable, certain minimum qualifications shall be adopted and rigidly enforced. For appointing the doctor to the medical staff of a reputed, ethical hospital, a doctor shall be a graduate of a recognised medical college with a degree in Medicine or Surgery; shall be a post-graduate degree in his speciality and/or also Doctorate Graduation like DM, MCh in his/her super speciality; legally licensed to practise medicine or surgery in the country where the hospital is situated; enjoy the reputation of being an ethical and conscientious doctor; participate in the activities of organised medicine as demonstrated by his/her membership in local, state and national medical societies; have served an internship of at least 1 year; and temperament and disposition to work in harmony with his/her colleagues, professional, technical and other personnel in the hospital; to create an effective understanding with the administration of the hospital.

16.1 Staff Requirement

475

Appointment of the Medical Staff: Since the Governing Body representing the ownership of the hospital has both a legal and moral responsibility to protect from foreseeable and preventable harm to all those who come to the hospital for treatment and to maintain the highest quality of medical care, the Governing Body shall select the medical staff carefully, to protect both patients and the hospital and to absolve the hospital from liability. Since the Governing Board personally may not be qualified to judge the competence of medical staff, it shall seek advice from expert medical professionals in this field. To assure the character and standing of individual doctors, they shall take the reference from his/her previous employers, etc. before appointing the medical staff. For appointing the medical staff, the Governing Body shall formulate an advisory committee consisting of doctors, in whom the Governing Body has confidence. Appointment Procedure: The procedures for the appointment of the doctors may vary depending on whether the hospital is government or private. In the Govt. hospital, whether central, state or local hospital, the selection is by the Public Services Commissions and other similar recruiting bodies. These selections are based on the results of tests and interviews. In other hospitals, the position is different where the Governing Body appoints the doctors with the help of the Medical Superintendent/Medical Director/medical professionals. Every doctor desirous of joining the hospital for professional care of the patients shall make an application in writing. This application shall usually be presented to the Medical Superintendent/Medical Director. The application of doctor shall contain details as to (a) identification of the applicant, (b) his/her professional education, including premedical and medical education and postgraduate education, (c) his/her experience in the internship, residencies, fellowship, assistantships, etc., (d) his/her professional experience, (e) references, (f) his/her papers presented, (g) his/ her special achievement in the field of medicine or surgery, (h) his/her ability in research as evidenced by contributions to medical literature, (i) previous experience in specialities with the names of the preceptors and (j) applicants agree to abide by the rules and regulations of the hospital, etc. This application shall be reviewed by the Credentials Committee. The Credentials Committee shall go through the application in detail and if needed, shall call the concerned applicant for an interview. The committee shall make its recommendations to the Governing Body for acceptance or rejection of the application. Once the report of the Credential Committee is received, Governing Body shall discuss other terms and conditions like remuneration and perks, etc. and appoint the doctor to the team of medical staff. 16.1.2.1 Types of Medical Staff Consultant doctors: The consultant medical staff consists of the specialists and the super specialists, in different disciplines of the medical field, who are appointed as such because they can show evidence of qualifications or experience as specialists. These doctors shall be recruited either on a fixed basis (Closed System of payment)

476

16  Manpower Planning, Hospital Committees and Staff Policies

or sharing basis (Open system of payment) or otherwise on a salary plus incentive system. They shall attend OPD and operation theatre as and when required. They shall also be responsible for the morning and evening rounds of a patient admitted under his/her care in the hospital for treatment. Honorary doctors: The honorary doctors consist of those doctors who have been active in the work of the hospital but who are now retired and those whom the hospital wishes to honour because of outstanding reputation or for some other reason even though they may not be connected with the hospital. Doctors of this type have no active duties in the hospital, nor they can hold office. They shall, however, be encouraged to attend conferences of the medical staff and have the privilege of participating in discussions. These types of doctors are appointed on a salary basis but on comparatively very low emoluments. Visiting doctors: The visiting medical staff consists of the doctors who wish to attend to the patients in the hospital but do not desire to become a member of the active medical staff of the hospital. If the Governing Body feels that the income from a particular speciality or super-speciality will be less and the emoluments of the doctors of that speciality or super-speciality cannot be recovered, the doctors in those departments can be appointed on a visiting basis. These types of doctors shall conduct OPDs and are allowed to admit the patient and perform surgeries. Courtesy doctors: The courtesy medical staff consists of the doctors who wish to avail the services of the hospital and is desirous of admitting, operating and treating his/her private patient. These types of doctors are appointed purely on sharing basis, and no fixed liability of salary is undertaken by the hospital. These doctors are generally not allowed to conduct OPD in the hospital and mainly bring their patients to the hospital. Associate doctors: The associate doctors are junior or less experienced doctors and other doctors who have not been actively interested in the hospital but who wish eventually to become an active doctor as and when the vacancy arises. The members of this division are associated in a junior capacity with the members of active staff and perform such duties as may be assigned to them. These doctors mainly carry out the treatment of a patient under a consultant. They normally work under the control and guidance of the consultant or the senior doctor. This division of the medical staff is not necessary for the smaller hospitals. Under this category, there are two types of doctors: (1) Resident Doctors also called Senior Residents and (2) Junior Residents or General Duty Doctors Senior resident doctors: These are the Resident Medical doctors with a postgraduate degree like M.D. or M.S. and are called Senior Residents. These doctors shall be normally appointed on salary and shall be the full-time worker of the hospital. These doctors shall normally not be allowed to practise outside the hospital. These doctors shall assist and help the consultant. They shall normally help the consultant in conducting the OPD and shall be on duty to attend the call from OPD, ward and Emergency department. They also shall assist the consultant in taking rounds in the wards and shall be responsible for the preparation of the discharge card of the patient at the time of discharge.

16.1 Staff Requirement

477

Junior resident doctors/general duty doctors: These shall be normally graduate doctors who are not postgraduate and shall be appointed in the hospital on a salary, i.e. full-time basis. They shall not be allowed to practise outside. These doctors shall be on rotational duty and shall be present around the clock to attend to the complaints of the patient. They shall also be responsible for helping the consultants to take the rounds of wards. These doctors shall generally be posted in the intensive care wards like the ICU, ICCU, NICU, Emergency department or even on the floors, etc. 16.1.2.2 Remuneration Types of Medical Staff: The Governing Body of the hospital shall be clear about the terms and conditions on which the doctors are to be appointed. There can be two systems of appointment, that can be CLOSED Type and OPEN Type. Under the ‘OPEN’ type of the system, the attending doctor is appointed on a sharing basis, i.e. the doctor is paid remuneration in the shape of a particular percentage as a share of the doctor out of the total consultation fee collection of that doctor. Normally in a good hospital, the senior doctors and the superspecialist are appointed on this system as the expectations of these doctors are normally high and always may be difficult for the hospital to afford them on a fixed salary basis. Under the ‘CLOSED,’ the medical staff is appointed on the salary and they get the fixed remuneration in the shape of the salary. Under this system, the employee doctors are not allowed to practise outside the hospital. Considering the pros and cons of both systems, nowadays hospitals prefer to appoint doctors adopting both systems, i.e. Open and Closed systems. It means that the doctors are appointed on the salary as per the closed system, and the salary portion is nominal. Apart from the salary, doctors are given incentives in the shape of a share of the total earning as detailed in the Open type of system. Hence, the doctor under this system gets (1) a fixed salary and (2) a share of his professional earning. This system is also called the Salary Plus Incentive System. Similarly, in the hospital, courtesy consultants are also appointed. These types of doctors are not the regular doctors in the hospital and use the facilities of the hospital for the treatment of their patients. These doctors are also called visiting consultants in some hospitals.

16.1.3 Investigations and Support Departments See Table 16.3. These are the doctors who are directly responsible for investigative and support departments. The investigation departments are like Biochemistry, Microbiology, Histopathology, pathology and Radiology. All of these doctors are also medical graduates with a degree and/or post-graduation in their respective disciplines. Each

478

16  Manpower Planning, Hospital Committees and Staff Policies

Table 16.3  Investigation and support department Status of works Activity Pathologist Biochemists Histopathologist Microbiologist Radiologist Anaesthetist

::::::-

Start date Yes Yes Yes Yes Yes Yes

End date No No No No No No

Not Responsible Complete In-progress started person Qualification Experience Qualification Experience Qualification Experience Qualification Experience Qualification Experience Qualification Experience

Remarks No.____ No.____ No.____ No.____ No.____ No.____

of these departments is headed by the Head of the Department performing duties with the help of other junior postgraduate doctors. The department of anaesthesia, being a support department, is headed by the Head of the Anaesthesia department and is assisted by the junior anaesthetists. These doctors take care of the operation theatre and administrate anaesthesia during surgeries. As the anaesthetists are the intensivists, they are responsible to take care of the ICUs also. These doctors are generally appointed on a fixed salary basis. But some hospitals do have the practice to give some sharing to these doctors as an incentive.

16.1.4 Technicians See Table 16.4. For an effective service in hospitals, the role of various types of technicians who assists the physicians cannot be underestimated. Some of the common types of technicians that are required in the hospital are like laboratory technicians, OT Technicians, CSSD Technicians, Radiology Technicians, Endoscopy technicians, Blood Bank technicians, Optometrist, etc. Apart from this, some technicians may also be required for a special investigation like neurology lab technicians, Cath Lab Technicians, CTVS technicians, etc. Technicians are the persons who contribute a lot to keeping the hospital running by conducting diagnostic tests and helping the doctors and physicians. Hospital technicians provide direct and indirect care to patients. As a rule, the technicians shall be fully trained and qualified to complete specialised tasks and these tasks may vary from hospital to hospital or from department to department. Usually, the hospital appoints a mixture of Senior Technicians and Junior Technicians in all the departments of the hospital. The duties of both types of technicians are different and well-defined. The Technicians shall be well-qualified and shall have the required degree and shall be a qualification. Usually, the degrees can be graduate, postgraduate or in some cases diploma courses also acceptable. Most of the time the technicians shall

16.1 Staff Requirement

479

Table 16.4 Technicians

Activity X-Ray Technician (Senior) X-Ray Technicians (Junior) Laboratory Technician (Senior) Laboratory Technicians (Junior) Phlebotomist Operation Theatre Technician (Senior) Operation Theatre Technician (Junior) Dialysis Technician (Senior) Dialysis Technician (Junior) CSSD Technician (Senior) CSSD Technician (Junior) ECG Technician Echo Technician Cath Lab Technician Plaster Technician Physiotherapists Occupational Therapist Audiometerist Speech Therapist Endoscopy Technician Neurology Technician

Status of works Start End Not Responsible date date Complete In-progress started person :- Yes No Qualification Experience

Remarks No.____

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

:- Yes :- Yes

No No

Qualification Qualification

Experience Experience

No.____ No.____

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

:- Yes :- Yes :- Yes

No No No

Qualification Qualification Qualification

Experience Experience Experience

No.____ No.____ No.____

:- Yes :- Yes :- Yes

No No No

Qualification Qualification Qualification

Experience Experience Experience

No.____ No.____ No.____

:- Yes :- Yes :- Yes

No No No

Qualification Qualification Qualification

Experience Experience Experience

No.____ No.____ No.____

:- Yes

No

Qualification

Experience

No.____

be appointed as full-time salary on a salary basis. However, the hospital can also opt for appointing the specialised technicians on sharing basis, or the combination of both salary and sharing. In hospitals, various types of technicians are as follows: Radiology Technicians: These technicians are for performing the X-ray, mammography, CT scan, MRI, Dexa scan, Per Scan, Bone scan, etc. These technicians

480

16  Manpower Planning, Hospital Committees and Staff Policies

shall be aware of the machine and shall have the capability of handling the machines and performing the scans. Laboratory Technician: These technicians are to assist the laboratory in-charge for preparing and conducting tests in the clinical laboratory. This is an important task, as doctors up to a great extent, depends on the finding and reporting of the clinical laboratory to make diagnoses and plan treatment for their patients. These technicians collect the blood or body fluid samples (which is generally done by the phlebotomist), prepare lab samples for testing and operate equipment like auto biochemistry analysers, hormone analysers, cell counters, centrifuges, refrigerators, incubators, etc. If the tests are simple, even the technicians are allowed to conduct tests themselves. Operation Theatre Technicians: These technicians are to manage the operation theatre and assist the surgeons and the anaesthetists to perform the surgeries. It is the responsibility of these technicians to maintain the OT hygienically and sterilised. They are also responsible to arrange the requires, linen, instruments, consumables and implants for the surgery. These technicians shall also be well versed to operate the OT equipment like OT table, OT Light, MGPS system, anaesthesia workstations, heart-lung machine, surgical cautery, etc. Pre and post-operative shifting of the patient shall also be the responsibility of these technicians. Dialysis Technicians: These technicians are to perform dialysis for patients suffering from Chronic Kidney Disorder (CKD). It is the responsibility of these technicians to prepare the dialysis fluids, arrange for dialysers, and wash and store the dialysers. These technicians shall be well-versed to operate the dialysis machines. CSSD Technicians: These technicians are to manage the Central Sterilization Supply Department (CSSD) by performing functions like receiving the unsterilised materials, washing instruments, preparing packs of the instruments and linen, sterilising the instruments and linen, storing and distributing the sterilised material. These technicians shall be well-versed to operate the instrument washers and the sterilisers. ECG Technicians: These technicians are to perform the ECG of the patient in the OPD and the indoor wards. These technicians shall be well-versed to operate the ECG machines. Echocardiography Technicians: These technicians are to perform the Echocardiogram and assist the cardiologist. These technicians shall be well-versed to operate the Echocardiography machine. Cath Lab Technicians: These technicians are to manage the Cath Lab and assist the cardiologist in performing the scans. The responsibilities of these technicians are to shift the patient before and after the scan, maintain the hygiene in the Cath Lab, arrange for the catheters and other devices, arrange implants, process the scan on the workstation and keep ready the things for reporting by the cardiologist. These technicians shall be well-versed to operate the Cath Lab. Plaster Technicians: These technicians are to apply and/or remove the plaster of cast to/from the patients. Physiotherapists: This department apart from physiotherapy also includes Rehabilitation. The department carries out multidisciplinary physiotherapy and

16.1 Staff Requirement

481

rehabilitation procedures and therapies to improve the status of a patient suffering from pain, disability, impairment or handicap. The department is managed by Physiotherapists. The facilities of these departments are utilised by both outpatients and inpatients. Apart from this, the services of the department are also utilised by patients who have to be treated for a long period and generally have a slow recovery rate. This is a department that the majority of patients attend the department daily. This department may also be required to provide their services in the indoor patient wards/room, apart from their department. In addition, the department may also require Occupational Therapists. Some hospitals may also have the facilities of providing assisted devices for the physically disabled, for which workshop technicians are also required. Audiometry Technicians: These technicians are to perform the audiometry of the patient who may be hard of hearing. These technicians shall be well-versed to operate the Audiometry machines. Speech Therapist: These technicians are to train children to speak who have a problem in speaking. Endoscopy Technicians: These technicians perform endoscopic investigations like Upper GI Endoscopy, Colonoscopy, Bronchoscopy, etc. It is the responsibility of these technicians to maintain and wash the endoscope immediately after the test is over. They are also responsible to process the investigation on the workstation and keep ready the things for reporting by the doctor. These technicians shall be well-­ versed to operate the endoscopes.

16.1.5 Nursing Care See Table 16.5.

Table 16.5  Nursing care Status of works Activity Nursing Superintendent Dy. Nursing Superintendent Asst. Nursing Superintendent Sister In-Charge Wards In-Charges Staff Nurses ANMs Ward Attendants

Start date :- Yes

End date No

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

:::::-

No No No No No

Qualification Qualification Qualification Qualification Qualification

Experience Experience Experience Experience Experience

No.____ No.____ No.____ No.____ No.____

Yes Yes Yes Yes Yes

Not Responsible Complete In-progress started person Qualification Experience

Remarks No.____

482

16  Manpower Planning, Hospital Committees and Staff Policies

Nurses are the backbone of hospitals and, by the very nature of their profession, affect a lot in providing effective treatment and care in the hospital. The primary role of a nurse is to help, advocate and care for the patients and support them during their illness and make it easier for them to come out of the pain and illness and to main good health. Nurses are the persons, who spend more time with patients than the treating physician do. At times, due to the unique circumstances of their patient, even the nurses might have to step in and advise the doctor to take an alternative approach. It is the nursing staff due to which the patients would receive the quality of care at the scale that is necessary for the treatment of the patient in a hospital. However, there are various other responsibilities of a nurse that form a part of the duties of the nurse. Some of them can be like regularly keeping a watch on the vital of the patients; recording medical history and identified symptoms; coordinate with the physicians and other support staff of the hospital to plan for patient care; advocating for the health and well-being of patients; monitor the patient’s health; administer medications and treatments as per the directions of the physicians; educate patients about management of illnesses; maintain the hygiene of the patient; operate medical equipment; coordinate or perform diagnostic tests; provide support and advice to patients, etc. This department is responsible for the nursing care of the patients, not only in the Indoor Wards but also in the OPD and Emergency. The head of the nursing department is the Nursing Superintendent, to whom the Asst. Nursing Superintendent reports. In the hierarchy below them are the Nursing In-charges of different wards and the OPDs, who in turn are assisted by and gets the report from the Staff Nurses. The Staff Nurses are assisted by the ANMs and the Trainee Nurses. Parallel to the nursing care by the nurses, also the Nursing Superintendent is responsible for the patient care by the Ward Attendants. The Ward Attendants are responsible for the movement of the patient, bed making, sending the samples to the laboratory and getting back the reports from the laboratory and the Radiology. They are directly reporting to the Nursing Superintendent or the Asst. Nursing Superintendent as the case may be but work as per the instructions of the Ward In-charges of the Staff Nurses. Qualification wise the Nurses shall be well-qualified and shall possess the required degree of qualification. Usually, it is the graduate, postgraduate or in some cases, diploma courses like GNM/ANM are also acceptable. As far as the qualification of the Ward Attendants is concerned, they need not be much qualified. It is enough if they are 10th-class pass outs. The nurses and the ward attendants shall be full-time employees of the hospital and shall be on salary.

16.1.6 Housekeeping See Table 16.6.

16.1 Staff Requirement

483

Table 16.6 Housekeeping Status of works Start Activity date Supervisor :- Yes Sweepers :- Yes

End date No No

Not Complete In-progress started Qualification Qualification

Responsible person Experience Experience

Remarks No.____ No.____

The basic purpose of housekeeping is to keep the hospital building clean and hygienic including the floors, walls, fixtures, fitting, furniture, certain types of equipment, countertops and other surfaces. As hospitals generally receive a lot of sick people wanting to get better, having the cleanest surroundings is crucial. Keeping hospital rooms and common areas clean and hygienic through regular housekeeping services is healthy for patients, visitors and hospital staff. With effective housekeeping in hospitals, a peaceful, infection free and pleasant atmosphere can be created which is always required for the speedy recovery of the patients. Effective housekeeping can create a home-like atmosphere for the patients. Housekeeping is a department concerned with cleaning the hospital from the inside and the outside. The department shall be headed by the Executive Housekeeping and shall be assisted by the Supervisor Housekeeping. The Supervisors can be one or more depending upon the area and location of the area to be taken under the housekeeping. Below the Supervisor are the Sweepers who carry out the instructions given. Executive and Supervisors for Housekeeping shall be well-qualified and experienced. However, the sweepers need not be that qualified. The house keeping staff shall be appointed as full-time employees on a salary basis. However, some hospitals also prefer to outsource housekeeping services to an outside agency. In that also, they shall be the full-time employees of the outsourcing agency.

16.1.7 Dietary See Table 16.7. Supplying appropriate nutrition in the hospital set-up is a challenging task due to the diverse nutritional wishes of the population. Meals in hospitals are a vital part of an integrated programme for improving nutritional care in hospitals. All leading hospitals shall provide nutritious and healthful diet meals, based on the instruction of the physicians and the requirement of the patient inside the hospital itself. Plenty of things have to be kept in mind while presenting offerings of meals to patients in the hospitals. Utmost attention is required to be given to preparing meals that are tasty, safe and nutritional and is served hygienically.

484

16  Manpower Planning, Hospital Committees and Staff Policies

Table 16.7 Dietary Status of works Activity Dieticians Kitchen Supervisor Cooks Store Officer Kitchen Helpers Packers Bearers

Start date :- Yes :- Yes

End date No No

:- Yes :- Yes :- Yes

No No No

:- Yes :- Yes

No No

Not Complete In-progress started Qualification On Contract

Responsible person Experience Experience

Remarks No.____ No.____

On Contract Qualification Qualification

Experience Experience Experience

No.____ No.____ No.____

Qualification Qualification

Experience Experience

No.____ No.____

Meals not only desires to meet a person's nutritional necessities but ought to be appropriate for different age groups, cultural and social backgrounds, religion and different clinical conditions of the patients. The important factors that need to be considered for effective healthcare catering are the use of certified ingredients; hygienic preparation of the meals; modern food preparation methods; timely preparation; efficient handling and distribution of meal orders; management of food at appropriate temperatures and specialised personnel handling the dietary services. It needs to be ensured that the ration and ingredients are of the best quality, certified and clean. While buying fresh produce like fruits and vegetables, ensure that they are all fresh and try to buy them on daily basis instead of storing them. In the case of dairy products like milk, cheese, curds, butter, etc., take care so that they are kept under the prescribed temperature and shall not be stocked for a long time. The meals shall be freshly prepared by professional chefs and their teams. Once the food is prepared and ready to be served, trained staff shall pack the food hygienically and deliver it to the concerned patients effectively in time. Dieticians play an important role to ensure that food preparation is being done hygienically, by regularly visiting and supervising the stores and kitchen area. The Dietary Service Department is headed by the Dietician, who is responsible for all the activities of the department. Below the Dietician is the Kitchen Supervisor who works with the assistance of the kitchen staff like the Cooks, the Bearers and the other kitchen staff. As far as the dietician is concerned, he/she shall be well-qualified and experienced and shall be appointed as a full-time employee on a salary basis. However, some hospitals also prefer to outsource the services of the kitchen to an outside agency. In that also the kitchen supervisor and the kitchen staff shall preferably be full-time employees of the outsourcing agency.

16.1 Staff Requirement

485

16.1.8 Accounts and Finance See Table 16.8. The finance department does more than just keep records of payments made to and by a hospital. In any hospital, financial management also involves billing and registration; handling routine financial transactions like cash collections, maintaining the books of accounts; payments for routine expenses; payroll preparation; handling banking transactions and maintaining a cash cushion for unexpected costs. The role of the Accounts and finance in the hospital is unlimited. This department is responsible for (a) Registration for OPD. (b) Billing for the investigations. (c) Billing for the indoor patient treatment. (d) Preparing all types of vouchers for entries in the books of accounts like cash vouchers, bank vouchers, journal vouchers, purchase vouchers, income vouchers and debit/credit vouchers. (e) Maintaining basic books of accounts like cash books, bank books and journal books, purchase books, income register, petty cash books, day books, etc. (f) Maintaining all types of ledgers and sub-ledgers like general ledger, creditors ledger (suppliers ledger), debtors ledger (receivables ledger) and staff advance ledger. (g) Reconciliation of accounts like bank accounts, interparty accounts, control accounts of sundry debtors, creditors and staff advance with the sub-ledgers, expenses payable, prepaid expenses, cash book and day book. Table 16.8  Accounts and finance Status of works Activity Chief Financial Officer (CFO) Accounts Manager Accounts Officer Accountant Asst. Accountants Billing Supervisor Billing Clerks Admission and Discharge Officers Cashiers Auditor

Start date :- Yes

End date No

Not Responsible Complete In-progress started person Qualification Experience

:- Yes

No

Qualification

Experience

No.____

::::-

Yes Yes Yes Yes

No No No No

Qualification Qualification Qualification Qualification

Experience Experience Experience Experience

No.____ No.____ No.____ No.____

:- Yes :- Yes

No No

Qualification Qualification

Experience Experience

No.____ No.____

:- Yes :- Yes

No No

Qualification Qualification

Experience Experience

No.____ No.____

Remarks No.____

486

16  Manpower Planning, Hospital Committees and Staff Policies

(h) Finalisation of books of accounts by preparing balance sheet, profit and loss/ income and expenditure account, schedule of fixed assets, schedule of investments, schedule of current assets, schedule of current liabilities, audit reports and cash flow/funds flow statements. (i) Budgeting and comparing the actuals with the budgets finding out the variations and reasons for these variations. (j) Cost accounting. (k) Pricing of hospital services. (l) Management information reports like clinical information, statistical information and accounting information. (m) Working our various financial ratios. (n) Dealing with the banks and financial institutions, etc. The Chief Financial Officer (CFO) shall head the Accounts departments. Below the CFO is the Accounts Manager or the Finance Manager. The Accounts or the Finance Manager shall be assisted by the Accounts Officer, who is in turn assisted by Accountants. The Billing Supervisor is responsible for handling the Billing counters and is assisted by the Billing Clerks and the Admission & Discharge Clerks. The Cashiers are also placed to manage cash collection payments and the General Duty Clerks for miscellaneous works of the department of accounts. Further, the Accounts Officer shall be assisted by the Auditors.

16.1.9 Medical Record See Table 16.9. Good medical records are essential in any hospital for the effective and continuity of care of the patients irrespective of the fact that the records are electronic or handwritten. The main purpose of medical records and documentation is for recording the facts, statements and sheets for a patient’s treatment and care, so medical professionals to monitor and plan the patient's status and care. An effective medical Table 16.9  Medical record Status of works Start Activity date Medical record :- Yes Officer Assistant :- Yes Medical Officer Record Clerks :- Yes General Duty :- Yes Clerks

End date No

Not Responsible Complete In-progress started person Qualification Experience

Remarks No.____

No

Qualification

Experience

No.____

No No

Qualification Qualification

Experience Experience

No.____ No.____

16.1 Staff Requirement

487

record reduces the risk of treatment errors and improves the likelihood of a positive outcome. The medical record mainly consists of, notes written by the physicians; notes written by previous physicians attending the patient; the patient’s discharge summary; radiological films and reports; laboratory reports; ECG traces; video recordings; photographs; notes written by the nursing staff; record of drug and medicines administered; clinical research forms and clinical trial data; insurance forms and approvals; billing and payment records; disability assessments; medico-legal records; patient consent forms; death certificates and autopsy reports; referral letters to and from other hospitals; etc. The department of medical records of the hospital is headed by the Medical Record Officer who is assisted by the Asst. Medical record Officer. The department is provided with Record Clerks and General Duty Clerks for the day-to-day work of the department.

16.1.10 Public Relation Department See Table 16.10. The Public Relation Manager heads the public relation department and if the size of the hospital is big, he/she is assisted by the Public Relation Manager. The Public Relation Manager is assisted by the Social Welfare Officer. Parallel to this, the Counsellor is also appointed to interact with the patient or the attendants of the patient and convince them of further treatment and care in the hospital.

16.1.11 Marketing and Branding See Table 16.11

Table 16.10  Public relation department Status of works Start Activity date Public Relation :- Yes Manager Public Relation :- Yes Officer Social Welfare :- Yes Officer Counsellor :- Yes

End date No

Not Responsible Complete In-progress started person Qualification Experience

Remarks No.____

No

Qualification

Experience

No.____

No

Qualification

Experience

No.____

No

Qualification

Experience

No.____

488

16  Manpower Planning, Hospital Committees and Staff Policies

Table 16.11  Marketing and branding Status of Works Activity Marketing Manager Marketing Executives Corporate relation officer Designers

Start date :- Yes

End date No

Not Responsible Complete In-progress started person Qualification Experience

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

remarks No.____

As hospitals are now a days facing lots of challenges, and opportunities to brand themselves effectively and efficiently. There have been major increases in the amount of consumer choice available on the market, and suddenly brands have to appeal to customers in ways that they have not had before. Branding is the path that establishes an image of the hospital in the eyes of the public and the patients. Branding also helps in improving the quality of hospital services by obtaining the views and requirements of the patients. Hospital branding is a promise as to what customer expects and how the hospitals fulfil the needs of the patients. For any hospital, it is necessary to communicate and create the demand for hospital services by reaching the target population. The marketing aims to make the population aware of the services provided in the hospital, the quality of the services, the equipment and instruments in the hospital, the panel of experts in the hospital and the value addition by the hospital as compared to the other hospital in the vicinity. This creates a high level of patient satisfaction levels so that the patient returns to the hospital again and again and recommends others to avail of the services of the hospital. Outreach to the population is essential and can be achieved through various modes of advertisements, camps, seminars and conferences, etc. A good marketing team can benefit the hospital by creating a stronger base of patients availing the services of the hospital; increasing local physician referrals; promoting important medical services and promoting health awareness in the population. This department is headed by Marketing Manager, assisted by Marketing Executives and Corporate Relations Officers. Similarly, the Designers also play an important role in designing the advertising and marketing material.

16.1.12 Information Technology (IT) See Table 16.12. The IT department of the hospital plays an important role in assisting hospital staff to provide efficient and quick care to patients. New and emerging technologies

16.1 Staff Requirement

489

Table 16.12  Information technology (IT) Status of works Start Activity date ERP Manager :- Yes ERP :- Yes Supervisor Hardware :- Yes Mechanic

End date No No

Not Complete In-progress started Qualification Qualification

No

Qualification

Responsible person Experience Experience

Remarks No.____ No.____

Experience

No.____

in the healthcare sectors have transformed healthcare in recent years and are still on their pathway to improve further. Hospitals and physicians have adopted and implemented the new technologies and shall be prepared to adopt future technological improvements. On the other hand, the hospital needs to respond to a changing regulatory environment and improve the overall quality of services and care to the patients. The IT department is mainly responsible for managing the clinical software called Hospital Information System (HIS) along with the other processes to help hospital staff maintain and preserve patient records, clinical data and other administrative controls. The IT department is also responsible to facilitate the indoor wards, operating rooms, labour and delivery suites and emergency departments, pharmacy, dietary, laundry and clinical laboratory in providing the services and maintaining the records of the same. Other functions for which the IT department is responsible include registration, billing, ordering and receiving lab results, accounts and finance, human resources, health information management and specialised software for things like radiology, etc. This is in addition to facilitating the hospital staff for its routine functioning, IT Department is also responsible for providing network infrastructure, IT security, server maintenance, software deployments and so on. This department is headed by ERP Manager, assisted by ERP Supervisors. The role of the Hardware Mechanic is also equally important to maintain the IT hardware system and the networking.

16.1.13 Human Resources See Table 16.13. The Human Resource Department in the hospitals is responsible for various issues like planning the requirement of staff, selection and recruitment of staff, training, employee retention and legal matters of staff. The human resource department also manages the disputes between workers, management and labour and firing and hiring workers. Hiring is one of the main responsibilities of a human resources department in the hospital. The HR department has to identify the requirement, frame recruitment

490

16  Manpower Planning, Hospital Committees and Staff Policies

Table 16.13  Human resources Status of works Activity Human Resource Manager Assistant HR Manager Personnel Officers Trainers HR Clerks

Start date :- Yes

End date No

Not Responsible Complete In-progress started person Qualification Experience

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

:- Yes :- Yes

No No

Qualification Qualification

Experience Experience

No.____ No.____

Remarks No.____

policies, advertise, sort the applications, conduct interviews and finally complete the formalities of recruitment. The HR department shall also arrange for induction training and refresher training from time to time. Training new employees is an essential requirement for any hospital. This is where the HR department has to intervene in developing a well-designed training program. Human resources leaders need to devise plans and systems so that new employees can easily know about their roles and responsibilities, standard operating systems, schedules and expectations from them. HR department shall also make the new employees familiar with their day-to-day tasks, the vocabulary used in the hospital and developing relationships with co-workers. Another important task of the HR department is to strengthen the relationship between employers and their subordinates to help hospitals achieve high satisfaction, morale and performance levels. The department also needs to ensure the employee's job satisfaction, promote staff welfare activities, frame award and punishment policies and conduct job satisfaction surveys to motivate workers in a hospital. Human Resource Department is also responsible for framing and assigning a set of duties tasks and responsibilities for every employee of the hospital. HR department shall also ensure the risk and safety of the employees at the workplace. The department has to ensure that for the safety of the employees, proper precautions have been taken and safety regulations have been complied with. The HR department shall also keep a record of workplace fatalities and injuries. The Human Resource Department is headed by the Human Resource Manager and assisted by the Asst. Human Resource Manager. Below the hierarchies are the Personnel Officer and the HR clerks. Training Officers also play an important role in providing the induction training and scheduling of the on-job and periodical training of the staff.

16.1 Staff Requirement

491

16.1.14 Purchase See Table 16.14. The purchasing department of the hospital is responsible for a steady supply of materials and consumables required for the daily functioning of the hospital. This task requires excellent planning and management. If not properly planned and implemented, it may disrupt the supply of essential items, which as a result will adversely affect various functions of the hospital. As the purchase function involves a huge amount of funds, inefficient management of the procurement and consumption can significantly reduce a lot of financial burden on the hospital. The purchase department is responsible for the formation of the purchase committee; documenting the purchase policy; assessment of the requirement; vendor/supplier evaluation mechanism; finalising the purchase requirement; processing the purchase order; negotiating the prices and purchase contracts; receiving the goods; processing the bills of the vendors and payment to the vendors. The primary goal of the purchasing department is to obtain materials at the lowest possible price, procure the best quality material and ensure continuity of supply. At the top of the purchasing department is a Purchase Manager who supervises the entire departmental staff and works closely with the hospital authorities and workers of the hospital to plan and oversee the budget. The purchasing manager has to maintain close communications with departmental heads and other workers of the hospital to better understand their needs and consumption pattern. For the purchase of medical items, the purchase manager has to coordinate with the Medical Superintendent/Medical Director, whereas for other purchases, he/she needs to coordinate with the Administrator/Director of Hospital Administration. Purchase Officers and Purchasers work under the supervision of the purchase manager. Below the line are the General Duty Clerks, who assist the higher officers in the purchasing department.

Table 16.14 Purchase Status of works Activity Purchase Manager Purchase Officer Purchasers General Duty Clerks

Start date :- Yes

End date No

:- Yes

No

:- Yes :- Yes

No No

Not Complete In-progress started Qualification

Responsible person Experience

Remarks No.____

Qualification

Experience

No.____

Qualification Qualification

Experience Experience

No.____ No.____

492

16  Manpower Planning, Hospital Committees and Staff Policies

16.1.15 Stores See Table 16.15. Material management is an important department in any hospital which has to manage the material and assets of the hospital concerning planning, procurement, transportation, storage, distribution, etc. This is an important task for the department to manage the procurements and sufficient stock as the non-availability of any item due to stock shortage, when required, could lead adversely affect in the treatment of a patient or even create a life-threatening situation. On the other hand, overstocking of items could lead to blockage of finance or even the expiry of the item. This situation would be a costly proposition to any hospital. Therefore, planning for the procurement of items and assets has to be well calculated and well on time. The department has to plan in advance as to what and how many of various items are to be kept in stock at a given time. The department even has to work out various levels of stock like minimum quantity, maximum quantity, reordering quantity, etc. The responsibilities of the Store is to maintain the adequate inventory of materials; good information system regarding the items; right time for procurement; right quantity of purchase; low procurement and storage cost; consistency in the quality of the product; continuity in the supply of stores; forecasting requirement; awareness of new materials and products; raise indent of material required; prepare GRN of materials received in stores; arrange check for quality of material from respective department of the hospital; receive the invoice/bill from the supplier; check the invoice with purchase order and the materials for the quantity, appropriateness of brand and batch number; checking the date of expiry; accepting goods and marking the receipt with seal with date and sign; return of rejected materials; moving the material to the appropriate place/rack in the store; issue of the indented material; recording the receipts in the stock ledgers; recording the issued materials in the ledgers; preparing bin cards; ensuring proper and safe storage of materials; condemnation of unusable or expired materials; disposal of scrap; periodical stock taking of the materials in the stores, etc.

Table 16.15 Stores Status of works Activity Stores Manager Store In-charge Store Assistants General Duty Clerks

Start date :- Yes

End date No

:- Yes

No

:- Yes :- Yes

Not Complete In-progress started Qualification

Responsible person Experience

Remarks No.____

Qualification

Experience

No.____

No

Qualification

Experience

No.____

No

Qualification

Experience

No.____

16.1 Staff Requirement

493

Types of Hospital Stores: Generally, the hospital maintains different types of stores like non-consumable stores; consumable stores; general stores; medical and drug stores; surgical stores; linen stores; dietary stores; stationery stores; engineering and maintenance stores, etc. It is not always necessary to provide all the stores in the hospital. However, depending on the size of the hospital, the management has to decide how many types of stores are to be provided. The Stores Manager supervises all the different types of stores in the hospital. The Stores Manager has to work in close association with the organisation executives to plan and oversee the store's requirements. The Stores Manager has to maintain close communications with departmental heads and other users of the hospital, to better understand their needs and requirements of the items. For the medical items, the store manager has to coordinate with the Medical Superintendent/Medical Director, whereas for other items, he/she needs to coordinate with the Administrator/ Director Hospital Administration. Store In-charges works under the supervision of the Store Manager. It is better to provide Store In-Charge for each type of store separately. Below the line are the Stores Assistants and General Duty Clerks in each type of store separately, which assist the Store In-charges in stores.

16.1.16 Reception and Communication See Table 16.16. The Reception or Communications department is concerned with the system of reception, enquiry, help desk and telephone exchange. The Supervisor shall be responsible for the efficient working of this department. He/she is assisted by the Receptionist who shall receive the patients and shall provide the information to settle the queries of the patients and their attendants. On the other side for handling the Telephone exchange of the hospital, the Telephone Operators are employed (Generally not required nowadays because of the automated EPABX system), who shall be responsible only for handling the telephone calls and shall be responsible for receiving and making the telephone calls.

Table 16.16  Reception and communication Status of Works Activity Receptionists Telephone Operators Public Relation Officers

Start date :- Yes :- Yes

End date No No

:- Yes

No

Not Responsible Complete In-progress started person Qualification Experience Qualification Experience Qualification

Experience

Remarks No.____ No.____ No.____

494

16  Manpower Planning, Hospital Committees and Staff Policies

16.1.17 Linen Supply Department See Table 16.17. The laundry service of the hospital is responsible for providing an adequate, clean, sterilised and constant supply of linen to all users of the hospital. The basic tasks of the linen supply department are to ensure proper sorting, mending, washing, extracting, drying, ironing, folding and delivery of the linen. The main purpose of this department is to provide clean linen to the patients when required and ensure that hygienic conditions are maintained in the process. The linen services in the hospital can be in-house or outsourced. A wide variety of linen is washed in the laundry like patient’s linen, curtains, kitchen linen, staff uniforms, doctors' dresses, OT linen and drapes, blankets, etc. The hospital has got three options for a laundry set-up. First is that the hospital purchases the laundry equipment and hires workers and the laundry is operated by the hospital. The second option is that the hospital provides the spaces for laundry and the contractor is hired for setting up the equipment and operation of the laundry. Third is that the hospital enters into a contract with the laundry service providers who have an off-site laundry setup at some other place except the hospital premises. Under this option, the contractors carry the linen to its place and bring it back the linen to the hospital after washing and processing. This department shall be headed by the Linen Manager who shall be in turn assisted by the laundry staff like Washerman, Ironing Persons, Tailors (for mending) and the General Duty Clerks.

16.1.18 Transport See Table 16.18. The Transport Officer shall handle this department regarding the running and maintenance of the hospital vehicles including the Ambulances. The Transport Table 16.17  Linen supply department Status of works Activity Linen Manager Washer Man Ironing Workers Tailor General Duty Clerks

Start date

End date

Complete In-progress

Not started

Responsible person

Remarks

::- Yes :- Yes

No No

Qualification Qualification

Experience Experience

No.____ No.____

:- Yes :-

No

Qualification

Experience

No.____

16.1 Staff Requirement

495

Table 16.18 Transport Status of Works Activity Transport In-charge Maintenance Mechanics Drivers

Start date :- Yes

End date No

Not Responsible Complete In-progress started person Qualification Experience

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

Remarks No.____

Officer shall have two teams, one relating to the running of the vehicles and the other relating to the repairs of the vehicles. Running of the vehicles shall be the responsibility of the Drivers and for the maintenance of the vehicles, a team of Automobile Mechanics shall be available.

16.1.19 Security See Table 16.19. Security service in a hospital is responsible for ensuring the security and safety of the hospital premises, assets, and other materials in the hospital. The department is also responsible for the security and safety of the hospital staff, personnel, patients, visitors and the public as well as regulating the traffic within the hospital premises. For the smooth functioning of the hospital, the security services of the hospital are also responsible to prevent and handle any disturbance or breach in security. Therefore, the hospitals need to have a separate and specialised department of security service, entrusted with the responsibility to keep watch over the entire hospital and to prevent anything untoward incident. However, nowadays, it is a trend to outsource the security service to an outside professional security agency. The Security service shall be headed by a Security Officer, who shall be fully trained in security procedures and techniques. Below the Security Officer are the Security Supervisors and Guards, who shall be well-trained, tough and mature persons. The security team shall also include some female staff to check/frisk or otherwise handle the female staff/visitors. In case, the hospital has a fire detection and firefighting system in place, it shall be headed by the Fire Officer and assisted by the Fireman. For operations of the lifts and elevators, the Lift Operators are deployed. These lift operators report to the Security Officers if the operations of the lifts and elevators are under the security department or to the maintenance engineer.

496

16  Manpower Planning, Hospital Committees and Staff Policies

Table 16.19 Security Status of works Activity Security Officer Security Supervisors Guards Fire Officer Fireman Lift Operators

Start date :- Yes

End date No

:- Yes

No

Qualification

Experience

No.____

::::-

No No No No

Qualification Qualification Qualification Qualification

Experience Experience Experience Experience

No.____ No.____ No.____ No.____

Yes Yes Yes Yes

Not Responsible Complete In-progress started person Qualification Experience

Remarks No.____

16.1.20 Electricity See Table 16.20. In any hospital, it is very important to have a separate electricity department as the requirement of power for operating the equipment, operating air-conditioning plants, providing power for light and fans, providing general use electrical outlets, etc. is huge and the department has to ensure that a good quality of uninterrupted electricity supply is available round the clock. The second important factor is the immediate attention and removal of the electrical faults by the electrical maintenance team. The Electricity Department shall be headed by an experienced Electrical In-charge, who shall be a qualified electrical engineer. Below the Electrical In-charge are the Electrical Supervisors. Down the line are the Electricians and the Line Mans. For running and maintenance of the captative generation plants, the Generator Operators are deployed.

16.1.21 Heating, Ventilation and Air Conditioning (HVAC) See Table 16.21. HVAC systems play an important role in hospitals by providing comfortable climatic conditions for patients and staff of the hospital and also providing a germ-­ free, clean and hygienic environment to prevent the spreading of diseases. Further, the medical equipment in the hospital is very sensitive, its performance may be affected due to the uncontrolled temperature and humidity levels. Therefore, perfect air control in terms of temperature and humidity is essential to make the equipment work accurately.

16.1 Staff Requirement

497

Table 16.20 Electricity Status of Works Activity Electrical In-Charge Electrical Supervisor Electricians Lineman Generator Operator

Start date :- Yes

End date No

Not Responsible Complete In-progress started person Qualification Experience

:- Yes

No

Qualification

Experience

No.____

:- Yes :- Yes :- Yes

No No No

Qualification Qualification Qualification

Experience Experience Experience

No.____ No.____ No.____

Responsible person Experience

Remarks No.____

Remarks No.____

Table 16.21  Heating, ventilation and air-conditioning (HVAC) Status of Works Activity HVAC In-Charge AC Mechanic (Senior) AC Mechanic (Junior) Plant Operators

Start date :- Yes

End date No

Not Complete In-progress started Qualification

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

:- Yes

No

Qualification

Experience

No.____

Additionally, different rooms in the hospital have different uses, which further adds to the complexity of designing the HVAC systems. In a hospital, patient rooms are provided, where patients suffering from various diseases are admitted and treated. Out of all, some may be exposed to infectious-contagious diseases and may require the facility of isolation. Some of the patient rooms shall be required for patients who may be depressed or have weak immune systems. There are certain areas in the hospital, such as ICUs, neonatal units, etc., where it is necessary to restrict the arrival or growth of pathogens that may be present in the hospital. Hospitals are places where the concentration of micro-organisms and pathogens accumulation is very high as compared to any other commercial building. Therefore, the hospital shall have its HVAC department operate and maintain the HVAC system. The HVAC department shall be headed by an experienced HVAC In-charge, who shall be a qualified HVAC engineer. Below the HVAC In-charge shall be the Senior and Junior AC Mechanics. For running and maintenance of the HVAC plants, the Plant Operators are deployed.

498

16  Manpower Planning, Hospital Committees and Staff Policies

16.1.22 Water Supply and Drainage See Table 16.22. Though the supply of water and proper drainage system is necessary for the survival of human beings, still in the case of hospitals, where there is a question of treating the sick and critical patients, the water supply and drainage system have to be excellent. More importantly, in hospitals, clean hygienic, good quality of water and drainage is necessary. The quality of water supplied and the drainage system impact a lot on issues like infection control, the life of the medical equipment, staff and patients' hygiene, etc. In hospitals, lot, many services like dialysis, etc. are fully or partially dependent upon clean and treated water supply. Also, the performance, accuracy and efficiency of some of the medical equipment depend on the quality of water being supplied to the said medical equipment. Similarly, the drainage and treatment of wastewater are equally important. The reliability of the water supply system is another important factor in the case of hospitals. Therefore, it has to be ensured that the system placed shall be such that it can ensure an uninterrupted water supply at all times in the hospital building. Also, it has to be ensured that the volume of the water shall not more than the requirement and that the stagnation of water in the tanks is avoided. Therefore, the hospital shall have its own Water Supply and Drainage department to operate and maintain the water supply and drainage systems. The Water Supply and Drainage department shall be headed by an experienced Sanitary and Water In-charge, who shall have sufficient experience in handling the systems. Below him/her shall be the Plumbers. For running and maintenance of the water supply plant, the Pump Operators are deployed.

16.1.23 Medical Gas Pipeline System (MGPS) See Table 16.23.

Table 16.22  Water supply and drainage Status of Works Activity Sanitary and Water In-Charge Plumber Pump Operator

Start date :- Yes

End date No

:- Yes :- Yes

No No

Not Responsible Complete In-progress started person Qualification Experience

Qualification Qualification

Experience Experience

Remarks No.____

No.____ No.____

16.1 Staff Requirement

499

Table 16.23  Medical Gas Pipeline System (MGPS) Status of works Start Activity date MGPS Engineer :- Yes MGPS :- Yes Mechanics Plant Room/ :- Yes Manifold Operator

End date No No

Not Responsible Complete In-progress started person Qualification Experience Qualification Experience

No

Qualification

Experience

Remarks No.____ No.____ No.____

Medical gases are one of the main support services used in hospitals. Commonly used medical gases in hospitals are: Oxygen (O2): Three sources are used for oxygen supply; liquified oxygen tank also called Vacuum-Insulated Evaporator (VIE), Gas Cylinders and Oxygen Concentrator (PSA) system. Nitrous oxide (N2o): Nitrous oxide is a medical gas administrated via an anaesthesia machine. Usually, a manifold supply system is the source of nitrous oxide gas. Compressed Medical air 4 bar: In general, medical air 4 is used for respiratory applications. The source of supply can be a centralised medical compressor plant. Compressed Medical air 7 bar: Medical air 7 is known as surgical air because it is used mainly to derive surgical equipment like drills, tourniquets, bone saws, etc. The supply source is similar to medical air is through a compressor plant. Carbone dioxide (CO2): Carbone dioxide is a medical gas used for insufflations purpose in laparoscopy procedures. Usually, portable cylinders are the source of CO2. Nitrogen (N2): Nitrogen for surgical power tools is likely to be used only on the sites where there is availability for the production of synthetic air. Medical vacuum: Medical vacuum is provided through a vacuum central plant. In fact, it is not a gas; it is a negative pressure used for suctioning patients and anaesthetic gas scavenging system. Vacuum pipes are known for their yellow colour. As the MGPS is one of the most important support services, the hospital shall have its own MGPS department to operate and maintain the gas supply system. The MGPS Department shall be headed by a well-qualified and experienced MGPS In-charge, who shall be a qualified MGPS engineer. Below him/her shall be the MGPS Mechanics to maintain the MGPS system. For running and maintenance of the liquid oxygen plant, manifold system and pump room, the Plant Room/Pump Operators are deployed.

16.1.24 Building Maintenance See Table 16.24. It is a universal fact that whatever asset you create requires repairs and maintenance. In hospitals also, repairs and maintenance are required for building. The

500

16  Manpower Planning, Hospital Committees and Staff Policies

Table 16.24  Building maintenance Status of works Activity Chief Civil Engineer Maintenance Supervisor Site Engineers Masons Helpers Carpenter Welder Gardeners Painters

Start date :- Yes

End date No

:- Yes

No

Qualification

Experience

No.____

:::::::-

No No No No No No No

Qualification Qualification Qualification Qualification Qualification Qualification Qualification

Experience Experience Experience Experience Experience Experience Experience

No.____ No.____ No.____ No.____ No.____ No.____ No.____

Yes Yes Yes Yes Yes Yes Yes

Not Responsible Complete In-progress started person Qualification Experience

Remarks No.____

repair and maintenance can either be carried out in-house or outsourced to any maintenance agency. The disadvantage of outsourcing is, firstly the elevated repair and maintenance cost and secondly the times lag to repair and maintain the asset. However, it is recommended that the repair and maintenance facilities in the hospital shall be developed in-house. For building maintenance, the hospital requires personnel for repair and maintenance of firefighting, building including, civil repairs, plumbing, electrical, painting, steel works, wooden works, aluminium works, landscape works, automobiles, etc. To carry out the above repair and maintenance works, workshops are required. Depending on the load of the work or frequency of repair and maintenance, the workshops are designed and planned. There are some which shall necessarily be provided, but others can be clubbed with other workshops if a load of a single workshop is not enough. However, the total workshops required are Biomedical Workshop; MGPS Workshop; Electrical Workshop; Low voltage Workshop; HVAC Workshop; Mechanical Workshop; Building Maintenance; Fire Fighting Workshop Automobile Workshop, etc. Out of all these most of the workshops are being managed by the concerned departmental heads. As far as Building Maintenance is concerned, the department shall be headed by the Chief Engineer, who shall be a well-qualified Civil Engineer with sufficient experience. He/she is assisted by the Maintenance Supervisors or the Site Engineers. These Maintenance supervisors or the Site Engineers shall get the work done from the Masons, Helpers, Carpenters, Welders, Gardner, Painters, etc.

16.1 Staff Requirement

501

16.1.25 Biomedical Maintenance See Table 16.25. This workshop is intended to be utilised for repair and maintenance of the biomedical equipment in the hospital like Ventilators, X-Ray, Defibrillator, Vital Monitor, Ultrasound, Lab instruments and other medical equipment used in the hospital. In-house repair and maintenance of medical equipment is always the preferred choice of the management because the repairs can be quick and less costly as compared to outside agency repairs. Only if there is any major fault, it shall be got repaired by the original manufacturer of the machine. Therefore, the hospital shall have its own Biomedical Workshop. The Biomedical workshop shall be headed by a well-qualified and experienced Chief Biomedical Engineer who in turn shall be assisted by the Biomedical Engineer.

16.1.26 Pharmacy See Table 16.26. The Pharmacy is the department, which deals with the supply of medicine to patients. The central medical stores also perform the duty of issuing medicines to Table 16.25  Biomedical maintenance Status of works Activity Chief Biomedical Engineer Biomedical Engineer

Start date :- Yes

End date No

:- Yes

No

Not Responsible Complete In-progress Started person Qualification Experience

Qualification

Experience

Remarks No.____

No.____

Table 16.26 Pharmacy Status of works Activity Senior Pharmacist Pharmacist Billing and Disbursing Clerks General Duty Clerks

Start date :- Yes

End date No

Not Responsible Complete In-progress started person Qualification Experience

:- Yes :- Yes

No No

Qualification Qualification

Experience Experience

No.____

:- Yes

No

Qualification

Experience

No.____

Remarks No.____

502

16  Manpower Planning, Hospital Committees and Staff Policies

the pharmacy, the O.T., Radiology, Pathology and the Emergency. In a hospital, either the hospital has a pharmacy of its own or it is outsourced to an outside agency. A department of the pharmacy is required in the hospitals where the medicines are provided from the hospital’s medical store. In case the medical shop is of the outsider, the department of the pharmacy is not required. The department of the Pharmacy is headed by the Senior Pharmacist and is assisted by the Pharmacists. For disbursement and billing, the Billing and Disbursement Clerks are appointed who in turn is assisted by the General Duty Clerks.

16.1.27 Library See Table 16.27. A library is a place where books on different types of medical topics are kept for updating the knowledge of the medical staff and for providing the staff and students with the necessary guidance. The library is managed by the Chief Librarian and is assisted by Librarian who is in turn again assisted by the General Duty Clerk.

16.1.28 Other Staff See Table 16.28. It is very difficult to list out the actual requirement of the staff required in the hospital as they may differ from one hospital to other. Still, apart from the list of staff to be hired and deployed as given in the above paragraphs, some more needs to be recruited. This stuff can be for a particular department or can be common to all the departments. These staff members are Personal Assistants, Office Attendants, General Duty clerks, etc. The hospital authorities need to access such staff requirements and recruit accordingly.

Table 16.27 Library Status of works Start date :- Yes

Activity Chief Librarian Librarian :- Yes General Duty :- Yes Clerks

End date No No No

Not Complete In-progress started Qualification Qualification Qualification

Responsible person Experience

Remarks No.____

Experience Experience

No.____

16.2 Procedure for Staff Appointment

503

Table 16.28  Water supply and drainage Status of works Activity Steno/Typists Personal Assistant Office Attendants General Duty Clerks

Start date :- Yes :- Yes

End date No No

:- Yes

No

:- Yes

No

Not Complete In-progress started Qualification Qualification

Responsible person Experience Experience

Remarks No.____

Qualification

Experience

No.____

Qualification

Experience

No.____

16.2 Procedure for Staff Appointment See Table 16.29. Now the procedural aspects of the manpower assessment and deployment The first step shall be the formation of the Governing Body. Once the Governing Body is in place, the actual work on building up the hospital project starts. Next shall be the appointment of the Advisory Body. At the planning and designing stage, the role of the advisory body is very crucial. It is the Governing Body and the advisory body who can jointly decide on the initial planning like, formation of the company/society, type of hospital needed, services to be provided in the hospital, DRP and feasibility report evaluation, arranging finances, site selection, site development, building area calculation, applying for initial approvals, approving the concept drawings and the layout drawings, calculating electricity load requirement, approval of all the other drawings as given by the architects and consultants, etc. The next step shall be to identify the team of office bearers and engagement of the consultants and the hiring of the required engineers. Thereafter, the construction works can be started. Once the civil works of the building are complete and finishing works start, this is the stage where the Medical Superintendent and the Nursing Superintendent shall be appointed and deployed because these two people will play an important role in subsequent planning. Now with the help of the Medical Superintendent and the Nursing Superintendent, and under the guidance of the Governing Body and Advisory body, the requirement of the staff shall be worked out. The recruitment and other staff policies shall be finalised. Now is the stage to appoint and deploy the Human Resource Manager and prepare the schedule of Duties and Responsibilities of the staff members. Once the requirement and the policies are finalised, the advertisement for the requirement of staff shall be released. Please remember that the advertisement shall be released about 4 months before the completion and operational date of the hospital services.

504

16  Manpower Planning, Hospital Committees and Staff Policies

Table 16.29  Procedure for staff appointment

Activity Formation of Governing Body Formation of Advisory Body Identifying the office bearer Identification of the team of consultants Appointment of Medical Superintendent Appointment of Nursing Superintendent Advertisement for the requirement of the staff Analysing the biodatas received Interviews for the staff Negotiations with consultants and finalising the deal Agreement with the consultants Appointment of Resident Doctors Finalising the security agency Appointment of Nurses Appointment of Ward Attendants/Sweepers Appointment of Technicians and Paramedical Staff Appointment of Marketing staff Appointment of other Staff Members Preparing the Duty and responsibilities of all the staff members Providing the Induction Training

Status of works Start End Not Responsible date date Complete In-progress started person :::::-

:-

:-

:::-

::::::-

:::-

:-

Remarks

16.3 Committees

505

Once the resumes of the aspiring candidates are received, these shall be analysed based on the hospital’s requirements and policies of the hospital. After analysis, the resumes shall be shortlisted. About 3 months before the operational date, the candidates shall be called for interviews. During the interview, the remuneration and other terms and conditions shall be finalised with the candidate. Once agreed, the appointment letters shall be issued to them. Similarly, for the physicians/doctors, the remuneration and other terms and conditions shall be finalised with the physicians/doctors. The joining of the hospital staff shall be phase-wise depending on the progress of project work and operational date. In the first phase, the Security staff shall be deployed to take care of the assets of the hospital. In the next phase, a few nurses shall be appointed and deployed, so that they can take care of their respective departments and helps set-up the department. Now is the stage to appoint and deploy the Technicians and the Paramedical Staff. They shall take care of their respective departments and helps in setting up the department. Then come the appointment and deployment of Ward Attendants and Housekeeping Staff, to clean and set up all the departments and areas of the hospital building. It is the time now to appoint and deploy all the balance nurses. Then appoint and deploy the physicians/doctors. Thereafter, the appointment and deployment of the other administrative staff including the marketing staff shall be done. It has to be ensured that the induction training has to be provided in a phased manner, as soon as the staff is deployed.

16.3 Committees See Table 16.30. The working in the present days of most organisations is through committees. If carried out properly, it can be of great help. It brings out the combined wisdom of knowledge of the people who discuss matters concerning the organisation. The committee views the problem from various angles and finally, a consensus emerges which is, hopefully, the best alternative. The committees elected from the staff appointed by the Governing Body may perform much of the work of the hospital. These committees are, normally, of two types Standing committees: The standing committees are those elected or appointed for the full year and having assigned duties and responsibilities, with possibly some degree of authority to act. The usual standing committees are:

506

16  Manpower Planning, Hospital Committees and Staff Policies

Table 16.30 Committees Status of works Activity Administrative Committee Anti-Sexual Harassment Committee Capital Purchase Committee Condemnation Committee CPR Committee Credentials Committee Death Review Committee Disaster Management Committee Employee Grievance Redressal Committee High-Power Committee Image Enhancement Committee Infection Control Committee Intern Committee Joint Conference Committee Management Review Committee Medical Audit Committee Medical Committee Medical Record Committee Nursing Quality Improvement Committee Patient Grievance Redressal Committee

Start date :- Yes

End date No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes :- Yes

No No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes :- Yes

No No

:- Yes

No

:- Yes

No

:- Yes :- Yes

No No

:- Yes

No

:- Yes

No

Responsible person Not Complete In-progress started

Remarks

16.3 Committees

507

Table 16.30 (continued) Status of works Activity Pharmaco therapeutic Committee Pharmacy Committee Program Committee Quality Control Committee Safety Committee Sentinel Event Committee Tissue Committee

Start date :- Yes

End date No

:- Yes

No

:- Yes :- Yes

No No

:- Yes :- Yes

No No

:- Yes

No

Responsible person Not Complete In-progress started

Remarks

1. Administrative Committee is for helping administrators for day-to-day work of the hospital. 2. Medical Committee is for efficient clinical management. 3. Medical Audit Committee is for quality control of medical services. 4. Credentials Committee is for the appointment of staff. 5. Joint Conference Committee is for medico administrative liaison. 6. Medical Record Committee is to supervise medical records. 7. Tissue Committee is for analysing the diagnostic reports. 8. Infection Control Committee is for controlling the infection. 9. Intern Committee is for the appointment of interns and resident doctors. 10. Pharmacy Committee is for guidance on pharmacy. 11. Program Committee is for regulating the meeting of different Committees. 12. The High-Power committee is the committee above all the committees. Special committees: The special committees are formed from time to time as may be required to carry out the properly assigned duties of the medical staff. Such committees shall confine their work to the purpose for which they are formed. The members of the committee and their duties depend upon the purpose for which the committee is formed. The usual special committees are: 1. Anti-Sexual Harassment Committee is to provide women protection against sexual harassment and to prevent and redressal of complaints of sexual harassment. 2. Capital Purchase Committee is for the planning, selection and installation of new equipment. 3. Condemnation Committee is for the condemnation and disposal of goods. 4. CPR Committee is to guide the care of patients requiring cardiopulmonary resuscitation. 5. The Death Review Committee is to review the causes of death in the hospital.

508

16  Manpower Planning, Hospital Committees and Staff Policies

6. Disaster Management Committee is to manage the disaster. 7. Employee Grievance Redressal Committee is for reviewing and resolving employee grievances. 8. The Image Enhancement Committee is to enhance the image of the hospital among the public. 9. Management Review Committee is to ensure that hospital governance is ethical and professional. 10. The nursing Quality Improvement Committee is to evaluate the quality improvement of nursing activities. 11. The patient Grievance Redressal Committee is to resolve grievances/complaints and concerns of patients or their representatives. 12. Pharmaco therapeutic Committee is to guide the formulation and implementation of policy and procedures for pharmacy and medication usage. 13. Quality Control Committee is to check and form policies for quality control of services. 14. Safety Committee is to identify the potential safety and security risks to staff, patients and visitors in the hospital. 15. Sentinel Event Committee is to ensure the reporting, documentation and responsibilities of all committees.

16.4 Human Resource Policies See Table 16.31. To enhance coordination and collaboration and to enrich organisational culture, it is extremely important to stress legal and ethical issues of the employees, provide safety to the employees, place welfare and motivation schemes for employees and enhance the support activities. A healthcare sector is a place wherein there are patients and employees with a huge diversity of cultural backgrounds. Therefore, the Human Resources department needs to pay closer attention to the issues of recruitment, disputes, discipline, termination, leaves, overtime, etc. as these are the major factors that the day-to-day functioning of the hospital depends on. To ensure the success of the systems, the Human Resources department must frame the set of policies which shall govern the recruitment and working of the employees in the hospital. There is a wide range of policies which needs to be worked out such as recruitment, Attendance, Leaves, employees’ benefits, travelling and conveyance, discipline, termination and suspension, overtime, performance evaluation, promotion, salary increment, reimbursement, security and safety, training and development, and workers compensation. The set of policies as mentioned above in the table shall be prepared well in advance, and the employees shall be made aware of all such policies either at the time of recruitment or later.

16.4 Human Resource Policies

509

Table 16.31  Human resource policies Status of works Activity Attendance Policy Confidential Policy Contract Hiring Policy Conveyance Policy Discipline Policy Dress Code Policy Drug/Alcohol Abuse Policy Employee Termination Policy Employees Insurance Policy Employment of Minors Policy Family and Medical Leave Policy Health and Safety Policy Health Care Plans Policy Holiday Leave Policy Housekeeping Policy Increment Policy Laptop Policy Leave and Holiday Policy Mobile Policy Overtime Policy Patient Entry Policy Pantry and Canteen Policy Performance Evaluation Policy Pest Control Policy Promotion Policy Recruitment and Selection Policy Refreshment Policy

Start date :- Yes :- Yes :- Yes

End date No No No

::::-

Yes Yes Yes Yes

No No No No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes

No

:- Yes :- Yes :- Yes

No No No

::::-

Yes Yes Yes Yes

No No No No

:- Yes

No

:- Yes :- Yes :- Yes

No No No

:- Yes

No

Not Responsible Complete In-progress started person

Remarks

(continued)

510

16  Manpower Planning, Hospital Committees and Staff Policies

Table 16.31 (continued) Status of works Activity Reimbursement Policy Relocation Policy Salary and Incentive Policy Security and Safety Policy Shift Duty Policy Student Employment Services Policy Suspension Policy Temporary Disability Leave Policy Temporary Hiring Policy Training and Development Policy Travelling Policy Visitor Policy Workers' Compensation Policy

Start date :- Yes

End date No

:- Yes :- Yes

No No

:- Yes

No

:- Yes :- Yes

No No

:- Yes :- Yes

No No

:- Yes

No

:- Yes

No

:- Yes :- Yes :- Yes

No No No

Not Responsible Complete In-progress started person

Remarks

Further Reading Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. India: Springer Singapore; 2022.

Chapter 17

Policies and Standard Operating Procedures (SOP)

To provide quality care to the patients, the hospital must run like a well-oiled machine. Right from admission onwards, all the pieces, activities, and processes must work together to provide consistent and excellent care. All these activities and processes include the patient’s assessment, treatment, investigation, nursing care, interventions, discharge, billing, etc. This motive can only be achieved if the hospital has a well-defined set of policies and procedures in place. Staff members must know what is expected from them and be provided with a defined and detailed set of rules, regulations, responsibilities, and procedures to guide them in their day-to-day tasks. In a hospital, deviating from the rules and standards can be detrimental to the hospital or the patient. Inconsistent practices will lower the quality of patient care and could even harm the patient and put the hospital at risk. Hence considering the importance, the hospitals shall have good policies and procedures to function effectively and efficiently and keep both employees and patients safe. Still further considering the laws, rules, regulations, and guidelines as issued or prescribed by various government bodies or the accreditation agencies of the respective country, the policies and standard operating procedures shall be prepared and made applicable in the hospital. Hospital policies and procedures regulate day-to-day operations and ensure that everything runs smoothly. They convey expectations and standards to employees, provide operational and improvement guidelines, and streamline procedures. Hospital policies and procedures serve to hold personnel accountable for taking the proper steps when caring for patients. They standardize practises throughout the organization to guarantee that all patients receive the same level of care which also helps to keep patients safe. Policies and procedures for disinfection, charting, and medication contribute to the prevention of common errors and infections. These standards prevent doctors

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7_17

511

512

17  Policies and Standard Operating Procedures (SOP)

and nurses from having to guess what steps to take or how to perform a surgery. This results in fewer errors. A hospital employee may interact with dozens of patients and other staff members every day. Policies and procedures for hospitals improve and streamline internal communication. The standard operating procedure (SOP) is developed for the hospitals based on the Health Care Standards involved over some time by the experts. SOPs reflect the difference in opportunities, capacity, and vulnerability of the healthcare staff at different levels of the healthcare system. The purpose of the standard operating procedures is to provide a clear and detailed description of step-by-step routine actions of the service providers providing services in the facilities. Apart from SOPs, a few other essential activities need to be addressed. These are like designing and developing the formats of the hospital stationery, registers, records, operational policies, roles and responsibilities, templates, logbooks, rules and regulations, etc. Once all these above SOPs and documents are in place, the quality of patient care will substantially improve. This set of checklists shall help the planner and designer to remember all such activities and frame the desired hospital policies, SOPs, formats of the hospital stationery, registers, records, operational policies, roles and responsibilities, templates, logbooks, and rules and regulations well in time.

17.1 Policies 17.1.1 Hospital Policies Joint Commission International (JCI) and National Accreditation Board of Hospitals (NABH) accreditation in India have established guidelines so that hospitals may attempt to develop a baseline that will help them provide better healthcare services. It will allow healthcare providers to benchmark their services against the finest providers, allowing hospitals to remain competitive. The JCI accreditation maintenance programme assures staff satisfaction as their opportunities for development and leadership expand, and they have the opportunity to work in a great environment. The development team will be properly trained and will adhere to standard operating practises. Furthermore, accreditation ensures that the staff receives consistent support. Here, we will be discussing about the JCI standards, as these standards are applicable throughout the globe (Table 17.1) For more details on the norms as prescribed and laid down by the JCI, please refer to the “Joint Commission International Accreditation Standards for Hospitals. Including Standards for Academic Medical Center Hospitals 7th Edition”

17.1 Policies

513

Table 17.1  Policies and standards as prescribed by JCI

Activity Access to care and continuity of care (ACC) Screening for admission to the hospital Admission to the hospital Continuity of care Discharge, referral, and follow-up Transfer of patients Transportation Patient-centred care (PCC) Patient and family rights Patient consent process Patient and family education Organ and tissue donation information Assessment of patients (AOP) Standards Laboratory services Blood bank and/or transfusion services Radiology and diagnostic imaging services Care of patients (COP) Care delivery for all patients Care of high-risk patients and provision of high-risk services Clinical alarm system management

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

:::::-

::::-

::::-

::-

:(continued)

514

17  Policies and Standard Operating Procedures (SOP)

Table 17.1 (continued)

Activity Recognition of changes to patient condition Resuscitation services Administration of blood and blood products Management of patients at risk of suicide or self-harm Management of lasers Food and nutrition therapy Pain management End-of-life care Hospitals providing organ and/or tissue transplant services Transplant programs using living donor organs Anaesthesia and surgical care (ASC) Organization and management Sedation care Anaesthesia care Surgical care Medication management and use (MMU) Organization and management Selection and procurement Storage Ordering and transcribing Preparing and dispensing Administration Monitoring

Status of works Start End Not Responsible date date Complete In-progress started person :-

::-

:-

:::::-

:-

::::-

:::::::-

Remarks

17.1 Policies

515

Table 17.1 (continued)

Activity Quality improvement and patient safety (QPS) Management of quality and patient safety activities Measure selection and data collection Analysis and validation of measurement data Gaining and sustaining improvement Prevention and control of infections (PCI) standards Responsibilities Resources Goals of the infection prevention and control program Medical equipment, devices, and supplies Environmental cleanliness Infectious human tissues and waste Food services Engineering controls Construction and renovation risks Transmission of infections Quality improvement and program education Governance, leadership, and direction (GLD) Governance of the hospital Chief executive(s) accountabilities

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

::-

:-

:-

:::-

::::::::-

::(continued)

516

17  Policies and Standard Operating Procedures (SOP)

Table 17.1 (continued)

Activity Hospital leadership accountabilities Hospital leadership for quality and patient safety Hospital leadership for contracts Hospital leadership for resource decisions Clinical staff organization and accountabilities The direction of hospital departments and services Organizational and clinical ethics Health professional education Human subjects research Facility management and safety (FMS) Leadership and planning Risk assessment and monitoring Safety Security Hazardous materials and waste Fire safety Medical equipment Utility systems Emergency and disaster management Construction and renovation Education Staff qualifications and education (SQE) Planning Staff health and safety

Status of works Start End Not Responsible date date Complete In-progress started person ::-

:::-

:-

:::-

:::::-

:::::-

::-

Remarks

17.2 Standard Operating Procedures (SOPs)

517

Table 17.1 (continued)

Activity Determining medical staff membership The assignment of medical staff clinical privileges Ongoing professional practice evaluation of medical staff members Medical staff reappointment and renewal of clinical privileges Nursing staff Other health care practitioners Management of information (MOI) Information management Management and implementation of documents Patient medical record Information technology in health care Medical professional education (MPE) Human subjects research programs (HRP)

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

::-

:-

:-

::-

::-

::-

17.2 Standard Operating Procedures (SOPs) Therefore, the standard operating procedures (SOPs) manual shall be developed to standardize and formalize the systems for providing quality clinical services in the hospital. SOP is a written set of procedures that the users shall use in practice, for discharging their duties and responsibilities and to obtain the desired outcome. Usually, such SOPs and documents are prepared for all the major departments like OPD, IPD, emergency, operating rooms, diagnostic services, accounts, administrative services, ambulance services, anaesthesia services, blood bank, CSSD,

518

17  Policies and Standard Operating Procedures (SOP)

dietary, finance, diesel generator, hospital certificates, housekeeping, human resource department, immunization, laundry, medical record, medico-legal cases, nursing services, paraclinical departments, infection control, reception, security, inventory management, etc.

17.2.1 Administrative Services See Table 17.2. The administration department is the main hub of all the activities being carried out in the hospital. This is the department that has to keep a constant watch on all the clinical and non-clinical departments. This department is also responsible for Table 17.2  SOP of administrative services

Activity Services offered by the department Administers and directs all the activities of the hospital Coordinate effective communication inside the hospital Coordination with governmental and nongovernmental agencies Liaison with the governing body Transmit, interpret, and implement the rules and regulations Delegate duties and responsibilities to staff Prepare periodical reports including the annual report Provide personnel policies Maintain accurate and complete personnel records. Control and effective utilization of the physical facilities Effective accounting and internal controls

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:-

:-

:-

::-

::-

::-

:-

:-

17.2 Standard Operating Procedures (SOPs)

519

Table 17.2 (continued)

Activity Effective utilization of financial resources Establish a good financial structure including the fee schedules Prepare the budget proposals Maintenance and protection of building and equipment Determine the need for staff, select, employ, confirm, grant leave, train, prescribe their duties, responsibilities and accountability and disciplinary action Ascertain the need for the purchase of new equipment and machinery Look into various training functions Provide for research and professional enrichment of the staff. Understand and implement the legal requirements Avoid the misutilization of the funds Control the purchasing department Supervise the planning and construction when alteration and addition to the buildings Prepare the standing orders for a) professional/medical care and b) administrative matters

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::-

::-

:-

:-

::-

:-

:-

::-

:-

(continued)

520

17  Policies and Standard Operating Procedures (SOP)

Table 17.2 (continued)

Activity Promote employer and employee relation Promote social activities of the personnel Interact with the press; give the news and the achievements to the press Providing education to the community for the prevention of diseases Issue daily circulars Allot the residential accommodation to the staff Distribution of non-technical manpower to various departments Arrangements for all the meetings and functions in the hospital Surprise check Periodical stock verification Investigate losses and damages and deal expeditiously Review the daily and monthly accounts and reports Ensure the running the maintenance of the medical/non-medical equipment Ensure the effective housekeeping Efficient and flawless maintenance of the medical records Safety and security of the men and material Condemnation of stores beyond repairs and their replacement and disposal

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::-

:-

:-

::-

:-

:-

:::-

:-

:-

::-

::-

17.2 Standard Operating Procedures (SOPs)

521

Table 17.2 (continued)

Activity Maintenance of all the vehicles Organise fire services for the hospital Roles and responsibilities of administrative staff Roles and responsibilities of officers Roles and responsibilities of Medical Superintendent/ Medical Director Roles and responsibilities of Dy. Medical Superintendent Roles and responsibilities of Administrator Roles and responsibilities of Assistant Administrator Roles and responsibilities of Head Clerks Standard operating procedures Grooming standards Procedure to release medical information Hospital indemnity policy Records of doctors with departments Records of technicians with departments Records of facilities Interhospital communication Draft duties and responsibilities to staff Accounting and internal controls Budget proposals

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::-

:-

:-

:-

:-

:-

:-

::::::::::(continued)

522

17  Policies and Standard Operating Procedures (SOP)

Table 17.2 (continued)

Activity Purchase of new equipment and machinery Training schedules and functions Allotment of residential accommodation Periodical stock verification Maintenance of the medical/non-medical equipment Safety and security of the men and material Condemnation of equipment and machinery Forms and formats Marketing circular formats Templates for experience certificate for staff Templates for certificate required by patients for Mediclaim List of specialty departments available in the hospital Duties and responsibilities of staff Budget Staff training and assessment Equipment requirement Condemnation proposal Reports Prepare periodical reports including the annual report All other reports as required by the top management for day-to-day working and policy-making

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

::::-

::-

::-

:-

:-

::::::-

:-

17.2 Standard Operating Procedures (SOPs)

523

providing assistance and decision for the efficient working of all the clinical, non-­ clinical and support departments of the hospital. The administration department shall perform the following functions: 1. Administers and directs all the activities of the hospital. He should ensure that all activities are geared to the achievement of the objectives in providing comprehensive healthcare, training and research, and participation in community health. 2. Takes all necessary steps for the maintenance of high-standards professional, technical, and supportive. 3. Coordinate effective communication inside the hospital between departments and sections and outside the hospital with governmental and nongovernmental agencies involved in healthcare. 4. Be the liaison among the governing body (higher authority, which may be the Director of Health Services or the Secretary to Government) helping in the formulation of policies and their implementation. 5. Be the transmitter, interpreter, and implementer of the rules and regulations among the staff and the departments of the hospital and should be responsible for getting the philosophy and objectives of the hospital to permeate the working of the hospital giving necessary directions in this regard. 6. Delegate duties and responsibilities to appropriate persons in the hospital and establishes means of accountability from those to whom duties have been assigned. 7. Prepare periodical reports including the annual report and attend meetings with the governing body regarding all activities of the institution and also the likely impact of new policies of the Government affecting healthcare services. 8. Provide personnel policies and the maintenance of accurate and complete personnel records. 9. Provide practices for all personnel for adequate support for sound patient care. 10. Implement the control and effective utilization of the physical facilities. 11. Provide a system of responsible accounting and effective internal controls. 12. Utilize effectively the financial resources. 13. Establish a good financial structure including the fee schedules and the careful, economical, and safe administration of funds and ensure that the fee fixed is charged properly. 14. Prepare or cause to prepare the budget proposals and recommendations covering operations of the hospital and also an audited financial statement of Income and Expenditure for the year ending March every year. 15. See to the maintenance and protection of the building and grounds and also the equipment. 16. Determine the need for staff and has the responsibility to select, employ, confirm, grant leave, train, prescribe their duties, responsibilities, and accountability, and take disciplinary action, as required and should be interested in their educational activities.

524

17  Policies and Standard Operating Procedures (SOP)

17. Ascertain the need for the purchase of new equipment and machinery and takes the necessary steps for their acquisition. 18. Look into various training functions and ensure their proper conduct and attend the conferences. 19. Provide for research and professional enrichment of the staff. 20. Maintain good public relations; all communications regarding the hospital with outside agencies should be carried out by or through the Administrator. 21. Understand and implements the legal requirements 22. See to the ethical conduct of the activities of the hospital. 23. Personally control the purchasing department to avoid the mis-utilization of the funds. 24. Supervise the planning and construction when alteration and addition to the buildings become necessary. 25. Prepare the standing orders for (a) Professional/Medical care and (b) Administrative Matters. 26. Provide the equipment and accommodation to each department for performing their duties. 27. Be responsible for employer and employee relations and delegate duties as per the Organizational Chart. 28. Take an interest in the social activities of the personnel, particularly the members living in the institution. 29. Make sure that the patient is properly admitted, and the staff is available immediately and all the departments are coordinated to give efficient and effective service in the shortest possible time. 30. Interact with the press; give the news, the achievements, the health education media, etc. to the press. 31. Report to the Government about communicable diseases, births and deaths, and other similar statistics. 32. Be the leader in the community and should be responsible for the prevention of diseases and providing education to the community about the prevention of diseases and medical and healthcare. 33. Be responsible for nursing care; call for various reports on admissions and discharges, census, and conditions of the patients. 34. Be responsible for providing a better nursing education facility through the proper lectures, demonstrations, etc. 35. Control the disposal of waste and garbage, to keep the hospital and its surroundings clean and free from infections. 36. Ensure the efficient and economical working of the departments under him. 37. Issue daily circulars in consultation with the other senior staff. He/she should publish causalities among hospital staff (arrival, departure, temporary duty, leave, admission to hospital, discharge from hospital, etc.) as and when occur. 38. Be responsible to allot the residential accommodation to the staff. 39. Ensure that the orders and circulars are displayed at the proper time and in the proper place.

17.2 Standard Operating Procedures (SOPs)

525

40. Be responsible for the distribution of non-technical manpower to various departments. He should also keep watch of the economic utilization of the manpower and review the establishment and submit his recommendations to the Medical Superintendent whenever necessary. 41. Coordinate the administrative arrangements for all the meetings and functions in the Hospital. 42. Arrange for the purchase of all the stores and machinery other than the medical stores and equipment with the approval of the Administrator and after receipts of the stores, pass the Material Receipt Report voucher and the bill and send to the accounts for payment. 43. Surprise check of ground balances. 44. Check the ground balance of the ration. 45. Periodical stock verification of all the stores and have this recorded for audit purposes. 46. Simultaneous check of a few items in all the departments to ensure the correctness of the total stocks in charge. 47. Checks of stock of any item desired by the Duty Officer/M.S. 48. Maintain the records in respective departments to pinpoint responsibilities for losses/damages. 49. Arrange for the periodic analysis of samples of milk supplied to various departments and maintain a record for the same. 50. Maintain the record of inoculation/vaccination of all the staff of the hospital. 51. Prepare contracts for canteen services, supply of fresh items of ration, supply of dry ration, cycle–scooter–car stand, and shops inside the hospital campus. 52. Ensure that all losses and damages are investigated promptly whenever reported/ discovered and dealt with expeditiously and ensure that corrective action has been taken to avoid the reoccurrence in the future. 53. Ensure that the correct quality and number of various items of the uniforms are issued to staff and that they are maintained in a serviceable condition at all times. 54. Ensure that the telephone operators and the receptionist of the information department are up to the mark and are working in good behaviour. 55. Review the daily and monthly accounts, and reports and present them to the administrator along with the account manager. 56. Ensure the maintenance of the building and its surroundings concerning painting, carpentry jobs, welding jobs, plumbing, electricity, water, and gardening. 57. Ensure the running the maintenance of the medical/non-medical equipment and arrange for their repairs whenever required. 58. Ensure effective housekeeping concerning cleanliness, etc. 59. Get the arrangement done for the supply of linen and packed clothes to the departments and the wards. 60. Arrange for admission and timely discharge for the same and ask for the daily reports of admission and discharges. 61. Be responsible for the efficient and flawless maintenance of the medical records of the hospital. 62. Be responsible for the safety and security of the men and materials.

526

17  Policies and Standard Operating Procedures (SOP)

63. Arrange for condemnation of stores beyond repairs and their replacement, and disposal of condemned stores to the best advantage of the hospital. 64. Promptly investigate and regularize all the losses and damages immediately after they are reported. 65. Account for cash collected as recoveries against losses and damages. Such cash should be deposited with the Accounts Manager at the end of each day. 66. Look after the maintenance of all the vehicles on his charge for the good running order, accounting for their daily runs, fuel used, and repairs record. 67. Have a strict watch over abnormal trends in consumption to bring them to the notice of the Administrator. 68. Implement all measures to ensure the economy and to prevent losses due to improper storage, lack of preservation, misuse, and pilferage. 69. Ensure the efficiency of tradesmen under his control. 70. Organize fire services for the hospital, carrying out firefighting practices and ensuring that firefighting equipment is adequate and in serviceable condition at all times.

17.2.2 Emergency Department See Table 17.3. An emergency department (ED) is a department in the hospital to provide immediate and urgent medical treatment facilities to the patient by persons specialized in emergency medicine. Hence, emergency department plays an important role in providing the public with access to urgent and acute healthcare facilities apart from extending support to primary healthcare and community services. The emergency department is also addressed as Accident & Emergency Department (A&E), Emergency Room (ER), or Casualty Department, etc. in different countries of different hospitals. The emergency department of the hospital is the window or can say door of the hospital from where the patients enter the hospital. Therefore, an emergency department creates the first impression on the patients, relatives, and friends who come along with the patient. If the patients in the emergency department are handled quickly and efficiently in a friendly environment, it leads to a positive impact on the patients or their relatives and friends, who in turn can form their opinion about the care they will receive. The quicker and more efficient the care, the more the chances to save lives and also reduce the severity and duration of illness. The patients landing in the emergency department are of varied types like major trauma patients, elderly patients, patients with physical and mental disabilities, patients with mental health issues, patients with infectious diseases or who are immunocompromised, children and adolescents, sexual assault patients, domestic violence, custodial patients, victims of child abuse, and patients affected by chemical, biological or radiological contaminants, etc.

17.2 Standard Operating Procedures (SOPs)

527

Table 17.3  SOP of emergency department

Activity Services and functions of the emergency department Immediate relief and management of patients arriving in the department Attending to the medico-legal cases and coordinating with the local police for the same Providing first aid and/ or providing the required treatment to the patients Patient arrival and registration Triage services Initial assessment Patient resuscitation Admission/discharge/ transfer To operate an ambulance control centre To ensure proper triaging, diagnosis, resuscitation, initial treatment, and disposition of all patients brought into the emergency department Isolation of emergency patients with suspicion of infectious disease Coordination and delivery of emergency care Training of all emergency staff in the current protocols and clinical guidelines

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:-

:-

:-

::::::-

:-

:-

:-

:-

(continued)

528

17  Policies and Standard Operating Procedures (SOP)

Table 17.3 (continued)

Activity Roles and responsibilities of emergency staff Roles and responsibilities of emergency medical officer Roles and responsibilities of nursing staff Roles and responsibilities of on-call doctors Roles and responsibilities of general duty clerks Roles and responsibilities of technicians Standard operating procedures for Grooming standards of emergency staff Emergency handling procedure Handling a dead body Miscellaneous activity handling Handling blood and body secretions of patients' spills Checklist of minimum basic medicines required in the emergency department Instrument sets requirements in the emergency department Monitoring of service standards Triage policy Receiving a patient General working guidelines in accident and emergency department

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:-

:-

:-

:-

:-

:::::-

:-

:-

::::-

17.2 Standard Operating Procedures (SOPs)

529

Table 17.3 (continued)

Activity Admission for further treatment/surgery Death/breaking bad news in the emergency department Handling medico-legal cases Unidentified and unconscious patient protocol for initial alert and escalation Brought dead patients’ protocol for isolation Transfer from ED to operation room (for patients with a surgical emergency) Transfer from ED to the outpatient department Handling various medical equipment, tools, and instruments Infection control BLS and ACLS protocols Forms and formats Emergency assessment sheet Emergency register Medicine requisition form Emergency record register Police information book Injury reports/register Death certificate book Medical certificate book Patient’s case record Patient reference forms

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::-

::-

::-

:-

:-

::-

::::::::::(continued)

530

17  Policies and Standard Operating Procedures (SOP)

Table 17.3 (continued)

Activity Investigation requisition form Patients register Medico-legal registers Brought in dead register Notifiable disease register Patient valuable register Doctors call duty register Reports Daily patient census Patients transferred to other centres/hospitals Patients admitted from ED Patient refused admission MLC registered Death in ED Stock statement of equipment, instruments, and tools in ED Stock statement of drugs, medicines, and consumables in ED

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::::::-

:::::::-

:-

The staff in the emergency department should be professional experts in their field who can effectively manage the patients, provide immediate critical care, resuscitate the patient, relieve the patient from pain, and save the life of the patient. The assistance of the support departments like radiology and pathology etc. is also crucial for the emergency department to perform. Hence, the set-up of these supporting departments should be excellent and shall maintain good communication with an emergency department. The emergency department needs to establish a close relationship with all these support departments as well as with the other departments and units of the hospital. The objective of the emergency department is to provide effective and immediate treatment to the patients, provide first aid to the patients, and save the life of the patient and relieve him/her of pain. Also, the department has to attend to

17.2 Standard Operating Procedures (SOPs)

531

medico-­legal cases and coordinate with the local police for the same, screening patients for admission and providing care during non-OPD hours or on holidays. While planning and designing any emergency department in the hospital, it has to be ensured that all the works are complete and operational. Similarly, all the services shall be operational before the emergency department starts taking patients. On the other side, the emergency departments of the hospitals shall be operative 24 h a day for all weekdays. Hence, it becomes very easy for the patient with acute illness or accidents to land in this department without a prior appointment, but who requires immediate medical attention. There are a few issues which need to be ensured before the emergency department is in operation. Such issues are like the required infrastructure is provided; the layout of the department is perfect; required services are available; proper furniture and fixtures are in place; required electrical points and communication ports have been provided; public utilities have been provided; signage, wayfinding, and display mechanisms are in place; required instrument/equipment/gadgets are available; required facilities are available; patient/staff/visitors safety mechanisms are available; proper lighting is ensured; proper environmental control with heating and air-­ conditioning is available; security devices and mechanisms are provided; announcement systems are in place; and wall, ceiling, and interior decoration are up to mark and appealing, etc.

17.2.3 Outpatient (OPD) Services See Table 17.4. The department in a hospital where ambulatory patients receive consultation from specialists or superspecialists is known as the outpatient department (OPD) unit, also known as the ambulatory care unit. The OPD treats patients who do not need to stay in the hospital overnight. The primary goal of OPD is to avoid crowding in the indoor department and to provide follow-up care for indoor patients after discharge. This is a win–win situation for everyone involved, including the doctor, the patient, society, and the hospital. The OPD services in the hospital support the patient by providing consultation with medical specialists and super specialists; physical examination and investigations; referring the patient for admission to a hospital for inpatient services; follow­up consultation and ongoing case management, providing treatment on a day-care basis; pre-operative screening of the patient; performing minor procedures; referring the patients to other specialities or super-specialities for a second opinion or on-going care and treatment; providing health education and counselling of the patients and families; centre for providing the training and education to the students; etc. There are a few issues which need to be ensured before the hospital is operational. Such issues are like required infrastructure has been provided; the layout of

532

17  Policies and Standard Operating Procedures (SOP)

Table 17.4  SOP of outpatient department (OPD)

Activity Services and functions of OPD Provide consultation to the patients Prescribe investigations and treatment Advice patient for further treatment protocols Check the reports of investigations General health check-ups Public awareness of health issues Educate patient on the prevention of disease Roles and responsibilities of OPD Staff Roles and responsibilities of physicians Roles and responsibilities of nursing staff Roles and responsibilities of technicians Special duties performed by OPD staff Roles and responsibilities of general duty clerks Standard operating procedures for Grooming standards Facility requirements at OPD Receiving the patient in OPD

Status of works Start End Not Responsible date date Complete In-progress started person

::-

:-

::::-

:-

:-

:-

:-

:-

:::-

Remarks

17.2 Standard Operating Procedures (SOPs)

533

Table 17.4 (continued)

Activity Registration of patient Consultation with the physicians Prescribing investigations Prescribing drugs/ medicines OPD timing OPD turnaround time Health check-up Forms and formats OPD registers Treatment register OPD slip Prescription slip Investigation requisitions Referral slips Receipt book Appointment card Immunization card Cardiac clinic record Eye examination form Reports Daily patient census of OPD Patients admitted from OPD Patient refused admission Investigations prescribed by OPD Stock statement of equipment, instruments, and tools in OPD Stock statement of drugs, medicines, and consumables in OPD

Status of works Start End Not Responsible date date Complete In-progress started person ::::::::::::::::::-

:::::-

:-

Remarks

534

17  Policies and Standard Operating Procedures (SOP)

the department is perfect; required services are available; proper furniture and fixtures are in place; required electrical points and communication ports have been provided; public utilities have been provided; signage, wayfinding, and display mechanisms are in place; required instrument/equipment/gadgets are available; required facilities are available; patient/staff/visitors safety mechanisms are available; proper lighting is ensured; proper environmental control with heating and air-­ conditioning is available; security devices and mechanisms are provided; announcement systems are in place; and wall, ceiling, and interior decoration is up to mark and appealing, etc. While planning and designing any OPD in the hospital, it has to be ensured that all the works are complete and operational. Similarly, all the services shall be operational before the OPD starts taking patients.

17.2.4 Inpatient Department (IPD) Services See Table 17.5. The significance and usefulness of the patient rooms are important issues and shall not be ignored in any hospital setup. It is a place where the patients are kept while undergoing the necessary treatment and recovering. This is one of the places where the patient or family members can observe the standard of care given to the patient, along with other hospital services and treatments. Patients depend on professionals to act immediately in an emergency, check on them frequently, and ensure a good recovery. However, the staff can only provide patients with appropriate care when they fulfil their responsibilities quickly and have access to sufficient tools and materials that may be required for the treatment and comfort of the patient. Therefore, the key aspects influencing patient satisfaction are the room's layout, furnishings, comfort, cleanliness, and safety as well as the nursing staff's attentiveness and care. The following three crucial functions shall all be accommodated when designing a hospital room, which is one of the biggest obstacles faced by designers. The patient's room shall first be relaxing and pleasant. Second, health professionals need to be able to move rapidly and effectively navigate the area. Finally, there needs to be a place where family members and other visitors can sit comfortably or sleep without interfering with the work of the staff or the patient's recovery. Small hospitals might not always be able to do this, but the designer shall always make an effort to incorporate such areas. In a hospital, there are various ward types, including Family Suites, Deluxe Rooms, Single-bed (Private) Rooms, Sharing beds (Semi-private) Rooms, General Ward (Multiple Beds), Isolation Ward, Postoperative Ward, ICU, ICCU, Nursery, etc. According to the patient's ability to pay and/or the severity of their illness, the patients in each of these wards shall be kept. Some of the factors which shall be considered while designing these wards are,

17.2 Standard Operating Procedures (SOPs)

535

Table 17.5  SOP of in-patient department (IPD) services

Activity Services and Functions of IPD Provide treatment to the admitted patients Prescribe investigations and treatment Advice patient for further treatment protocols Check the reports of investigations Daily rounds of the physicians Information about the patient to the attendants of the patient Discharge of the patient Inter-ward transfer of the patient Ward management Prescribing interventions and surgeries Postoperative care Critical care Preventing hospital-­ acquired infections Maintaining cleanliness and hygiene Maintaining the safety and comfort of the patient and staff Roles and responsibilities of IPD staff Roles and responsibilities of nursing staff

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

::-

:-

:::-

::::-

::::-

:-

:-

(continued)

536

17  Policies and Standard Operating Procedures (SOP)

Table 17.5 (continued)

Activity Roles and responsibilities of resident medical officer Duties and responsibilities of ward assistants Duties and responsibilities of housekeeping staff Standard operating procedures for Grooming standards General procedures Admission procedure Discharge procedure Ward transfer procedure List of important instrument sets Infectious and isolation policies Infection control policies Maintaining patient files with case papers Daily activities in the wards Patient handling of emergency The emergency arising in case a fire breaks out Work patient safety and comfort Forms and formats Nurses report book Ward inventory book/ sheet Emergency medicines stock register Patient case sheet papers

Status of works Start End Not Responsible date date Complete In-progress started person :-

:-

:-

::::::::::::-

:-

::::-

Remarks

17.2 Standard Operating Procedures (SOPs)

537

Table 17.5 (continued)

Activity Patient file folder Face sheet/admission discharge summary Patient consent form Patient treatment sheet Doctor's order sheet Patient temperature chart maintenance Input–output chart Certificate for admission Referral sheet Charge slip indoor patient Operation theatre charge sheet for procedure Operation theatre charge sheet for medicines/drugs Patient visit record doctor Post-acute care and operation notes Nurse notes/vital sign Blood requisition form Discharge booklet Investigation record sheet Subsidy application—for the underprivileged Patient’s feedback Reports Daily patient census of IPD Patients admitted from IPD Patients discharged from IPD Deaths in IPD

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:::::::::::-

:-

:::::::-

:::::(continued)

538

17  Policies and Standard Operating Procedures (SOP)

Table 17.5 (continued)

Activity Patients went LAMA from IPD Patients referred to other centres/ hospitals Patient refused admission Investigations prescribed by IPD Stock statement of equipment, instruments, and tools in IPD Stock statement of drugs, medicines, and consumables in IPD Collection of charges from the IPD patients Fumigation report of the IPD areas Patients feedback reports

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

::-

:::-

:-

:::-

The safety of the workers and patients shall come first while creating the patient rooms. There shall be no hiding places, CCTV can be utilized for surveillance, and every corner of the room shall be visible from the exterior corridor, among other precautions. There shall not be any sharp-edged furniture, equipment, or accessories in the space that could be used as a weapon against other people or oneself. The space shall have as few curved angles, hidden, and pull-out items as possible; glass shall be avoided in the room; tempered glass shall be used in place of regular glass; plastic silver-coated mirrors shall be used in place of glass mirrors; the lowest height of the windows shall be higher so that the patient cannot leap out; all windows shall have double glazing or grills installed. Additionally, ceiling fans, curtain rods, or cloth hanging rods shall be avoided. The flooring in the bathroom and the room shall be non-slippery and at zero level, and the bathroom shall  have the appropriate grab bars. The degree of patient satisfaction, which contributes to a rise in the business, is one of the most crucial elements in a hospital setting. The degree of employee satisfaction is above this. There are a few factors that can help patients and employees feel more satisfied, such as having outstanding facilities and attractive surroundings; maintaining average humidity levels; and keeping the room’s temperature which shall not be either too high or too low. Rooms shall also have adequate natural lighting, be odourless, be silent and free from disturbing sounds and noises, be constructed to allow cross ventilation, and have windows that provide views of the

17.2 Standard Operating Procedures (SOPs)

539

outdoors such as trees, gardens, etc. Similar to this, the room shall have space for the patient's family and friends to sit comfortably, be designed to be easily cleaned, and have entertainment options like television or small indoor/board games like ludo, playing cards, chess, etc., as well as attractive wall paintings, wall arts, and scenery. Additionally, patients shall have access to free Wi-Fi so they can use their smartphones or laptops to access the internet. Ensure the family’s comfort and convenience. Anxious family members and friends frequently accompany patients to hospitals. Additionally, the support of the family helps the patient to recover and lowers morbidity. Hence, a Family Support Zone shall be provided and shall be situated close to the patient rooms. Facilities including a family lounge, consultation rooms, meditation areas, a family cafeteria, family sleep rooms, family laundry, etc. shall be available in this area.

17.2.5 Operation Theatre Services See Table 17.6. An operating room (O.T.) is a room used for performing operations, surgeries, and other invasive interventions. All employees entering the OT Complex are required to wear protective apparel such as shoe covers, masks, caps, eye shields, and other coverings to stop the spread of germs and microorganisms, creating a sterile atmosphere. The area is well-lit, and the humidity and temperature are kept within acceptable ranges. The phrase “Operating Theatre Suite/Complex” cannot be fully defined by the Operating Theatre alone. It represents a bundle of distinct rooms located around the entire complex. It must be verified that before the beginning of the surgeries in the Operating Room, all construction work is finished and services operational. Before the operating complex can be used to operate, a few things need to be addressed are like the necessary infrastructure has been provided, the necessary services are available, the proper furniture and fixtures are in place, the necessary electrical points and communication ports have been installed, the required public utilities have been installed, the essential signage, wayfinding, and display mechanisms are in place, the relevant instrument/equipment/gadgets are available, the necessary facilities are available, and the appropriate patient/staff/visitor safety mechanisms are available.

17.2.6 Delivery Room See Table 17.7. Childbirth takes place in the labour room, often known as the delivery suite. It also goes by the name “Birthing Unit.” The facilities offered by this unit are to provide secure prenatal care, delivery, and immediate postpartum care for women and

540

17  Policies and Standard Operating Procedures (SOP)

Table 17.6  SOP of operation theatre services Status of Works Activity Services and functions of OT Performing the interventions Performing surgeries and procedures Pre-anaesthetic check-up (PAC) Patient preparation Taking consent and explanation about the surgery Counselling of patients/attendants Postoperative care in the recovery room Sterility in the whole OT complex Patient care in the preoperative area Patient care in the recovery room Roles and responsibilities of OT staff Roles and responsibilities of in-charge operation theatre (O.T.) Roles and responsibilities of O.T. technician Roles and responsibilities of scrub nurse Roles and responsibilities of housekeeping staff Standard operating procedures for Operation theatre procedure Discipline, duties, and obligations for maintaining OT

Start End date date

:::::-

:::::-

:-

:-

:-

:-

::-

Not Responsible Complete In-progress started person Remarks

17.2 Standard Operating Procedures (SOPs)

541

Table 17.6 (continued) Status of Works Activity OT booking/ scheduling Patient care in the preoperative area Patient care in theatre Patient care in the recovery room Shifting patient from recovery to ward/ICU Maintenance of equipment/ instruments/ infrastructure Requisition/ condemning of instruments (new/ replacement) Waste disposal Hand washing and scrubbing Gown and gloveswearing technique in the OT Shaving and part preparation Skin preparation Checking anaesthetic apparatus Managing patients who are infected with HIV, Hepatitis B, and Hepatitis C Precaution for the surgical team Procurement and maintenance of linen Cleaning and disinfection of OT Cleaning of used instruments Maintenance of lap – instruments Disposal of the foetus or amputated body parts

Start End date date

Not Responsible Complete In-progress started person Remarks

::::::-

:-

:::-

::::-

::::::-

(continued)

542

17  Policies and Standard Operating Procedures (SOP)

Table 17.6 (continued) Status of Works Activity Use of implantable prostheses and medical devices Work instruction for the scrub nurse Work instruction for circulating nurse Work instruction for recovery nurse Work instruction for operation theatre Fumigation Emergency expiry medicine checklist High-risk medicine checklist Forms and formats OT register Non-consumable stock register Consumable stock register PAC and operation notes Anaesthesia record/ notes OT charge slip OT drug charge slip Operation list proforma Blood requisition form Adverse anaesthesia event register Fumigation register Medicine/consumables requisition form OT note Postoperative checklist Postoperative order form Pre-anaesthesia check form Pre-operative re-evaluation

Start End date date :-

:::::::-

:::::::::::::::::-

Not Responsible Complete In-progress started person Remarks

17.2 Standard Operating Procedures (SOPs)

543

Table 17.6 (continued) Status of Works Activity Recovery room record Surgical safety checklist Reports Daily major surgeries Daily minor surgeries Consumption of drugs and consumables Death in OT Indicators of sterilized instruments and linen Collection of charges from OT Stock statement of equipment, instruments, and tools in OT Stock statement of drugs, medicines, and consumables in OT Fumigation report and record of the OT areas

Start End date date

Not Responsible Complete In-progress started person Remarks

::-

:::::::-

:-

:-

babies. This shall be referred to as “LDR” for this chapter (Labor, Delivery, and Resuscitation). To assess the LDR, the staff is required to wear protective apparel such as shoe covers, masks, caps, eye shields, and other coverings to stop the spread of germs and microorganisms, creating a sterile atmosphere. The area shall be well-lit, and the temperature and humidity kept within acceptable ranges. Delivery Suits, on the other hand, are more like a collection of various rooms dispersed around the complex's many zones, such as the Unsterile Zone, Protective Zone, and Delivery Zone. While planning and designing the Delivery Suite in the hospital, it has to be ensured that all the works are complete and operational. Similarly, all the services shall be operational before the delivery starts in the Delivery Suite. Just like the Operating Complex, in Delivery Suite also few issues need to be ensured before the hospital is in operation. Such issues are like the required infrastructure is provided; the layout of the department is perfect; required services are available; proper furniture and fixtures are in place; required electrical points and communication ports have been provided; public utilities have been provided; signage, wayfinding, and display mechanisms are in place; required instrument/

544

17  Policies and Standard Operating Procedures (SOP)

Table 17.7  SOP of delivery room

Activity Services and functions of delivery room Conducting vaginal deliveries Performing caesarean section deliveries Pre-anaesthetic check-up (PAC) Patient preparation Taking consent and explanation about the surgery Counselling of patients/ attendants Postpartum care in the recovery room Sterility in the whole delivery suite Antinatal patient care To deliver a well-being healthy baby and to provide standard nursing care to the mother and the baby The consistent application of established best practices leads to improved outcomes and decreased complications Care of high-risk obstetrical patients Management of eclampsia Procedure for anticonvulsive drugs Management of post-partum haemorrhage Diagnosis of vaginal bleeding after childbirth Management of shock

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:::::-

:::::-

:-

::::-

::-

17.2 Standard Operating Procedures (SOPs)

545

Table 17.7 (continued)

Activity Roles and responsibilities of delivery room staff Roles and responsibilities of the in-charge delivery suite Roles and responsibilities of a technician Roles and responsibilities of scrub nurse Roles and responsibilities of housekeeping staff Standard operating procedures for Discipline, duties, and obligations for maintaining OT Delivery room booking/ scheduling Initial assessment of patient Reassessment of patient Provision of continuous and multidisciplinary care Uniform care of patients Care of high-risk obstetrical patients High-risk pregnancies Management of atonic uterus Management of shock HSG (hysterosalpingography) Cervical pap smear Management of patients having induction/ augmentation of labour Management of the client/patient with eclampsia

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:-

:-

:-

:-

:-

::::-

::::::::-

:-

(continued)

546

17  Policies and Standard Operating Procedures (SOP)

Table 17.7 (continued)

Activity Management of the client with antepartum haemorrhage Premature rupture of membranes Care of the client with a cord prolapse Patient care in the pre-labour area Patient care in the delivery room Patient care in post-labour Maintenance of equipment/instruments/ infrastructure Requisition/condemning of instruments (new/ replacement) Waste disposal Hand washing and scrubbing Support for the family who has experienced the death of the baby Shaving and part preparation Skin preparation Checking anaesthetic apparatus Managing patients who are infected with HIV, Hepatitis B, and Hepatitis C Precaution for the surgical team Procurement and maintenance of linen Cleaning and disinfection of OT Cleaning of used instruments Maintenance of lap – instruments Disposal of the foetus or amputated body parts

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

::::::-

:-

:::-

::::-

::::::-

17.2 Standard Operating Procedures (SOPs)

547

Table 17.7 (continued)

Activity Use of implantable prostheses and medical devices Work instruction for the scrub nurse Work instruction for circulating nurse Work instruction for recovery nurse Work instruction for operation theatre Fumigation Emergency expiry medicine checklist High-risk medicine checklist Forms and formats Delivery register Antenatal care card Initial assessment by the nurse Treatment sheet Incidence report CPR Turnaround time of initial assessment Register Live saving medicine checklist Adverse drug reaction register Urinary tract infection (UTI) register Blood stream infection register Non-consumable stock register Consumable stock register PAC and delivery notes Anaesthesia record/notes Delivery room charge slip

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:::::::-

:::::::-

:::::::::(continued)

548

17  Policies and Standard Operating Procedures (SOP)

Table 17.7 (continued)

Activity Delivery room drug charge slip Blood requisition form Adverse anaesthesia event register Fumigation register Medicine/consumables requisition form Delivery note Post-labour checklist Post-labour order form Pre-anaesthesia check form Pre-labour re-evaluation Post-labour room record Surgical safety checklist Reports Daily vaginal deliveries Daily caesarean section deliveries Consumption of drugs and consumables Death in the delivery suite Indicators of sterilized instruments and linen Collection of charges from delivery Stock statement of equipment, instruments, and tools in the delivery suite Stock statement of drugs, medicines, and consumables in the delivery suite Fumigation report and record of the delivery suite

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::::::::::::::::::-

:-

:-

17.2 Standard Operating Procedures (SOPs)

549

equipment/gadgets are available; required facilities are available; patient/staff/visitors safety mechanisms are available; proper lighting is ensured; proper environmental control with heating and air-conditioning is available; security devices and mechanisms are provided; announcement systems are in place; wall, ceiling, and interior decoration are up to mark and appealing, etc. This set of checklists shall help the planner and designer to remember all such issues relating to the Delivery Suite and guide him/her to complete, test, and commission all works/activities well in time. This will help him/her to ensure himself/ herself that all the works/activities are carried out, completed, and working before the deliveries start in the delivery suite.

17.2.7 Imaging Department Services See Table 17.8. The department of Radiology is responsible for using medical imaging to diagnose and treat illnesses. Imaging modalities can be based on a variety of imaging techniques. X-rays, ultrasound waves, magnetic fields, and nuclear medicine are the main techniques. X-ray radiography, ultrasound equipment, computed tomography (CT), magnetic resonance imaging (MRI), mammography imaging, nuclear positron emission computed tomography (PET-CT), nuclear positron emission magnetic resonance imaging (PET-MRI), SPECT-CT, cyclotron/radio pharmacy, densitometer, bone scan, and digital subtraction angiography (DSA), among other imaging modalities, are examples of various imaging devices. Diagnostic vs. Therapeutic: Diagnostic radiology is a science that uses a variety of imaging techniques to diagnose diseases, leaving doctors to manage the actual treatment. In this case, diagnostic imaging aids doctors in correctly diagnosing an illness. On the other hand, therapeutic radiology includes both diagnosis and treatment, such as peripheral shunting. Therapeutic radiology, including interventional radiology, enables the performing of (usually minimally invasive) medical procedures under the guidance of imaging technologies. It is important to highlight that the department of radio diagnosis is at the correct location in the hospital premises, shall have sufficient resources to ensure radiation exposure protection, and shall not obstruct the operation of other departments. Radiology is the department that uses various types of imaging techniques based on which imaging modalities are worked out. These techniques are like X-ray, ultrasound waves, magnetic fields, and nuclear medicine. Imaging modalities based on these above four techniques are: • • • •

X-ray Radiography Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Ultrasound Machines

550

17  Policies and Standard Operating Procedures (SOP)

Table 17.8  SOP of imaging department services

Activity Services and functions of the imaging department Performing X-ray Performing special X-ray investigations like barium studies Performing USG/ Doppler Performing CT scan Performing MRI scan Performing mammography Performing interventions Preparing patient before the investigation Providing the report of investigation Roles and responsibilities of staff Roles and responsibilities of radiologists Roles and responsibilities of the radiographer Roles and responsibilities of technical staff Roles and responsibilities of nursing staff Roles and responsibilities of ancillary staff Roles and responsibilities of data entry operator Standard operating procedures for Patient preparation

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

::-

:::::::-

:-

:-

:-

:-

:-

:-

:-

17.2 Standard Operating Procedures (SOPs)

551

Table 17.8 (continued)

Activity Pre-entry safety check/ risk assessment Performing procedure Patient information Appropriateness/ justification Patient workflow protocol Drugs and medication Consumables and non-consumable materials requirement Inventory of all accessory and ancillary equipment Calibration of equipment Repair and maintenance of equipment Cleaning of equipment Statutory signages Statutory compliances Forms and formats Stock register Equipment logbook X-ray envelope X-ray requisition slip X-ray record register Ct record register Equipment logbook Request forms Consent forms Reporting formats MRI record register Mammography record register MLC record register MLC film storage Turnaround follow-up record imaging

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::::::-

:-

::-

::::::::::::::::::(continued)

552

17  Policies and Standard Operating Procedures (SOP)

Table 17.8 (continued)

Activity No report error, safety precautions and report corelation with the diagnosis Critical values intimation imaging Reports History sheet of equipment with details regarding purchase, operation, functionality, maintenance, and breakdown Machinery breakdown period Periodic maintenance (preventive) and periodic calibration and QA Leave records Monitoring records Material and consumable records

• • • • • • •

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:-

::-

:::-

Mammography Imaging Nuclear Positron Emission Computed Tomography (PET-CT) Nuclear Positron Emission Magnetic Resonance Imaging (PET-MRI) SPECT-CT Cyclotron/Radio Pharmacy Densitometer, Bone Digital Subtraction Angiography (DSA)

17.2.8 Clinical Laboratory Services See Table 17.9. Clinical laboratory tests are conducted on clinical specimens in a “clinical laboratory” to learn more about a patient’s health and to help with illness diagnosis, treatment, and prevention. The timeliness and correctness of the pathological investigation report heavily influence the hospital’s efficiency. One of the hospital’s primary investigative

17.2 Standard Operating Procedures (SOPs)

553

Table 17.9  SOP of clinical laboratory services

Activity Services and functions of clinical laboratory Collection of the sample to be processed in the laboratory Pre-testing preparation of the samples Providing diagnostic and management information to the physicians Carry-out the investigations asked and the prompt issue of inaccurate results Collection, handling, and processing of the specimen before analysis Validity of data obtained on the specimen itself Calibration of the laboratory equipment Carry-out the environmental cultures inside the hospital to curtail the infection rate in the hospital Roles and responsibilities of laboratory staff Roles and responsibilities of Head of Pathology Roles and responsibilities of Biochemist Roles and responsibilities of Microbiologist Roles and responsibilities of Laboratory Technician

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:-

::-

:-

:-

:-

::-

:-

:-

:-

:-

(continued)

554

17  Policies and Standard Operating Procedures (SOP)

Table 17.9 (continued)

Activity Roles and responsibilities of Phlebotomists Standard operating procedures Collection and handling of blood samples Collection and handling of urine samples, stool samples, or semen samples Handling of blood samples for haematology-related tests and procedures Handling of blood samples for biochemistry and immunochemistry Collection and handling of samples in the cytology section Quality assurance Laboratory safety Forms and formats Investigations requisition slip Sample receipt register Report and lab record Calibration register with reports Stock register of non-consumables and consumables Report delivery register Logbook for each machinery/equipment Individual bench register, e.g. ESR Quality control register EQAS register

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:-

:-

:-

:-

:::::::-

:::::-

17.2 Standard Operating Procedures (SOPs)

555

Table 17.9 (continued)

Activity Complaint register Critical value register Reports Daily collection of samples Daily number of tests performed The daily repetition of tests Samples wasted daily Wrong sample or inadequate sample received daily Daily reagent or cards consumption report Daily incident report

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::::::-

::-

services is the clinical laboratory, which should give the clinical services its wholehearted support. It is also known as the “LAB” in hospitals. The laboratory offers the tools necessary to use scientific methods in the diagnosis, treatment, and investigation of clinical phenomena related to a disease. To ensure that this department is being utilized to its fullest potential, it should be carefully planned and managed. Pathology laboratory tests are invaluable for confirming and enhancing clinical findings, but a laboratory diagnosis which only addresses a few bodily processes must never take the place of a clinical diagnosis based on an evaluation of the patient as a whole. Broadly, the laboratories are divided into three main branches, i.e., Pathology, Biochemistry, and Microbiology. Further, all these three branches are divided into different sub-branches. General pathology is performed by specialists in the field and focuses on analyzing known clinical abnormalities that are precursors or markers for both infectious and noninfectious diseases. Clinical pathology and anatomical pathology are the two main specializations. There are other specializations based on sample types (such as cytopathology, histopathology, and hematopathology), organs (such as renal pathology), physiological systems (such as oral pathology), and examination focus (such as forensic pathology). Promoters are responsible for determining which pathology branches and sub-­ branches need to be provided at the hospital and how much space is needed for each. The study of chemical reactions that take place inside and around living things is known as biochemistry. The sciences of structural biology, enzymology, and

556

17  Policies and Standard Operating Procedures (SOP)

metabolism might be considered subfields of biochemistry, a branch of both chemistry and biology. Biochemistry has excelled in explaining life processes through these three disciplines over the past few decades of the twentieth century. Biochemical methods and research are revealing and developing almost all aspects of the biological sciences. Understanding the chemical basis of biological molecules and the interactions between and within live cells is the focus of biochemistry. There are many sub-branches of biochemistry, and it is up to the promoters to select which branches and sub-branches should be provided at the hospital and how much space should be allocated as a result. Bacteriology (the study of bacteria), phycology (the study of algae), mycology (the study of fungi), virology (the study of viruses, and how they function inside cells), and parasitology (the study of parasites) are some of the sub-disciplines that make up the field of microbiology. In addition to these main branches, microbiology has numerous sub-branches. It is up to the promoters to select which microbiology branches and sub-branches should be offered in the hospital and how much room will be needed for each.

17.2.9 Blood Bank Services See Table 17.10. A blood bank is a facility that collects and tests donated blood, separates it into components, stores it, and prepares it for transfusion to recipients. Because the Blood Bank is a regulated department in the hospital, it is recommended that the rules, regulations, norms, and guidelines of the controlling authority of the respective country shall be considered before planning and designing the blood bank. Blood banks have four major functions area Receiving: The blood bank's receiving section is used to collect blood from donors and to give them facilities for recovering after bleeding Storage: The storage area is used for storing untested blood, tested blood, and blood components. Testing: A testing area is set aside for screening the blood donated for ruling out the presence of infectious diseases in the blood. Distribution: This area is designated to distribute the tested blood to the patients for transfusion. The testing area of the blood bank is designated for the testing of donated blood. There are two sections of the laboratory. One is the Serology Lab which is a division for blood group serology, and the second is the TT Lab for testing blood for hepatitis B antigens, HIV antibodies, etc. Storing area of the blood bank is used for storing the blood that has still to be screened. Also, the post-screened blood is stored in these areas. If the blood that has to be stored is excessively high, the option of chilled rooms shall be considered.

17.2 Standard Operating Procedures (SOPs)

557

Table 17.10  SOP of blood bank services

Activity Services offered by the Department Registration of the donor Medical examination of the donor Bleeding the donor and receiving a whole blood unit Storage of the untested blood Recovery and refreshment of the donor Screening the donated blood in the TT lab Screening the donated blood in the serology lab Storage of the tested and approved blood units Condemnation of the infected blood units Cross-match the donor and recipient's blood Issue and distribution of the blood units Preparing the components of blood from the tested blood units Storage of the components Issue of components to the recipient Maintaining the records of the blood bank according to the norms, rules, and regulations of the respective country Performing the apheresis

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:::-

::-

::-

:-

::::-

:::-

:(continued)

558

17  Policies and Standard Operating Procedures (SOP)

Table 17.10 (continued)

Activity Issue of the component produced by apheresis Roles and responsibilities of blood bank staff Roles and responsibilities of blood bank in-charge Roles and responsibilities of blood bank technician Roles and responsibilities of blood bank medical officer Standard operating procedures on Donor issues Component separation Serology laboratory Transfusion transmissible infections Labelling, preservation, and storage of blood components Quality assurance Forms and formats Donor card Donor register Record register – blood component Record register – outside blood Laboratory tests on the donor's blood Blood requisition form Laboratory tests on the recipient's blood Compatibility record Issue register

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:-

:-

::::-

:-

::::::::::-

17.2 Standard Operating Procedures (SOPs)

559

Table 17.10 (continued)

Activity Adverse reaction report registers Quality assurance records Daily assessment register Blood bank register Blood cross-matching report Blood requisition form Blood return form Blood component register Apheresis records Records of blood and components received from an outside source Record of recipient Compliance – local govt. grant of license application Compliance – renewal of the license to operate a blood bank for the preparation for the sale or distribution of its components Compliance – certificate of renewal of license for manufacture of blood products Certificate of approval to storage centre for storage of whole human blood or its components Reports Total blood units received Total blood units issued The number of components units prepared

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::::::::::-

::-

:-

:-

:-

:::-

(continued)

560

17  Policies and Standard Operating Procedures (SOP)

Table 17.10 (continued)

Activity Total number of component units issued Temperature charts Adverse reaction report Total infected blood units detected Total blood units condemned

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::::-

Otherwise, the blood can be stored in specially designed blood bank refrigerators. In this area, the blood is also processed to separate the component of the blood.

17.2.10 Nursing Services See Table 17.11. Nursing care is extremely important for good patient outcomes. While the doctor plans the treatment and carries out some of the procedures, it is the nurse who implements most of the management of the patient. Whereas the doctor sees the patient for a short time, the nurse is with him/her for most of the time looking after and caring for. The treatment of the patient or the name of the hospital depends upon the quality of the nursing care provided. A very important factor in the care of the patient is the close cooperation between the doctor and the nurse. Much depends on how his orders are carried out and on the nursing care rendered to the patient. As a result of the development of nursing, it has become a highly complex function that demands much training and skill. While planning the type of organization of nursing, the purpose of nursing is to be kept in mind. The primary purpose of a department of nursing is to provide safe, effective, and well-planned nursing care for patients. The organization of the nursing department of the hospital will depend upon several factors, i.e. the size of the hospital, the type of the hospital, whether the student nurses are taken, and whether the purpose is to have the school of nursing or not, etc. The motive of every hospital should be to provide the best medical care to the patient. In doing so, the major responsibility should be placed on the nursing department, which bears a constant and intimate relationship to the patient throughout the entire period of his stay in the hospital. The requirements for efficient nursing care are essential. They comprise the following four factors:

17.2 Standard Operating Procedures (SOPs)

561

Table 17.11  SOP of nursing services

Activity Services and functions of nursing Admission of patient Discharge of patient Room preparation after death/discharge Nursing care of the patient Intradepartment transfer Medicine/drugs procedure Arranging of blood Investigations Pre-operative care of the patient Post-operative care of patient Patient care in special wards like ICU, NICU, etc. Inventory control Roles and responsibilities of nursing staff Roles and responsibilities of nursing supervisor Roles and responsibilities of ward in-charge/sister Roles and responsibilities of staff nurse: general Roles and responsibilities of staff nurse: technical Roles and responsibilities of staff nurse: ICU patients Roles and responsibilities of sister tutor

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:::::::::::-

:-

:-

:-

:-

:-

:-

:-

(continued)

562

17  Policies and Standard Operating Procedures (SOP)

Table 17.11 (continued)

Activity Standard operating procedures for Grooming standards Hostel rules for nurses Routine medication Parental therapy Investigation of IPD patients The intervention of IPD patient Specific treatment Observation of symptom Inventory control Forms and formats Nurses – a contractual agreement Nurses – bond Nurses night register Stock register Medicines and consumables stock register Patient case sheet papers Nursing roster format Referral register Emergency medicine register Nurses note Medication chart Vital chart for ICU Reports Record relating to the care and treatment of the patients including the nurse's records Requisitions for the supplies of drugs or services to be furnished by other departments

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

::::::::::::::-

::::::::-

:-

17.2 Standard Operating Procedures (SOPs)

563

Table 17.11 (continued)

Activity Special permission for surgical operation Unit patient census Day and night reports on the condition of patients Notification of seriously ill patients Emergency operations and death Time schedule Work assignment Personal evaluation records for nurses Other records necessary for planning and carrying-out the nursing service

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :::-

::::::-

(a) Maintenance of a professional attitude with the patient, with the patient’s friends and towards her profession and progress (b) Administration of specific treatment towards medical, surgical, dietary, and those afforded by the adjunct facility (c) Observation of symptoms (d) Maintenance of good interdepartmental relations

17.2.11 Medico-Legal Services See Table 17.12. The Medico-Legal Cases (MLC) are cases of the nature which attract the law of the country. It may relate to the crime, i.e. Stab or the blunt injury caused by the weapon, traffic, or industrial accidents or attempted suicide, rape, drowning, electric shock, etc. In the case of the MLC, it is the responsibility of the hospital authority to inform the police regarding the details of the case. Except for the legal formalities involved, the procedure for handling the patient is the same as in the case of non-­ MLC. In the case of MLC, care should be taken that no record is directly given to the police except with the written permission. The procedure in the case of the MLC is as follows: As soon as the patient is received in the emergency, first of all, it should be seen if the patient is of MLC nature. If the patient is of MLC nature, the police

564

17  Policies and Standard Operating Procedures (SOP)

Table 17.12  SOP of medico-legal services

Activity Services and functions of delivery room Receiving medicolegal cases (MLC) Information to the police Filling up the MLC report Filling up the injury report Treatment of the MLC patient Preparing the body for postmortem Preservation and safe custody of the evidence material such as cloths, bullets, knives, vaginal swabs, etc. Roles and responsibilities of delivery room staff Roles and responsibilities of emergency medical officer Roles and responsibilities of paramedical staff Roles and responsibilities of nursing staff Standard operating procedures for Receiving MLC patient Documentation of case Information to the police Attending the courts when summoned

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:::::::-

:-

:-

:-

::::-

17.2 Standard Operating Procedures (SOPs)

565

Table 17.12 (continued)

Activity Documents to be handed over to the patient or attendants Preparing for postmortem Forms and formats Patients register Patient’s case record Medico-legal registers Injury reports Police information book Wound certificate register Brought in dead register Casualty incidental report book Reports Total MLC received Death of MLC patient Type of MLC cases

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

::::::::-

:::-

information should be filled up and the copy should be sent to the nearest police station under the acknowledgement. The Emergency Medical Officer (EMO) should take into custody the clothes of the MLC involved in rape, stab injury, bullet injury, etc. The EMO must sign the corresponding cut on the clothes. Then, these clothes should be packed in a parcel, sealed, and sent to the police. At the same time, the injury report should be filled up in duplicate and copy be kept with the hospital and the original be handed over to the police department as and when demanded by them. While filling up the injury report, care should be taken to mention the details in full as to the nature of the injury, the size of the injury, the person who brought the patient, the initial findings as to the blood pressure, the pulse and the general condition of the patient, the mark of the identification, the thumb impression of the patient (LTI in case of the male patient and the RTI in the case of the female patients), time at which the patient was received, the address of the patient, etc. Also at the time of filling up the injury report, the injury details should be filled up in the injury identification form. While getting the registration of the MLC, the seal in a red colour stating “MLC” should be stamped on every document as a symbol that the patient is an MLC and no document should be given to the patient or the attendant thereof except with the written permission of the police.

566

17  Policies and Standard Operating Procedures (SOP)

In case the MLC patient expires, the body of the patient should be sent to the mortuary for the postmortem and should not be handed over to the relatives of the deceased. The body in such a case has to be handed over to the police and with the written permission of the police or the court of law, the body can be handed over to the relatives of the deceased.

17.2.12 Accounts/Financial Management See Table 17.13. In a hospital, accounting means maintenance of the records of the amounts of money received and spent, amount collectable and payable, borrowed, and lent. Preparation and presentation of the results of the income and expenditure of a particular period by preparing the Profit and Loss or Income and Expenditure Account. Calculating the position of the assets and liabilities on a particular date by preparing the Balance Sheet. At times prepare the Funds Flow Statement for analysing the movement of the funds collected. These statements are prepared for the owners, trustees, and shareholders of the hospital and various Government departments and lending institutions. The records under financial accounting are maintained in a format prescribed by the statutory authority, say income tax department, or the professional bodies. The role of financial accounting starts right from the billing and ends with the preparation of the Balance Sheet. Management Accounting also a part of accounting can be defined as the process of identification, measurement, accumulation, analysis, and communication of information regarding the operations. The main purpose of this accounting is to provide the management with the required information to ensure a more effective discharge of their duties and responsibilities. It helps the management to plan for the long-term and the short-term planning, enforcing indirect financial discipline over its operation, advising for making decisions when faced with alternatives which have financial implications and of course the formulation of the policies of the hospital. Management accounting includes the preparation of the Budget based on the forecasting of the income and the expenditure, etc. and the comparison of the actual transaction with the budget figures and reasoning for the difference. It also includes the Costing for determining the actual cost of the product and services and to calculate the cost of operating various centres, which in turn helps in the preparation of the charge list of the hospital. The term management accounting also includes the Management Information System (MIS) to provide information on the activities of the hospital in terms of figures and the analysis of the data. The information for management accounting is mainly derived from financial accounting and supporting records. This information is then analyzed to reach a particular conclusion. The information not only includes the financial figures but also quantitative data such as the number of beds, the employees working, the number of laboratory tests done, the number of the X-rays

17.2 Standard Operating Procedures (SOPs)

567

Table 17.13  SOP of accounts/financial management

Activity Services offered by the department Billing for OPD registration Billing for OPD procedures Billing for IPD patients Cash collection Cash disbursement Maintenance of all the accounts of the hospital Maintain daybook Maintain all the required books of accounts such as Cashbook, Bankbook, Main ledger, Sub-­ ledgers, Purchase registers, etc. Prepare reconciliations Drawing and depositing money from/in the bank Finalization of the accounts and preparing the Balance sheet and the profit and loss account, etc Adherence to Income Tax, Service Tax, VAT, PF, or any other Act applicable in the country Arrange for the periodic internal audit and the external audit Payroll preparation Money and valuables deposited by patients for safe custody Passing all the invoices and bills of purchases Payments to the parties and creditors

Status of Works Start End Not Responsible date date Complete In-progress started person Remarks

::::::::-

:::-

:-

:-

::-

::(continued)

568

17  Policies and Standard Operating Procedures (SOP)

Table 17.13 (continued)

Activity Budgeting Comparison of budgets vs actual performance Vendor/distributor record keeping Vendor management and coordination Roles and responsibilities of accounting staff Roles and responsibilities of accounts manager Roles and responsibilities of finance manager Roles and responsibilities of accounts officer Roles and responsibilities of cashier Roles and responsibilities of billing clerks Standard operating procedures General billing guidelines Gratuity computing Billing for patients Cash management Concession policy for the underprivileged Accounting standards Internal audits Bill/invoice passing procedures Tracking credit card and online payments Annual budgeting Collection policies Forms and formats

Status of Works Start End Not Responsible date date Complete In-progress started person Remarks ::::-

:-

:-

:-

:-

:-

:::::::::::-

17.2 Standard Operating Procedures (SOPs)

569

Table 17.13 (continued)

Activity Cash/bank/journal voucher formats Receipt book Clearance form The full and final settlement I owe you Indent for cash Local conveyance bill Overtime sheet TA bills format Salary slip formats Daily wages payment format OPD billing format Indoor bill Subsidy application Cheque records register Reports P & L Statement Bank accounts book Sundry debtors report Doctor's professional income calculation sheet Running regular financial reports Invoice review and processing

Status of Works Start End Not Responsible date date Complete In-progress started person Remarks :::::::::::::::::::-

::-

done, the area of the hospital premises, the occupancy of the beds, the number of patients in the OPD, etc. The term management accounting also includes Pricing, which means the structuring of the rates to be charged to the patient for the service provided. The pricing also helps the management to take decisions as how much discounts can be given to the poor patient and also to decide how many patients can be treated for free. Before the capital investment in the equipment or the building, the management has to decide the cost of the equipment or the building and the feasibility of the purchase of the same. The Capital Expenditure Appraisal Technique is the answer for the same.

570

17  Policies and Standard Operating Procedures (SOP)

17.2.13 Human Resources Department See Table 17.14. The organization of the hospitals helps in delivering the optimal and the best service to the patients and thus fulfils the aims of the institution. To achieve this objective, control and coordination of hospital services are essential. In turn, better Table 17.14  SOP of human resource department

Activity Services offered by the HR department Annual performance review Attendance tracking Disciplinary proceedings Employee benefits Employee hiring process Employee on-board orientation Employee personal file Employee suggestion scheme ESI management Leave management New employee orientation Salary processing and disbursement Time sheet submission and approval process Provident fund management Orientation and induction Probation, confirmation, and termination Manpower planning Leaves management Training, development, and motivation Working conditions

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:::::::::::::-

:::-

:::-

:-

17.2 Standard Operating Procedures (SOPs)

571

Table 17.14 (continued)

Activity Employee benefits and welfare Performance assessment, carrier progression Preparing the organization chart Separation, retirement, resignation, and death Design of job descriptions and job specification for all categories of employees Formation of various committees Roles and responsibilities of HR staff Roles of responsibilities of the HR manager Roles of responsibilities of HR personnel Roles of responsibilities of the trainer Roles of responsibilities of general duty clerks Standard operating procedures Grooming standards Health and safety Honesty, integrity, and teamwork Interaction with patients, doctors, and management IT, E-mail, and social media policy Organization code of conduct

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::-

::-

:-

:-

:-

:-

:-

:-

::::-

::(continued)

572

17  Policies and Standard Operating Procedures (SOP)

Table 17.14 (continued)

Activity Outsourcing process Performance appraisal, increment, and promotion Procedure for lay-offs and downsizing Transfer policy Travel policies Recruitment policy Training and development policy for staff Disciplinary procedure Time office guidelines Grievance handling All the HR policies Forms and formats Annual health check-ups for employees Grievance form Job description and job specification Performance appraisal form Personal file checklist Vaccination record Manpower requisition form Reports List of employees Salary and payroll statements Attendance sheets Overtime sheets Leave records Employees' health check-up report Training schedules Welfare schedules Provident fund statements ESI statements

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::-

:::::-

:::::-

::::::-

::::::::::-

17.2 Standard Operating Procedures (SOPs)

573

control and coordination will depend on a suitable organizational structure and adequate supervision. Activities to be performed and personnel needed shall be grouped in such a way as to achieve smooth functioning. An organization chart is a working tool for the orderly arrangement of work and people. Through its design, it shall indicate the grouping of persons concerning one another and bring out the lines of authority. The chart shall fit the individual hospital. While human elements shall be taken into consideration, adjustments on this basis shall not violate the basic principles underlying lines of authority. The medical staff is the chief agency through which the hospital achieves its prime objective, which is the proper care of patients who are sick or injured. Here, the doctor is the decision-maker on the major part of treatment whether as an outpatient or inpatient. Hence, the proper choice and retention of doctors are extremely important for the smooth and competent functioning of the hospital. The management philosophy of the hospital administrator will determine the philosophy of personnel management in each department and the relationship among the department heads. In most hospitals, patient care is the main objective. There can be other objectives in the hospital, which depend upon the size and the scope of the hospital, e.g. the training programme, the education programme, community health, the research activities, etc. Human endeavour in this twentieth century has become so complex that the administration of any activity offers problems unknown in the simple enterprises of an earlier civilization. Any organization provides for a combined effort of men and materials and efforts made to prevent negligence of any duty or duplication of work, and thus to produce the required results. All this can be efficiently achieved with the help of the predefined and designed ORGANIZATIONAL CHART, where all the duties and responsibilities of the individual are predefined and elaborated. The Governing Body shall release that the medical staff of the hospital must be appointed with utmost care and only capable staff to be appointed so that the maximum care can be provided to the sick patient. While preparing the organizational chart, it shall be made clear that all the duties are defined and there shall be no overlapping of duties, i.e. every individual shall have a predefined set of duties. Waste of effort and extravagance in the use of men and materials prevent the economy. In the organizational chart, the authority shall be centralized, responsibilities fixed, and duties and interrelationships clearly defined. First of all, department-wise and category-wise staff requirements shall be worked out based on factors like the number of beds, clinical departments, services provided, the number of patients, duty hours, and availability of staff. As a guide in selecting the Medical Staff and as a safeguard for preventing the appointment of those who are not desirable, certain minimum qualifications shall be adopted and rigidly enforced. The working of present days of most organizations is through committees. If carried out properly, it can be of great help. It brings out the combined wisdom of knowledge of the people who discuss matters concerning the organization. The committee views the problem from various angles and finally, a consensus emerges

574

17  Policies and Standard Operating Procedures (SOP)

which is, hopefully, the best alternative. The committees elected from the staff appointed by the Governing Body may perform much of the work of the hospital. These committees are, normally, of two types (a) Standing committees and (b) Special committees. A good hospital runs just like a well-lubricated machine. Excellent and safe patient care can be achieved if all the pieces and processes work together. This result can only be achieved if the hospital has all of those systems, manpower, and processes in place. Staff members shall be made very clear as to what they have to do and what is expected from them. It is equally important that the staff shall be given an effective set of rules, regulations, and procedures which shall guide them in their day-to-day tasks. In a hospital where the staff diverts from the defined, rules, regulations, procedures, and standards, it can be detrimental to the hospital. Inconsistency can deteriorate the quality of patient care and could be detrimental to the patient and can spoil the reputation of the hospital. This is the reason why the set of rules, regulations, systems, policies, and procedures is important for hospitals. Therefore, there is a strong need to develop a good and time-tested set of rules, regulation, systems, policies, and procedures policies, to ease the staff to function effectively and efficiently and ensures the safety of the patients and staff. Hospital policies and procedures guide day-to-day operations and make sure that everything is running as it was expected. The policies and procedures define the expectations and standards of staff, set guidelines for operations and improvements, and streamline processes. To summarize we can say that the main purpose of having these policies and procedures is to establish a high degree of understanding, efficiency, cooperation, and unity among the employees of the hospital. It also helps to provide uniform policies for all employees of the hospital, so that there are no discrepancies.

17.2.14 Central Sterile Supply Department (CSSD) See Table 17.15. In any hospital, the importance of sterilization cannot be overemphasized. Sterilization is a process that removes microorganisms from hospital instruments, linen, operating rooms, and other areas, ensuring infection prevention in the hospital. The sterilization process kills all microorganisms, whether they are disease-­ producing or not. As a result, proper sterilization procedures shall be followed. The Central Sterile Services Department (CSSD) in hospitals is a centralized location that sterilizes medical devices, instruments, linen, and consumables. This is a department that assists other hospital departments. This department’s primary functions include cleaning, preparing, disinfecting, packing, and sterilising reusable medical devices, linen, and surgical instruments. The goal of the CSSD is to prepare and furnish other departments with sterile equipment and supplies needed in the patient's care in OR, ICU, dialysis, all wards,

17.2 Standard Operating Procedures (SOPs)

575

Table 17.15  SOP of central sterile supply department (CSSD)

Activity Services and functions of CSSD Supply of sterile instruments Supply of sterile equipment Supply of sterile accessories Supply of sterile linens Supply of sterile draping Dressing materials for procedures carried-out in the hospital Washing and cleaning of instruments Disinfection and sterilization of medical equipment like ventilators, oxygen face masks, and oxygen tents baby incubator’s part, endoscopes Selection and supply of single (disposable) sterile supplies like catheters, suction tubing, syringes glass slides, vials, etc. Roles and responsibilities of CSSD staff Roles and responsibilities of CSSD in-charge Roles and responsibilities of CSSD Technician Standard operating procedures Decontamination Washing and cleaning of the instrument used in OT

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

::::::-

::-

:-

:-

:-

::-

(continued)

576

17  Policies and Standard Operating Procedures (SOP)

Table 17.15 (continued)

Activity Disinfection of instruments Assembling and packing of instruments and textile Steam sterilizer process Ethylene oxide gas sterilization Handling of sterilized items Cleaning of sterilizers Storage of Sterile items Personal hygiene for personnel performing sterilization processes Fumigation schedule Swab culture schedule Forms and formats Register for material received and delivered Stock register of equipment and furnishings Stock register of consumables Logbook/card of each machine Record register for each cycle of autoclaving Working register Indicators register Reports Autoclave master register ETO master register

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::-

::::::-

::::-

:::-

:-

::-

17.2 Standard Operating Procedures (SOPs)

577

and all departments; provide supplies of sterile instruments, linen packs, and other items used in patient care; establish and follow protocols for effective, sterilization process, and maintain records; monitor and ensure controls necessary to prevent cross infection according to infection control policy; and maintain supplies and instruments inventory. The sterilization process can be broadly divided into the following categories: 1. Before preparing for sterilization, cleaning the instruments and the linen 2. Packing for sterilization 3. Sterilization 4. Storage after sterilization 5. Distribution of sterilized material to the end users Typically, the CSSD sterilizes the items like surgical instruments, the linen of O.T and emergency, disposables, dressing drums, ward linen, etc.

17.2.15 Dietetic Services See Table 17.16. Cooking and serving healthy meals to patients is the responsibility of kitchen services, a crucial hospital support service. The kitchen may also provide food to hospital workers and guests, depending on hospital policy. The food service may also involve catering for events and meetings such as board meetings, seminars, conferences, and special occasions. Patients of all ages, from all religious, ethnic, and social backgrounds, as well as those who are nutritionally susceptible due to sickness, shall be able to recognize, enjoy, and enjoy the food. The hospital kitchen shall be configured and furnished to accommodate a variety of dietary requirements. The kitchen must be able to provide all prescribed diets because hospital patients are given diets based on their diseases.

17.2.16 Laundry and Linen Services See Table 17.17. The laundry service is to ensure that all users have an adequate supply of clean, sterile, and consistent linen. Their primary responsibilities include sorting, washing, extracting, drying, ironing, folding, mending, and delivering. This department's primary goal is to provide clean materials to patients while also maintaining hygiene throughout the process. In hospitals, laundry can be set up in three ways: To begin, the hospital can buy laundry equipment and hire employees to run the laundry on hospital grounds. Second, the hospital can provide laundry space and hire a contractor to set it up and

578

17  Policies and Standard Operating Procedures (SOP)

Table 17.16  SOP of dietetic services

Activity Services and functions of the dietary department Assessment of the nutritional status of admitted patients Reassessment of patients Patient’s satisfaction Diet counselling Preparation of diet sheet Quality assurance of dietary services Ensuring food safety and hygiene Ensuring personal hygiene in dietary services Patient complaint handling Roles and responsibilities of dietary staff Roles and responsibilities of dietician Roles and responsibilities of the in-charge dietary department Roles and responsibilities of cooks Roles and responsibilities of bearers Standard operating procedures for

Status of works Start End Not Responsible date date Complete In-progress started person

:-

:::::::-

:-

:-

:-

:-

:-

Remarks

17.2 Standard Operating Procedures (SOPs)

579

Table 17.16 (continued)

Activity General procedures and policies Procedure for canteen operations Nutritional assessment of critical patient Nutritional assessment of normal patient Preparation of diet sheet Ensuring food safety and hygiene Ensuring personal hygiene in dietary services Patients’ complaint handling Forms and formats Patient's inquiry proforma Diet requisition form Format for agreement, if outsourced Reports Daily patient food test record Daily food orders by dieticians Daily patient feedback Weekly kitchen round checklist Nutrition assessment form

Status of works Start End Not Responsible date date Complete In-progress started person :::-

:-

:::-

:-

:::-

:::::-

Remarks

580

17  Policies and Standard Operating Procedures (SOP)

Table 17.17  SOP of laundry and linen services

Activity Services offered by the laundry An adequate supply of linen to user departments Provide linen free of dirt and stains to all user departments Steps for prevention of cross-infection Monitor and enforce controls necessary to prevent spoilage Receipt of soiled or dirty linen from the hospital Cleaning and disinfection of received linen Washing, drying, and ironing the linen Inspection and assembly Clean linen storage Distribution to the user departments Mending the torn-out linen Roles and responsibilities of laundry staff Roles and responsibilities of laundry in-charge Roles and responsibilities of the washer man Roles and responsibilities of general duty clerks Roles and responsibilities of housekeeping Roles and responsibilities of tailor

Status of works Start End Not Responsible date date Complete In-progress started person

:-

:-

::-

:-

:-

:::::-

:-

:-

:-

:-

:-

Remarks

17.2 Standard Operating Procedures (SOPs)

581

Table 17.17 (continued)

Activity Standard operating procedures Assessing missing and torn linen Segregation of linen Collection of linen and internal transportation of linen Washing of linen Drying and extracting Mending of linen Ironing Distribution of linen Forms and formats Agreement format for outsourced laundry agency Washerman's book Log card for laundry machines Stock register Daily receipt and dispatch register Stitching and mending record of linen Master stock register Record of dirty linen sent to the laundry Record of clean linen received from laundry Condemned items register Equipment registers Reports Record of the effectiveness of cleaning, disinfection, and turnover

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:::-

::::::-

:::::-

::::::-

(continued)

582

17  Policies and Standard Operating Procedures (SOP)

Table 17.17 (continued)

Activity Daily weight or number of articles received from the departments Daily weight or number of articles washed and sent to the departments Report on torn-out linen Consumption of washing materials like detergents, etc. Linen mended

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

:-

::-

:-

run it. Third, the hospital can hire a local laundry service to transport dirty linen to an off-site/local laundry and return it after washing and processing. During routine hospital operations, soiled linen is generated from various departments such as indoor patient wards/rooms, operation theatre complexes, OPDs, and so on. This soiled linen shall be replaced with washed and sterile linen for the next use. Bedsheets, draw sheets, blankets, towels, patient gowns, pillow covers, doctors' aprons, doctors' OR gowns, theatre drapes, napkins, kitchen cloths, curtains, staff uniforms, screens cloths, and staff aprons are all examples of linen that are commonly used and washed in the hospital laundry.

17.2.17 Medical Records Department (MRD) See Table 17.18. A Medical Record Department (MRD) is responsible for maintaining systematic documentation of a patient's medical history as well as current treatment and care. The medical record serves as a foundation for future patient care planning, documentation of communication between the hospital and any other health professionals involved in patient care, and aids in the protection of both the patient's and the hospital’s legal interests in patient care. Previously, the majority of medical records were stored in hard copies. As a result, a lot of space was needed to keep the hard copies of the records. However, most of the records are now being converted to electronic and digital formats as information technology advances. However, not all records can be kept digitally, and some have to be kept in hard copies. As a result, to effectively preserve medical

17.2 Standard Operating Procedures (SOPs)

583

Table 17.18  SOP of medical records department (MRD)

Activity Services offered by the MRD Build complete, effective, up-to-date, and efficient medical records management Become a centre for providing accurate, fast, efficient, and reliable information Provide quality service in processing medical reports and medical board applications Compilation of the medical record Storage of the medical records Reply and attend the court of law for legal issues Indexing and coding of the medical record Scanning the record to maintain soft copies of records ICD coding Binding of the records Statistical analysis of the records Transcription of the record Condemnation of the old record and disposal Roles and responsibilities of MRD staff Roles and responsibilities of medical record officer Roles and responsibilities of general duty clerk

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:-

:-

:-

:::-

::-

:::::-

:-

:-

(continued)

584

17  Policies and Standard Operating Procedures (SOP)

Table 17.18 (continued)

Activity Roles and responsibilities of binder Roles and responsibilities of medical transcription officer Roles and responsibilities of a statistician Standard operating procedures Storage and retention of medical records/data/ information Record retention policy Maintaining the confidentiality, integrity, and security of the medical records Information from the medical records department Review of medical records Protocol for amendment of medical records Forms and formats Medical records receipt register Birth record register Death record register Report to Municipal Authorities Medical record issue register MRD visitor’s logbook Medical record checklist Reports PNDT report to government authorities TB notification to government authorities

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:-

:-

::-

:-

::-

:::::::-

::-

17.2 Standard Operating Procedures (SOPs)

585

Table 17.18 (continued)

Activity Delivery notification to government authorities Hospital report (which shall include total admissions/discharges/ deaths Total outpatients/ surgeries performed (major/minor)/total births/stillbirths/total imaging/total lab test/ endoscopies/death patterns/occupancy statistics/MTP/ sterilization operation/ NSV operation/ implantation of IUD, and Immunization Daily notification of (Dengue/H1N1/Swine Flu) Weekly communicable disease surveillance report

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::-

:-

:-

:-

records, the MRD shall have an excellent information technology infrastructure in place. Electronic Medical Records (EMRs): It is a computerized recording system that tracks and records data about hospitalized patients and their care. The EMR also enables authorized clinicians to access patient records at any time and from any online location for assessments and further treatment of the patient. An EMR system also necessitates the scanning of various paper records, which can come from outside the facility or be brought in by the patient.

17.2.18 Ambulance Services See Table 17.19. Ambulances serve a vital role in hospitals and emergency medical services, enabling patients who require emergency medical care at critical times, allowing them to get to the hospital on time and potentially saving their lives. Non-emergency services include transporting patients from one hospital to another, transferring patients for any scanning or laboratory tests to the appropriate

586

17  Policies and Standard Operating Procedures (SOP)

Table 17.19  SOP of ambulance services

Activity Services offered by the department Transfer of patients from the hospital to other higher centres Transfer of patients from other hospitals to their own hospital Pickup of the patients from the accident site Pickup patients after the disaster Shifting the patient to a ventilator Roles and responsibilities of ambulance staff Roles and responsibilities of driver Roles and responsibilities of ambulance paramedic Roles and responsibilities of transport section Standard operating procedures Ambulance inventory – basic medical items Ambulance inventory – special stretcher trolley Ambulance logbook format Ambulance informing procedures

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

:-

:::-

:-

:-

:-

:-

:-

::-

facilities, and transporting patients with travel limitations to hospitals for treatment in regular vehicles. Emergency ambulance services are often outfitted with proper medical equipment and paramedics. Non-emergency ambulance transport services are sometimes equipped with basic medical devices and paramedics to meet patients' immediate medical needs.

17.2 Standard Operating Procedures (SOPs)

587

17.2.19 Housekeeping Services See Table 17.20. Housekeeping is one of the most fundamental and necessary jobs in a hospital. Housekeeping services are critical to maintaining a safe, clean, pleasant, orderly, Table 17.20  SOP of housekeeping services

Activity Services offered by the housekeeping department Check the cleanliness of the bathroom and toiletries Cleaning of patient care areas/rooms Cleaning doors, door handles, push plates, and touched areas of the frame Clean walls for visible soiling spots Clean light switches and thermostat Clean wall-mounted item Remove fingerprints and soil from glass partitions, glass door panels, mirrors, and windows Check privacy curtains for visible soiling and replace Clean all furnishings and horizontal surfaces in the room including chairs, window sill, telephone, over-bed table, etc. Wipe equipment on walls such as the top of the suction bottle, intercom, and blood pressure manometer as well as IV pole

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:-

::-

::::-

:-

:-

:-

(continued)

588

17  Policies and Standard Operating Procedures (SOP)

Table 17.20 (continued)

Activity Clean bed rails, bed controls, and call bell Clean bathroom/ shower Clean floors Place soiled clothes in designated containers or laundering Remove waste Roles and responsibilities of the housekeeping department Roles and responsibilities of executive housekeeping Roles and responsibilities of a sanitary technician Roles and responsibilities of chief housekeeper Roles and responsibilities of housekeeper Roles and responsibilities of sweeper Standard operating procedures Procedures involved in housekeeping Disinfecting agents preparations and using methods Cleaning protocol for housekeeping for all the departments of the hospital Daily cleaning Daily disinfection Deep cleaning Removal of waste as per waste management rules

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::::-

:-

:-

:-

:-

:-

:-

::-

:-

::::-

17.2 Standard Operating Procedures (SOPs)

589

Table 17.20 (continued)

Activity Forms and formats Agreement – format for outsourced housekeeping services Roster format for the housekeeping staff Department daily cleaning checklist Stock register Reports Daily cleaning report Stock consumption statement

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:::::-

and effective environment for both patients and hospital staff. A clean and sanitary atmosphere has a huge psychological impact on patients and visitors, and it indicates everything about the level of service provided by the hospital. Because it is difficult for lay people to assess the quality of medical care in a hospital, opinions about a hospital are frequently formed based on its appearance and cleanliness. Bacteriological purity, on the other hand, should not be overlooked. Good housekeeping is a valuable asset and a great public relations tool. It has a direct impact on a hospital’s prestige and reputation. Because housekeeping is responsible for all departments and areas of the hospital, minimizing the risk of cross-infection and providing a clean, safe, and comfortable environment are essential components of any good housekeeping service. The housekeeping department is critical to providing quality service and must focus on both bacteriological cleanliness and external cleanliness. The job of the housekeeping department has advanced fast in recent years, necessitating not just technical competence but also an awareness of the “Tools of Management.” Personnel management consumes a substantial portion of the housekeeper's work, as the housekeeper must manage the cleaners, the largest and most demanding type of human resource to manage. The goal should be to establish an efficient department with the lowest feasible operating costs. The housekeeping department should not be thought of in isolation because it is a vital source of information for many other departments. As a result, cooperative and cheerful personnel contribute to the hospital's welcoming and congenial atmosphere. The cleaning department is a service department that does not generate income. A poorly operated department, on the other hand, wastes money and leaves a terrible impression on patients, visitors, and employees, negatively affecting their view of the quality of treatment offered by the hospital. This, in turn, will have a negative

590

17  Policies and Standard Operating Procedures (SOP)

impact on the frequency with which patients visit the hospital, affecting income indirectly. Patients enter the hospital through the reception hall, and after completing the required basic examinations, they are sent to various places within the facility. The patient recognizes numerous features of hygiene and interior design that create a tasteful and pleasant mood in each of these locations. Housekeepers must not only maintain basic cleanliness and hygiene, but also contribute to the smooth operation of many departments such as linen, pest control, trash management, garden care, power, water supply, carpentry, and food delivery.

17.2.20 Physiotherapy and Rehabilitation Services See Table 17.21. Patients who are impaired, disabled, or handicapped can get multidisciplinary rehabilitation services and therapies from the Rehabilitation-Allied Health Unit. The Allied Health Treatments for Rehabilitation include, but are not limited to: 1. Physiotherapy, including (a) Electrotherapy (b) Laser Therapies (c) Manual Therapy (d) Gait Analysis (e) Hydrotherapy (f) Electromyography 2. 3. 4. 5. 6.

Occupational Therapy Audiology Speech Therapy Orthotics Podiatry Both inpatients and outpatients use the services provided by these departments. In addition, long-term patients with a slow rate of recuperation make use of this department's services. The great majority of patients come to this section daily. This department shall provide services to patients both within the department and in the indoor patient wards/rooms. Physiotherapy and its allied services are the most important. As a result, in this chapter, we will go over the Department of Physiotherapy and Occupational Therapy in greater detail.

17.2 Standard Operating Procedures (SOPs)

591

Table 17.21  SOP of physiotherapy and rehabilitation services

Activity Services offered by the department Promote health and provide disability preventive program Planning for physiotherapy treatment Providing rehabilitation treatments Providing occupational therapy Evaluation and planning for functional capacity Exercise training/ demonstration/patient education Constant motivation to change lifestyle Refer to nutritional consultation with Dietician Roles and responsibilities of staff Roles and responsibilities of Physiotherapists Role and responsibilities of occupational therapy Role and responsibility of rehabilitation nursing Standard operating procedures Work instructions and protocol Various treatment SOPs Forms and formats

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

:-

:-

:-

::-

:-

::-

:-

:-

:-

::-

(continued)

592

17  Policies and Standard Operating Procedures (SOP)

Table 17.21 (continued)

Activity Record of treatment Stock register, consumables, and non-consumables Consent form Patient register Reports Daily patient register

Status of works Start End Not Responsible date date Complete In-progress started person

Remarks

::-

:::-

17.2.21 Front Desk Services See Table 17.22. Any hospital is a busy place. To function properly, rigorous administration, scheduling, communication, and dedication are required. The front office personnel is in charge of these details. The front office is the first point of contact for patients during a hospital or medical facility visit, and it is critical to the organization's reputation and financial stability. Hospitals have specific security and operating requirements. Every day, hospital facilities serve hundreds of thousands of patients and visitors. Managing these visitors and patients in the reception area with a paper-based system is a time-consuming and insecure operation. The visitor management system, for example, is one method of managing these guests in the welcome area. For hospitals, the visitor management system makes handling guest check-ins simple and secure. A receptionist is essential in a medical facility because they provide customer service and administrative tasks such as organising appointments, answering patients’ inquiries, answering phone calls, and placing calls to confirm patients’ appointments.

17.2.22 Security Services See Table 17.23. Security service in a hospital is a service responsible for ensuring the security and safety of the hospital plant, personnel, patients and public as well as regulating the traffic within the hospital premises. A hospital is a busy public place where people come to get care, comfort, and cures. Every day, thousands of people visit the hospital. It is quite impossible to spot any antisocial elements in a crowd or predict anyone’s intentions. As a result, unforeseen unfavourable circumstances like disputes, raucous scenes, accidents, or

17.2 Standard Operating Procedures (SOPs)

593

Table 17.22  SOP of front desk services

Activity Services offered by the department Answering visitor queries Registering outpatient department patients Handling EPBAX Fees collection pertaining to registration, fees for various outpatient department investigation/ procedures Advance collection from patients getting admitted Welcoming patients, pharmaceutical representatives, and vendors on the telephone and in-person visitors and answering patient inquires Scheduling appointments for patients Maintaining records and accounts of patients Assisting patients in filling out medical forms Processing different payments for patients Transcribing physician notes Answering multiline phone and transferring calls to direct and departments Maintaining the confidentiality of patient and doctor information

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

::::-

:-

:-

:-

:-

:-

:::-

:-

(continued)

594

17  Policies and Standard Operating Procedures (SOP)

Table 17.22 (continued)

Activity Preparing customer bills and specimen labels for the next day's patient Keeping track of office supplies, inventories, and placing orders as necessary Ensuring maintenance of the reception area Roles and responsibilities of staff Role and responsibilities of a receptionist Role and responsibilities of help desk officer Role and responsibilities of cashier Role and responsibilities of registration clerk Role and responsibilities of admission and discharge clerk Standard operating procedures Receptionist grooming standards Operational SOP for receptionist Operational SOP for help desk Operational SOP for cashier Operational SOP for telephone operator

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:-

:-

:-

:-

:-

:-

:::::-

17.2 Standard Operating Procedures (SOPs)

595

Table 17.22 (continued)

Activity Operational SOP for admission and discharge clerk Forms and formats Attendant pass Appointment card Admission – discharge register Doctor's attendance register Maintenance logbook Dispatch register Daily report Patient suggestion/ feedback letter Reports Daily registrations of patients Daily admission of patients Daily discharge of patients Daily cash collection Daily appointments fixed Dispatch report

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

::::::::-

::::::-

thefts continue to occur in hospitals. In terms of security, the majority of hospitals are regarded as “soft targets.” As a result, they may be more susceptible to specific security threats. Although every staff member is responsible for safety and security, the technical staff, who are busy with patient care, do not have the time or training in these areas. Patients, on the whole, are incapable of protecting themselves or their families. As a result, hospitals must have a separate and specialized department called security service, which is tasked with overseeing the entire hospital organization and preventing anything unpleasant (of a nonmedical, nontechnical type) from occurring. The role of security services is to prevent and address any disruption or breach in security so that the hospital may operate efficiently and without interruption. Their primary responsibilities include the protection of the hospital, its staff and property, the patients/public and their property, traffic control, and the operation of a lost and found service.

596

17  Policies and Standard Operating Procedures (SOP)

Table 17.23  SOP of security services

Activity Services offered by the department Maintaining security in the total hospital Dealing with the fire emergencies To check return inward and outward good material, etc To reduce pilferage inside and outside of hospital premises Crowd management Key maintenance Issue of key for all hospital area Smooth two-wheeler and four-wheeler parking Act as a protection team during disaster and fire management. Meeting all hospital security and protection policies Roles and responsibilities of staff Roles and responsibilities of guards Roles and responsibilities of security officer Roles and responsibilities of hospital fire officer Standard operating procedures Instruction for security personnel Allocation of security in the hospital

Status of works Start End Not Responsible date date Complete In-progress started person

:::-

:-

::::-

:-

:-

:-

:-

:-

::-

Remarks

17.2 Standard Operating Procedures (SOPs)

597

Table 17.23 (continued)

Activity Dealing with fire emergencies Handling of theft case Handling incoming materials Handling outgoing material Crowd management Traffic control in front of the hospital Handling ambulance service Handling parking Internal communication Key management Monitoring the videos captured by CCTV cameras Fire orders and precautions against outbreak of fire Forms and formats Attendant pass Format for security agreement Material inward register Material outward register Gate pass register Vehicle in and out register Key issue and receipt register Reports Daily round report Report of specific incidents Report of accidents

Status of works Start End Not Responsible date date Complete In-progress started person :::::::::::-

:-

:::::::-

:::-

Remarks

598

17  Policies and Standard Operating Procedures (SOP)

Many people enter and exit large hospitals at various times of the day. Threats of violence, theft, and other crimes are real concerns in a hospital setting, and patients are most vulnerable when they are sick and admitted. If security measures are not in place, hospitals might be easy targets for theft of medical equipment or personal belongings of patients and staff members. Other disruptions, such as uninvited guests or inebriated visits, may cause patients unnecessary stress. Hospitals must also protect a large amount of personal information, which should be protected by a security system.

17.2.23 Stores, Purchase, and Materials Management See Table 17.24. Stores are an essential component of any hospital. It is the hub of activity where materials used in the hospital are managed. The store’s primary goals are to ensure (1) the availability of a balanced and timely flow of all materials such as consumables, medical disposables, spare parts and components, tools and equipment, and other general supplies, (2) the receipt, inspection, and issue of the aforementioned supplies/stores to the hospital, and (3) the acceptance, storage, and disposal of scrap and unwanted supplies/stores. Consumable stores, non-consumable stores, general stores, medical and pharmacy stores, equipment stores, surgical stores, stationery stores, linen stores, engineering and maintenance stores, dietary stores, and condemnation stores are the stores that a hospital requires. This set of checklists shall assist the planner and designer in remembering all such issues relating to the design of stores and shall guide him/her in completing all works/activities on time. This shall assist him/her in ensuring that all works/activities are completed. As medical equipment is the most vital component in any hospital. Therefore, it is, important that hospitals efficiently manage their medical equipment to keep their expenditures under control as well as ensure the quality of services delivered by the hospital. The best tool for efficient controlling of medical equipment is “Medical Equipment Management (MEM).” If a proper MEM system is implemented in the hospital, it will assist hospitals in properly developing, monitoring, and managing their equipment, as well as promoting the safe, effective, and economical use and maintenance of equipment. Responsible organizations should set up and review MEM regularly to ensure that a suitable medical device is used following the manufacturer’s instructions, is kept in a safe and reliable condition, and is disposed of properly at the end of its useful life. The total MEM consists of nine different stages, which are as follows: 1. Planning of the medical equipment in terms of requirements and specifications 2. Identification of the vendors

17.2 Standard Operating Procedures (SOPs)

599

Table 17.24  SOP of stores, purchase, and materials management services

Activity Services offered by the department To ensure quality procurement/purchase of non-capital items To ensure quality procurement/purchase and installation of capital equipment and machinery items To ensure timely supply against the requisitions of non-capital items All capital/non-capital items procurement/ purchase activities in the hospital Receiving and checking of non-capital items (consumables, disposables, electrical, and plumbing sanitary items) procurement/ purchase activities in the hospital Receiving requisitions and supply of non-capital items (consumables, disposables, electrical, and plumbing sanitary items) to user depts. in the Hospital Roles and responsibilities of staff Roles and responsibilities of in-charge storekeeper Roles and responsibilities of store assistants

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:-

:-

:-

:-

:-

:-

:-

:-

(continued)

600

17  Policies and Standard Operating Procedures (SOP)

Table 17.24 (continued)

Activity Roles and responsibilities of purchase manager Roles and responsibilities of purchase officer Standard operating procedures Stationery inquiry guidelines Procurement/purchase of non-capital items Procurement/purchase of capital items Receiving and verification of non-capital items Receiving and verification of capital items Receiving requisitions and supply of materials to user departments Evaluation of vendor approval Receipt and handling of indents Price finalization Receipt and handling of quotation Placement of orders Verification of purchased product Forms and formats Demands book Requisition slip Requisition-cum-Issue slip Bin card Log card Gate pass Rate comparison sheet

Status of works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

::::-

:-

:-

::::::-

:::::::-

17.2 Standard Operating Procedures (SOPs)

601

Table 17.24 (continued)

Activity Purchase order Stock register Room inventory Material return slip Vehicle gate pass Reports Daily/weekly/monthly material receipt summary Material inward report Material receipt report Daily material outward report

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::::::-

:::-

3. The procurement process for the medical equipment 4. Preparing the purchase order. 5. Inspection of the equipment delivered in terms of quality and quantity. 6. Inventory and documentation of the equipment received. 7. Installation, commissioning, and testing of the equipment 8. User training and certification 9. Handing over the equipment 10. Monitoring performance at regular intervals 11. Maintenance, safety, and care of medical equipment 12. Condemnation, disposal, and replacement of the equipment

17.2.24 Biomedical Engineering Department See Table 17.25. Biomedical engineering department in a hospital performs duties  intending to ensure that medical equipment in various departments is in its best working condition and is being effectively utilized. The efficiency of the end user is evaluated based on the knowledge to use the equipment in performing patient care. The biomedical department shall be responsible for assisting in procurement of the medical equipment, tools, and instruments. The department shall also be responsible for installations of equipment; preventive and corrective maintenance; providing pre-purchase evaluations of new technology and equipment; assisting clinical departments with service contract analysis, negotiations and management; providing coordination of clinical equipment installations including planning, scheduling, and oversight; conduct device incident investigations; educating by taking regular classes to nurses, other allied, healthcare professionals, and creating awareness on norms etc; maintaining an inventory record of all medical equipment in the hospital.

602

17  Policies and Standard Operating Procedures (SOP)

Table 17.25  SOP of biomedical engineering department

Activity Services offered by the department Procurement of new equipment or spares Finalization of the specification of the equipment to be procured Detailed discussion with the vendor Receiving the shipment and technical verification of the shipment Installation of equipment, machines, and spares Monitoring the installation of the equipment Checking the commissioning and testing Arrange user training and training certificates from the vendor Periodic maintenance of the equipment Breakdown maintenance Planned preventive maintenance of equipment and machines Scheduled calibration and testing process Maintenance contract management documentation Labelling of the equipment Proper safety management

Status of Works Start End Not Responsible date date Complete In-progress started person Remarks

::-

::-

:-

:-

:-

:-

:::-

::-

::-

17.2 Standard Operating Procedures (SOPs)

603

Table 17.25 (continued)

Activity Approval and licenses from various regulatory authorities of the country Roles and responsibilities of staff Roles and responsibilities of biomedical engineer Roles and responsibilities of mechanical engineer Roles and responsibilities of electrical engineer Standard operating procedures Equipment procurement policy and process Equipment condemnation policy and process Preventive and breakdown maintenance plan Calibration of equipment Turnaround time for responding to complaints or service requests Occupational health hazards they face and prevention strategies Equipment hygiene and infection control practices Equipment safety, device control Department functional procedure

Status of Works Start End Not Responsible date date Complete In-progress started person Remarks :-

:-

:-

:-

:-

:-

:-

::-

:-

:-

::(continued)

604

17  Policies and Standard Operating Procedures (SOP)

Table 17.25 (continued)

Activity Operational and maintenance plan Training for staff Periodic maintenance schedule Spare part procurement Annual maintenance contracts Condemnation of the equipment Disposal of the condemned equipment Forms and formats Calibration logbook Master list of biomedical equipment Outsourced instrument register Preventive maintenance log Master list of biomedical equipment along with preventive maintenance and calibration plan Breakdown maintenance request slip Preventive maintenance log Calibration records and certificates Training records Condemnation and disposal record of the equipment Reports Weekly log sheet Major breakdown report Condemnation report Maintenance report

Status of Works Start End Not Responsible date date Complete In-progress started person Remarks :::::::-

:::::-

:-

::::-

::::-

17.2 Standard Operating Procedures (SOPs)

605

17.2.25 Pharmacy See Table 17.26. Table 17.26  SOP of pharmacy services

Activity Services offered by the department Procurement of medicine, drugs, and consumables as per requirement Checking of invoice To keep a minimum stock Keeping a list of medicine, drugs, and consumables Issue medicine, drugs, and consumables to retail Refund of returned medicines, drugs, and consumables Manage expire medicine, drugs, and consumables Goods received and checking Proper storage of the medicines, drugs, and consumables in racks Receiving the doctor’s/Dept’s requirements Raising purchase requisition. Managing narcotic drug Monitoring of the stock level Monitoring of the expiry date of the medicine Medicine receipt notes from wards

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:-

:::-

:-

:-

:-

::-

:-

::::-

:(continued)

606

17  Policies and Standard Operating Procedures (SOP)

Table 17.26 (continued)

Activity Roles and responsibilities of Staff Roles and responsibilities of the senior pharmacist Roles and responsibilities of assistant pharmacist Roles and responsibilities of the pharmacist Standard operating procedures Approval of medicines and consumables Procurement of medicines and consumables Receipt and verification of medicines and consumables Storing of medicines and consumables Supply to the wards/ OT/ICU, etc Retail sales of pharma items from the pharmacy Licenses and narcotic drugs Expiry checks of departmental medicines Verification of physical stock Service deficiencies and corrective/ preventive actions Environment control Empanelment and approval of suppliers of pharmaceutical products and evaluation

Status of works Start End Not Responsible date date Complete In-progress started person Remarks

:-

:-

:-

::-

:-

:::-

::-

::-

::-

17.2 Standard Operating Procedures (SOPs)

607

Table 17.26 (continued)

Activity Procedure for returning medicine Procedure for purchase return Forms and formats Purchase requisition form Receipt verification form List of storage plans for medicine, drugs, and consumables Issue slips Invoice format Expiry medicine form Return note of medicine, drugs, and consumables Suppliers list Cash collection form Narcotic drugs procurement form Reports Daily collection statement Daily procurement report Daily expiry report daily sale of narcotic drugs Daily temperature chart of cold room/ refrigerator

Status of works Start End Not Responsible date date Complete In-progress started person Remarks ::-

:::-

::::-

:::-

:::::-

The pharmacy plays an important role in the hospital because it is the centre for dispensing medicines, injectable, cotton and bandages, surgical disposables such as catheters, and so on to all inpatients and outpatients. In most hospitals, there are two pharmacy units from which drugs shall be disbursed. One unit is responsible for dispensing medications to inpatients, while the other is responsible for dispensing medications to outpatients. For inpatients, medications are typically given directly from the pharmacy to the appropriate wards, eliminating the need for a separate drug dispensing counter.

608

17  Policies and Standard Operating Procedures (SOP)

Nonetheless, a retail pharmacy counter shall be available for patients who are outsiders. The pharmacy counter or store is essentially a licenced establishment, and both the inpatient pharmacy and the retail pharmacy counter need their own licenses. It shall be necessary to obtain a separate wholesale pharmacy license if the hospital distributes medications wholesale. Similar to this, additional licenses shall be needed to deal with narcotic medications like ketamine and other similar substances. In the hospital, pharmacy services are provided in a variety of ways. These can be self-owned pharmacies for both inpatients and outpatients; outsourced retail pharmacies for both inpatients and outpatients; or self-owned pharmacies for inpatients and outsourced retail pharmacies for outpatients. In any case, the hospital shall have dual pharmacies, one dealing with the inpatients and the other with the outpatients.

17.2.26 Maintenance Departments See Table 17.27. Any asset you develop shall, by definition, require repairs and maintenance. All medical equipment and hospital buildings require repairs and maintenance. This can be outsourced, or in-house repair and maintenance facilities can be built. Outsourcing, on the other hand, raises the expense of repair and maintenance, and it sometimes takes longer to fix an asset. As a result, it is recommended that hospitals build up in-house repair and maintenance facilities. For the upkeep and maintenance of the hospital assets, the hospital generally requires workshops such as biomedical workshops, electrical workshops, HVAC workshops, MGPS workshops, low voltage workshops, building maintenance, mechanical workshops, firefighting workshops, and automobile workshops, among others. The maintenance service is responsible for ensuring the safe, cost-effective operation, and maintenance of hospital facilities and expensive equipment to create a hospital physical environment conducive to the well-being of the patients.

17.2 Standard Operating Procedures (SOPs)

609

Table 17.27  SOP of maintenance departments

Activity Services offered by the department Create and maintain hospital air-­ conditioning system To make sure that facilities like electricity, air conditioning, water supply, utility equipment, and steam supply are in service Economical operation and maintenance of the physical plants such as the AC plant, generator, elevator, and other equipment Help in decision-­ making by providing information regarding the performances of both equipment and service providers Preventive maintenance of the utility equipment Attending and documenting breakdown calls Electrical and mechanical store items are requisitioned and supplied on time Maintain fire detection and protection devices Proper guide to in-house technicians and outside vendors for work with proper safety

Status of Works Start End Not Responsible Date Date Complete In-Progress Started Person Remarks

:-

:-

:-

:-

:-

:-

:-

:-

:-

(continued)

610

17  Policies and Standard Operating Procedures (SOP)

Table 17.27 (continued)

Activity Maintain all safety-related logbooks and file documents. Conducted fire training for all hospital staff Repair of the building concerning the masonry work Painting of the building Attending to the plumbing complaints Repair of furniture Repair of door/ windows Attending to the electrical faults and replacement of electrical fittings Attending complaints of the CCTV Attending complaints of medical piped gas supply system Attending complaints of fire detection and fighting system. Roles and responsibilities of staff Roles and responsibilities of chief engineer Roles and responsibilities of junior engineer Roles and responsibilities of air-conditioning engineer

Status of Works Start End Not Responsible Date Date Complete In-Progress Started Person Remarks :-

:-

:-

:::::-

::-

:-

:-

17.2 Standard Operating Procedures (SOPs)

611

Table 17.27 (continued)

Activity Roles and responsibilities of electrical engineer Roles and responsibilities of a plumber Roles and responsibilities of MGPS engineer Roles and responsibilities of a carpenter Roles and responsibilities of CCTV engineer Standard operating procedures Turnaround time for responding to complaints or service requests Occupational health hazards they face and prevention strategies Department functional procedure Operational and maintenance plan Training for staff Periodic maintenance schedule Spare part procurement Annual maintenance contracts Procedure for handling fire and non-fire emergency Maintenance plan for water treatment Cleaning of RO water tank and pipelines Forms and formats

Status of Works Start End Not Responsible Date Date Complete In-Progress Started Person Remarks

:-

:-

:-

:-

::::::-

(continued)

612

17  Policies and Standard Operating Procedures (SOP)

Table 17.27 (continued)

Activity Preventive maintenance log Outsourced instrument register Breakdown maintenance request slip Preventive maintenance log Calibration records and certificates Training records Breakdown complaint register Gate passbook Stores requisition book Purchase indent book Temperature checklist (room and fridge) Requisition format Daily checklist of electrical status Maintenance logbook A/C installed register A/C inspection checklist A/C repairing logbook Plumbing work repairing register Incident register Fire safety checklist Safety and facility audit Safety and facility audit checklist Reports Weekly log sheet Major breakdown report Maintenance report Condemnation report

Status of Works Start End Not Responsible Date Date Complete In-Progress Started Person Remarks :::-

:::::::::::::::::::-

::::-

Further Reading

613

Further Reading Garg A, Dewan A. Manual of hospital planning and designing for medical administrators, architects, and planners. India: Springer Singapore; 2022. Joint Commission International. Joint Commission International accreditation standards for hospitals. 7th ed. Joint Commission Resources; 2020. p.  1–424. [cited 2023 May 3]. Available from: https://store.jointcommissioninternational.org/jci-­accreditation-­standards-­for-­hospitals-­ 7th-­edition/

Glossary

°F   Degrees Fahrenheit 3D  3 Dimensional ABP  Ambulatory Blood Pressure AC  Air Conditioning ACH OA  Air Changes per Hour—Outdoor Air ACH SA  Air Changes per Hour—Smart Air ACT   Activated Clotting Time ADT  Admission, Transfer, Discharge AEP  Auditory Evoked Potential AHU  Air Handling Unit AMC  Annual Maintenance Contract Amp Amperes APC  Argon Plasma Coagulation ARD  Automatic Rescue Device ATM  Automated Teller Machine AV Audio-Video B.E.P  Break-Even Point BAC  Blood Alcohol Concentration BOD  Bio-oxygen Demand BP  Blood Pressure BSC  Bio-safety Cabinet BSL  Bio-safety Lab Cat Category Cath Lab  Coronary Catheterisation Laboratory CAV  Constant Air Volume CCTV  Closed Circuit Television System CD  Compact Disc cd/m2  Candela Per Square Metre CEO  Chief Executive Officer © © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Garg, Monitoring Tools for Setting up the Hospital Project, https://doi.org/10.1007/978-981-99-6203-7

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CFM  Cubic Feet per Minute CIC  Circulating Immune Complexes CMC  Comprehensive Maintenance Contract CNS   Central Nursing Station CO2  Carbon dioxide COPD  Chronic Obstructive Pulmonary Disease CPAP  Continuous Positive Airway Pressure CR  Computerised Radiography CRRT  Continuous Renal Replacement Therapy CSSD  Central Sterile Services Department CT  Computerised Tomography CTG Cardiotocograph CTVS  Cardiothoracic and Vascular Surgery CUSA  Cavitron Ultrasonic Surgical Aspirator D & C   Dilation and Curettage D.G  Diesel Generator D.S.C.R  Debt Service Coverage Ratio dBA Decibel Derma Dermatology DEXA  Dual Energy X-ray Absorptiometry dia Diameter DICOM  Digital Imaging and Communications DLCO  Diffusing capacity of the Lungs for Carbon Monoxide DNA  Deoxyribonucleic Acid DOT  Directly Observed Treatment DPR  Detailed Project Report DR  Digital Radiography DSA  Digital Subtraction Angiography DSE  Dobutamine Stress Echocardiography DVD  Digital Video Disc or Digital Versatile Disc DVR  Digital Video Recorder DVT   Deep Vein Thrombosis DX  Direct Expansion e.g.   For Example EBB  Earth Bonding Bar EBUS  Endobronchial Ultrasound ECG Electrocardiograph ECHS  Ex-Servicemen Contributory Health Scheme ECI  Extracorporeal Immunoadsorption ECM  Electronically Commutated Motors ECT  Electroconvulsive Therapy EDA  Electrodermal Activity EEG Electroencephalogram EGG Electroglottograph ELISA  Enzyme-Linked Immunosorbent Assay

Glossary

Glossary

ELV  Extra Low Voltage EMG  Electro Mayo Graph EMO  Emergency Medical Officer EMR  Electronic Medical Records ENG Electronystagmogram ENT  Ear Nose Throat EP Electrophysiology EPABX  Electronic Private Automatic Branch Exchange Epm  Unverricht–Lundborg disease EPS Electrophysiology Studies EPS  Earnings Per Share ERCP  Endoscopic Retrograde Cholangiopancreatography ESI  Employees’ State Insurance ESU  Electrosurgical Unit ESW  Extracorporeal Shock Wave ESWL  Extracorporeal Shock Wave Lithotripsy ETO  Ethylene Oxide ETP  Effluent Treatment Plant EUS  Endoscopic Ultrasound FAME  Fatty Acid Methyl Ester FAR  Floor Area Ratio FCC  Fire Command Centre FCU  Fan Coil Units FeNO  Fractional Exhaled Nitric Oxide FFP  Fresh Frozen Plasma FPI  Fins Per Inch FPM  Feet Per Minute FRLS  Fire Retard Low Smoke FRP  Fibre Reinforced Plastic FSI  Floor Space Index ft. Feet G.I  Galvanised Iron G.I.  Gastrointestinal Gastro Gastroenterology GC  Gas Chromatograph GC-VUV  Gas Chromatography-Vacuum Ultraviolet Spectroscopy GERD  Gastroesophageal Reflux Disease GRN  Goods Received Note Gynae Gynaecology H.R  Human Resources HDD  Hard Disk Drive HDMI  High-Definition Multimedia Interface HDU  High Dependency Unit HEPA  High-Efficiency Particulate Air HFNC  High-Flow Nasal Cannula

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HIS  Health Information System HIV  Human Immunodeficiency Virus HL7  Health Level Seven HMS  Hospital Management System HOD  Head of Department HP  High Pressure HRC  High Rupture Capacity HRUS  High-Resolution Ultrasonography HT   High Tension HVAC  Heating Ventilation and Air Conditioning I.A.B.P.  Intra-Aortic Balloon Pump IBMS  Integrated Building Management System ICCU  Intensive Cardiac Care Unit ICD  International Classification of Diseases ICRA  Investment Information and Credit Rating Agency ICT  Information and Communication Technologies ICTC  Integrated Counselling and Testing Centres ICU  Intensive Care Unit ID  Inner Diameter ID Identity Document IEEE  Institute of Electrical and Electronics Engineers IETF  Internet Engineering Task Force IgG Immunoglobulins IITV  Image Intensifying Television IOL  Intraocular Lens IOP  Intraocular Pressure IP  Internet Protocol IPD  In-Patient Department IPL  Intense Pulsed Light IPS  Isolated Power Supply IPTV  Internet Protocol Television IRDS  Infant Respiratory Distress Syndrome IRR  Internal Rate of Return ISMS  Integrated Security Management System IT  Information Technology IUP  Intrauterine Pressure IV Intravenous IVF  In Vitro Fertilisation JCI   Joint Commission International kPa Kilopascal KV  Kilovolt KVA  Kilovolt Ampere kW Kilowatt L/min   Litres Per Minute LCD  Liquid Crystal Display

Glossary

Glossary

LDB  Lighting Distribution Board LDR  Labour, Delivery, and Resuscitation LINAC  Linear Accelerator LIPA  Line Probe Assay LT  Low Tension Ltr. Litre Lux  Unit of Illumination mA Milliampere MA  Medical Air MCB  Miniature Circuit Breaker MCCB  Moulded Case Circuit Breaker MDB  Main Distribution Board MEP  Mechanical, Electrical and Plumbing MEP  Maximal Expiratory Pressure MERV  Minimum Efficiency Reporting Value MGIT 960  Mycobacteria Growth Indicator Tube MGPS  Medical Gases Pipeline System MHz Megahertz MICU  Medical Intensive Care Unit MIP  Maximal Inspiratory Pressure MIS  Management Information System MLC  Medico Legal Cases mm Millimetre MRD  Medical Record Department MRI  Magnetic Resonance Imaging MRL  Machine Room Less MS  Mild Steel N.P.B.T  Net Profit Before Tax N2 Nitrogen N2O  Nitrous Oxide NABH  National Accreditation Board for Hospitals NCV  Nerve Conduction Velocity NFPA  National Fire Protection Association NIBP  Non-invasive Blood Pressure Ni-Cd  Nickel–Cadmium NICU  Neo-natal Intensive Care Unit O.T.   Operation Theatre O2 Oxygen OAE  Otoacoustic Emissions OBS Obstetrics OCT  Optical Coherence Tomography OD  Outer Diameter OLTC  On-load tap changer Onco Oncology OPD  Out-Patient Department

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OPG Orthopantomogram OR  Operating Room Ortho Orthopaedic PA  Personal Assistant PA  Public Address PAC  Pre-anaesthetic Check-up PACS  Picture Archiving and Communication System PC  Personal Computer PCNL  Percutaneous Nephrolithotomy PDB   Power Distribution Boards PE  Premature Ejaculation Pedia Paediatrics PERT  Program Evaluation Review Technique PET CT   Nuclear Positron Emission Computed Tomography PET MRI   Nuclear Positron Emission Magnetic Resonance Imaging PF  Provident Fund PFT  Pulmonary Function Test PICU  Paediatric Intensive Care Unit PLC  Programmable Logic Control PNS  Peripheral Nerve Stimulation POP  Plaster of Paris PPE  Personal Protective Equipment PPM  Parts Per Million PPS  Primary Power Supply PRD  Pressure Relief Damper PSG Polysomnography PTS  Pneumatic Tube Systems PTZ   Pan Tilt Zoom PUVA  Psoralen and Ultraviolet A PVC  Polyvinyl Chloride PVR  Profit Volume Ratio PWS  Patient Warming System RCC  Reinforced Cement Concrete RCCB  Residual Current Circuit Breaker RF  Radio Frequency RFID  Radio Frequency Identification RH  Relative Humidity RNA  Ribonucleic Acid RO  Reverse Osmosis ROI  Return on Investment RONW  Return on Net Worth RR  Respiration Rate RT  Radiation Therapy RT-PCR  Real-Time Polymerase Chain Reaction S.S  Stainless Steel

Glossary

Glossary

SEP  Somatosensory Evoked Potential SICU  Surgical Intensive Care Unit SMDB  Sub-Main Distribution Board SMS  Short Message Service SOP  Standard Operating Procedures SOW  Scope of Work SPD  Surge Protection Devices SPECT CT   Single Photon Emission Computerised Tomography SPO2  Unit of Measuring Oxygen Saturation SPR  Skin Potential Response SPS  Secondary Power Supply Sq. Ft.  Square Feet Sq. Mtr  Square Metre SRS  Stereotactic Radio Surgery STP  Sewerage Treatment Plant T.B Tuberculosis TBNA  Transbronchial Needle Aspiration TCFR  Techno Commercial Feasibility Report TDS  Tax Deducted at Source TDS  Total Dissolved Solids TEE  Transoesophageal Echocardiography TMS  Transcranial Magnetic Stimulation TMT  Treadmill Test TPA  Third Party Administrator TPN  Triple Poll and Neutral TPS  Tertiary Power Supply TSSU  Theatre Sterile Supply Unit TT Lab  Transmissible Tests TV Television UGI  Upper Gastrointestinal UHID  Unique Health Identification UPS  Uninterrupted Power Supply UPVC  Unplasticised Polyvinyl Chloride USB  Universal Serial Bus UV Ultraviolet VAV  Variable Air Volume VCB  Vacuum Circuit Breaker VCD  Vacuum Constriction Device VED  Vital, Essential, Desirable VEEG  Video Electroencephalography VFD  Variable Frequency Device VIE  Vacuum Insulated Evaporator VLC  Visible Light Communications VNG Videonystagmograph VRLA  Valve Regulated Sealed Lead Acid

621

622

WC  Water Closet WC  Water Column WDV  Written Down Value WTP  Water Treatment Plant XLPE  Cross-Linked Polyethylene

Glossary