Healthcare infrastructure should stand the test of time
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Ayanabh Debgupta
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According to the WHO concept of safe hospital, “One which will not collapse in disasters, killing patients and staff and can continue to function and provide its services as a critical community facility when it is most needed.”
Hospitals are the most important buildings within a community, referred to as ‘essential facilities’. They are buildings that are intended to remain operational even in the event of extreme environmental conditions. Moreover, hospitals are affected both directly and indirectly in a disaster, i.e. directly due to the impact of external disasters like earthquakes, cyclones, floods and also due to manmade disasters like fire (medical gas leakage/faulty electric wiring, chemical spills). Secondly, indirectly it is called upon to provide enhanced quantum of services and manage mass casualties. But when a hospital fails, the affected communities are left without even basic emergency care. Hence, this calls upon an imperative need among healthcare organisations in building safer healthcare establishments.
In the course of creating safe healthcare structures, various intricacies needs to be taken into account. In the planning phase itself one needs to create a matrix of features focused on patient safety like the location, soil type and the kind of disaster the region is prone to, design specifications, resilience of materials used, type of beams, columns, slabs, load-bearing walls, braces or foundations, space planning for optimum output and presence of alternate sources of energy for 24X7 provision of basic lifeline services.
Fire safety has been quite an alarming issue in recent years due to increasing reports on fire mishaps within hospitals. Such incidents can be minimised by encouraging awareness on fire safety measures among healthcare personnel and provision of fire safety structures like alternate fire exits on each floor, presence of ramps, fire alarms in walls, peepholes in doors or smoke detectors in ceilings. In case of high-rise buildings, separate electric circuits for lift installation, lighting of passages, corridors and stairs and for internal fire hydrant system, underground water tank for fire management, and availability of fire fighting equipment at all floors are needed.
For earthquake prone areas, various safety features if adapted during designing and construction phase (reference to IS codes 1893, 4326, 13827, 13828 and 13920) like use of RCC construction materials wherein concrete resists compression forces and reinforcing steel resists tensile forces produced by an earthquake, opting for base-isolated foundation which allows the building to withstand a magnitude 7.9 class earthquake and still remain functional are extremely necessary. Moreover, adopting the concept of strong column weak beam design with well anchored shear walls and horizontal lintel band are certain options that are cost effective and help minimising the seismic effect.
Additionally, cyclones and floods seem to occupy a larger proportion among natural disasters creating havoc worldwide, destructing various establishments including healthcare setups which are otherwise supposed to remain functional to manage the after effects. Adoption of smarter design and construction techniques like aerodynamic circular building designs with reinforced clear span roof and radial truss array or hif roof or high gable roof, use of heavier foundation, reinforced windows with impact glass to prevent the entry of wind and water, and reinforced walls by means of reinforced concrete band as well as use of flood damage-resistant materials which include glazed brick, concrete, concrete block, glass block or stone (with waterproof mortar or grout); steel trusses, naturally decay resistant lumber, metal doors, cabinets, and window frames can provide stronger and safer structures.
Thus, good quality of design and construction is the most significant factor ensuring safety and durability and for an important establishment like hospital, costly one is that which fails to stand in time of its utmost need.
– Ayanabh Debgupta, CEO, Medica Synergie
India is waking up to the concept and benefits of patient-centric design
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Ram Reheja
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Healthcare designing and construction has undergone a lot of changes in all parts of the world with respect to safety and sustainability. India is slowly waking up to the concept and benefits of patient-centric design. In this dynamic environment, healthcare organisations are slowly adapting to the new opportunities they have to position their facilities in delivering the best patient outcomes. Surveys show that people make judgments about the quality of care they receive based on the condition of the healthcare environment.
Healthcare facilities are a lot more than just buildings; they are home to critical health services such as public health laboratories, blood banks, rehabilitation facilities or pharmacies. It is a place where a person feels safe and taken care of. Therefore, the safety norms in such projects are a lot more stringent than other buildings. A few features are mandatory when designing the building to ensure that the patients are safe in case of disasters such as fires, earthquakes, etc. Since, such buildings are air-conditioned, there should be adequate open spaces in the form of windows and balconies on each floor for evacuation. Considering that hospitals have a lot of inflammable materials, the storage areas should have proper exits and ventilation. The staff should be aware of the emergency drills and every floor should have a map with all details of exits in case evacuation is required.
With the help of sustainable architecture, a green design can successfully blend beauty and functionality together to save our planet for the coming generations. Green architecture is the need of the hour and when designing healthcare facilities it becomes even more important. The process of sustainability is two-fold; using materials which are less harmful to our environment and using the natural resources effectively to ensure limited usage of those materials. This can be done by designing the building in a way that maximum sunlight enters the building and also add open spaces to ensure proper ventilation. Features like rain-water harvesting, waste- reduction plants, preferable medical waste treatment and disposable should be added during construction to help in recycling.
Though cost is always an important factor in any project, the difference in expense between building a safe and an unsafe hospital can be negligible. But that tiny investment can be the difference between life and death, or between a community’s impoverishment and its sustainable development. Since hospital design is so detailed, a system of estimating floor areas and costs by function has evolved to enable the financial assessment of clinical needs ahead of the completion of detailed design work.
– Ram Reheja, Director and Head- Architecture & Design, Raheja Realty
Design innovation is the need of the hour in healthcare architecture
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Ratan Jalan
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Hospitals should be built as places to promote healing, not just as places for providing treatment. Any hospital design should start by an understanding of patients and the speciality. There has always been a disconnect between doctors, designers and hospital promoters. In the course of planning, there comes a stage when creative dominates over functionality, leading to tradeoffs, which during design stage seem too trivial. However, these are the tradeoffs that lead to problems at a later date. Some of the examples will make the point clear.
When a hospital is being built, one of the points of contention is always the number of columns and beams. Most of the promoters always like to minimise the number of columns and beams to make the hospital seemingly ‘look good’. What they fail to take into account is the load bearing capacity of the structure. In addition, there is always a temptation to fill as many beds as possible in the design. This leads to inherent compromises, including safe means of patient egress in case of an emergency.
Mechanical, Engineering and Plumbing, commonly referred to as MEP services is one of the commonly ignored areas. Promoters use all creative means to prove that the building is lower in height to comply with less stringent fire norms. On the flipside, HVAC, which is a fairly large percentage in the overall electrical cost, is never a point of deliberation. It is not at all difficult to create a hospital with proper ventilation to minimise AC. The same is true for natural light as well. Medical gases, again, account for a fraction of the overall project cost, but there is always a long drawn discussion on minimising the medical gas requirements.
Sometime back, I was involved in creating a niche boutique healthcare facility and there were quite a few meeting on interiors. Right from the overall design, which focused a lot on natural light to the choice of materials, everything was based on functionality of the place. For instance, the carpets inside the room were certified by international bodies proven to minimise risk of infection and had easy to clean, non-adherent surface to minimise the adherence of dust or any foreign bodies. While recently working on a project, we realised that on the schematic drawing, all doors opened inside the washroom. We have to take into account the fact that a patient could faint inside the washroom and fall on the door. It would be extremely difficult to open the washroom in such circumstances. Any hospital design has to consider some of these elements and incorporate the same in the overall design.
A recent trend in healthcare industry is the emergence of single speciality hospitals, that we refer as ‘focused factories’. While the idea of creating a focused facility is quite innovative, this does not always translate in design except the aesthetic treatment. Consider for instance, the furniture. A facility focused on obstetrics would need to have different furniture, for instance a chair with firm cushions to enable the expectant mother to be firmly seated, while a facility treating arthritis patients would need to consider the height of the same chair to enable patients rest their knees without any discomfort. A facility treating obese patients on the other hand would need to take into account the width of the same chair and the safe working load.
When I used to be the President at Asian Health Services, a healthcare architecture and consulting firm, we released a recruitment advertisement aimed at young architects. I still remember the headline. It said, “Wanted architects who can help in curing patients.” Design innovation is the need of the hour in healthcare architecture industry and in the same context, we need to stop being selfish and focus on patient requirements rather than ‘ours’.
– Ratan Jalan, Founder and Principal Consultant, Medium Healthcare Consulting
Safety management is vital while planning healthcare infrastructure
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Meeta Ruparel
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Hospital administrators and management executives, face a constant challenge to achieve customer satisfaction and at the same time meet the stakeholder requirements for maintaining a balance between costs and quality of service delivery.
Sometime ago, a fire in a hospital in eastern part of India resulted in a toll of approximately 89 casualties! Eventually it led to stringent steps like termination and/ or withdrawal of the hospital license, litigations against the hospital management and compensations to the victims’ families and to the injured. Compensation may provide a temporary monetary relief but cannot in any form replace a member loss of that family.
Safety management is a very important aspect of planning in every form of hospital infrastructure. Safety management as a whole includes aspects of not only fire safety, but also security measures in terms of safety from other unsafe encounters like thefts, pilferages, extortion, riots and natural calamities.
In circumstances in which hospital operations are disrupted or disabled, the adverse impact of disasters can be instantly compounded, many a times with catastrophic results.
Different disasters/accidents present different challenges, and each hazard requires a different strategy/ set of resources and a different approach to mitigation.
It is important to acknowledge that there are no universal design guidelines/thumb rules to protect buildings from all such events. I therefore initiated writing a book on hospital facility safety which is scheduled to release soon, i.e.; in the year 2014. The intent of this book is to provide guidelines for planning, de sign of hospitals and primers for existing ones for hospital facility safety and to ensure patient safety as first priority and motivate staff to practice a similar culture. The purpose of this book is to consider design options to make hospital buildings resistant to natural hazards in addition to the other general design considerations and recommended hazard mitigation measures for risk reduction.
– Meeta Ruparel, Director, AUM MEDITEC
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