Hosmac Pulse - Blueprints for a Healthier Planet by OneClickDrive

Editorial Board

Advisory Panel

Table Of Content

Combining forces to better healthcare

The right thing to do

Narendra Karkera narendra.karkera@hosmac.com Rakesh Mathur rakesh.mathur@hosmac.com

Intensively planned ICUs

Doctoring finance

Relax, breathe and heal

Streamlining the lab setting

Flexibility in healthcare planning

Imagining the Imaging Department right

A role model for the healthcare industry

Hosmac turns 14!

Isha Khanolkar Isha.khanolkar@hosmac.com Paresh Gujrathi paresh.gujrathi@hosmac.com Ipshita Dey ipshita.dey@hosmac.com Creative Consultant Amit Pandya amit@scarecrow.asia Chief Editor Vinay Pagarani vinay.pagarani@hosmacfoundation.org

HOSMAC Pulse is an initiative of HOSMAC Foundation. High quality standards have been maintained while preparing and presenting the information in this periodical. However, no legal responsibility will be accepted by HOSMAC Foundation or HOSMAC India Pvt Ltd for any loss or damage resultant from the contents. The views expressed are solely that of the authors or writers, and do not necessarily represent the views of HOSMAC Foundation or its consultants in relation to any particular projects. No part of this periodical may be reproduced in any form without the written permission of HOSMAC Foundation - the publisher.

Executive's Note

The creation of healthcare infrastructure in India has accelerated more than ever before. In addition to private sector companies, the Government is also showing signs of investing in the initiation of hospitals, medical campuses and healthcare SEZs, especially in the rural setting. The present scenario hence will entail wide-ranging participation from various agencies like healthcare consultants, architects, engineering consultants, construction companies and bio-medical equipment vendors, in the near future. Apart from hospital build design, it is equally important to meticulously plan individual departments. For instance, the fact that the room temperature and speed with which air flows in an operation theatre are vital for a clean outcome of surgical procedures in a super-specialty, is not known to many. Similarly, such engineering needs are a prerequisite in other departments of ICU, labs, imaging and radiology too. All these departments need 24-hour operation, and this adds to energy costs. It is therefore critical for hospital-planners and administrators to work out diverse mechanisms to engineer the departments as energy-efficient as possible. Going forward, such an approach will make hospitals of tomorrow more green. Healthcare design has thus become an indispensable cornerstone in the creation of future healthcare infrastructure. Towards this end, Hosmac has teamed up with Heery International, USA to provide value-added hospital design services to projects at large. In addition, this issue of HOSMAC Pulse is being dedicated towards the various facets of designing and planning clinical departments, popular in a healthcare facility.

â&#x20AC;&#x153;The fact that the room temperature and the speed with which air flows in an operation theatre are vital for a clean outcome of surgical procedures in a superspecialty, is not known to many. â&#x20AC;?

Dr. Vivek Desai Managing Director, Hosmac India Pvt. Ltd.

Combining forces to better healthcare

In an exclusive report, Mark D. Johnson, Vice President and Bhavik H. Rao, Project Architect of Heery International announce their collaboration with Hosmac India, and illuminate on how a healthcare facility can be streamlined. Healthcare & India The Indian economy, predicted to be one of the world's emerging economies in the near future, has begun to rise with a robust pace of growth. Its healthcare sector is also growing rapidly, and is estimated to be worth US $75 billion by 2012. The sector has shown momentous growth owing to the country's growing middle class, which can afford quality healthcare. Additionally, high-quality healthcare facilities at competitive costs have been instrumental in fetching hordes of foreign arrivals to the country, by way of medical tourism. Taking things forward, US based Heery International, Inc. has entered into a business teaming agreement with Hosmac India Private Limited, a leading hospital design and management consultancy firm, to collectively pursue opportunities in India, alongwith Africa and the Middle East. Heery is a full service Architecture, Master Planning, Interior Design, Commissioning, Engineering, Construction and Program Management firm with a history of stable leadership and financial strength. Throughout the years, Heery has expanded through a multitude of acquisitions. As a recent affiliate of Parsons Brinckerhoff, one of the world's leading professional services companies, Heery now operates as that firm's buildings division. This new association gives Heery access to dramatically increased resources, opportunities and international outreach. Optimizing operations One of Heery's primary focuses has been the delivery of superior healthcare design and planning services for specialty hospitals and clinics, community and acute care hospitals, academic medical centers, outpatient clinics and medical office buildings. With nearly 60 years of US healthcare experience, Heery brings its extensive expertise, seasoned professionals,

and knowledge of healthcare design and planning to its new affiliation with Hosmac. This enhances the team's ability to address various client situations and service requirements. Understanding current and future requirements is integral to our healthcare facility design process. The best case scenario is one where we are afforded the opportunity to create a master plan that addresses a variety of issues from current and future budgets, space and system requirements to trends in healthcare, all of which impact future growth. When we look five or ten years out, we are not only considering how a space will grow, we are also focused on how to expand in a way that makes the most efficient and cost effective use of existing infrastructure and equipment while maintaining the integrity of internal public and private circulation systems. Assimilation, of the essence The greatest challenge in the healthcare industry is designing and constructing facilities that not only meet fiscal, functional and environmental requirements, but exceed the needs of patients as well. Where does our healthcare planning and design process begin? By being collaborative. Defining a vision that incorporates the needs and desires of key project stakeholders, including administrators, physician leaders, nursing and support services, staff and even members of the community is critical. This initial information gathering helps us establish performance goals against which all decisions can be measured. Clinical programming and planning revolves around such performance goals and layers in the agency and code healthcare stipulations that dictate room type, function and and minimum size per department. Departmental gross up factors are utilized in conjunction with net room module methodology and the factors can vary per different facility type

Medical Center of the Rockies is located in Loveland, Colorado - USA

from lesser to greater in magnitude. Key room adjacencies within each specific department are critical in nature and help to properly 'zone' a department for proper staffing and patient care parameters. Also, key 'department to department' adjacencies are very important in terms of hospital efficiency and expedited patient care, service and safety. Being attentive to patient and family requirements is vital to overall facility success. Heery recently completed a state-ofthe-art cancer center in Augusta, Georgia, where we invited cancer survivors to play a critical role in the facility's planning and design process. Our goal was to understand their needs as well as their desires. The flow of exam and fusion areas, among other spaces, is based on their insightful input. Patient focused care

carefully evaluating potential sustainable features at the project's outset and weighing first costs against lifecycle savings. It has been documented in studies that patients have better outcomes in comfortable, natural environments than they do in sterile, clinical settings. In addition, greener facilities enhance the working environment, which in turn improves staff satisfaction and retention rates. Patients’ average length of stay are also reduced. Undoubtedly, our practice has embraced sustainability as one of our primary focuses. Heery's long history and expertise in the area of energy conservation puts the company in a strong position to assist our clients in the delivery of sustainable and LEED certified buildings. Beginning in the late 1970s, Heery began researching and developing approaches to building design that enhanced energy conservation. Over the years, this initiative has expanded to include broader sustainability issues, including water management, building materials and operational issues.

Many of Heery's projects embody the basic tenets of Planetree, a 'patient-centered care' healthcare philosophy rooted in patient focused care. Curved hallways and non-institutional finishes with minimal overhead lighting help to enhance a “healing environment” for patients. Incorporating family friendly and specific places, which can range from centrally located family lounges to larger patient rooms, is of paramount importance. These larger patient rooms are designed to accommodate visitors comfortably without impeding staff duties. We certainly believe that families play an integral role in the healing process.

Respect and contribute positively to local communities

Offer energy efficiency

Use renewable resources in preference to non-renewable

Sustainability is (ever)green

Use local and recycled materials where appropriate

Use water efficiently

One aspect that will not change is the demand for healthy, sustainable facilities. In the past, there was an assumption that the water and energy intensive requirements of hospitals made them ill suited for LEED Certification. There was also the assumption that green design and construction costs would be prohibitively expensive. In reality, it is simply a matter of

Heery has worked with clients to achieve sustainable design solutions that:

Heery provides guidance and expertise to those clients who seek LEED certification for their projects by:

路

Establishing green design project intent and procedures to meet the certification and budget goals of the client

路 Preparing necessary submittals to the US Green Building Counsel for the certification process 路 Providing leadership to the project team in the development and delivery of the project in accordance with the established LEED and sustainable goals To stand behind our commitment to sustainability, Heery designed Medical Center of the Rockies (MCR), a 595,000 Sq.Ft. tertiary care hospital in Colorado, which is currently the largest of three LEED Gold Certified hospitals in the US. Recently, MCR was awarded the 2010 International Sustainable Design Award, one of the most prestigious awards given by the Design & Health International Academy. An intensive approach From the project's inception, the owner's intention was to create a sustainable facility that would enhance the health of patients, visitors and staff. It was incumbent upon every member of the team to contribute the best ideas for bringing this vision to life. MCR was designed and constructed in 32 months using a fast track and integrated project delivery

amount of value in terms of energy and raw material conservation, durability, and performance over many years of service. Together with the assistance of all selected contractors and suppliers, the team managed the design and budget in real time to a fixed budget amount. Not only does the end product exceed the owner's and the community's expectations, but the project was completed for US $250 per square foot ($2550 per square meter), while still achieving LEED Gold. Footprint gambit Efficient medical planning and adjacencies resulted in a reduced footprint that conserved materials. Designed as a hospital within a hospital, MCR houses the Heart Center of the Rockies and the Trauma Center of the Rockies. While the separate centers are clearly designated throughout the building, they share key facilities, diagnostics and equipment, resulting in significant cost benefits and circulation efficiencies. Daylighting, a challenging feature to incorporate in hospitals, was not only woven into the patient rooms in an extensive way, where windows are larger than traditional hospitals, but into traditionally darker zones of the hospital by virtue of the hospital configuration and shape. Equally important in the western United States is conservation of water. MCR earned several key LEED points for water conservation in its design of landscaping and plumbing systems, and fixtures. Storm water from the 90-acre site is managed and discharged from a newly created wetland zone on the site. Other sustainable elements include recycling 75% of the construction waste, maximizing recycled materials, orienting the facility properly to increase daylight into the facility, storing information electronically to create a paper-lite facility, and specifying low VOC materials, wherever possible, to minimize off-gassing. As a result, the facility will use 35% less energy than the average hospital. Also, five Innovation and Design Process points were achieved with one attributable to Cooling Tower Efficiency and another point related to Floor Plan planning efficiency. Beyond the horizon Heery sees a huge untapped opportunity in the delivery of quality healthcare to the broader world. Our alliance with Hosmac India will bring innovative planning and design to the healthcare industry, and further the quality of healthcare within various nations. We believe the collaboration between Heery, Inc. and Hosmac India will benefit the world healthcare system and make a true difference in the lives of many for the years to come.

To know more, contact Mark D Johnson at mdjohnso@heery.com, Bhavik H Rao at brao@heery.com, or visit www.heery.com.

method, involving architects, engineers, designers, construction team members, clinicians, and the owner's representatives. Through this team process, every detail and material selection was evaluated for its first cost versus lifecycle cost implications. Unlike most new hospitals built in the US, MCR was planned for a 100-year life cycle, acknowledging the extremely high value of its land and the quality of views, public access, and the growing community in which it resides. With that in mind, the Heery Design Team focused its selection of materials and systems on those which provided the greatest

The right thing to do

Gaurav Chopra, Practice Leader - South Asia Region and Gaurang Sheth, Senior Designer at HKS, Inc. team up to unveil their rightsizing operation at The Hualapai Mountain Medical Center, USA.

At the heart of historic Route 66 in Kingman, Arizona is the new Hualapai Mountain Medical Center an 180,000-square-foot, 70bed general acute care Greenfield hospital. To make this a viable project, the design team implemented considerable lean cost-saving strategies as well as significantly streamlined the schedule. A project of this scope and size usually takes 24 months to construct â&#x20AC;&#x201D; instead, this project took 15.5 months. In addition, the owner saved approximately $75 per square foot construction cost when compared to similar projects. Situated serenely near the base of the Hualapai Mountains, the center welcomes patients and visitors to an oasis of healing featuring large open spaces, grand expanses of glass and soothing desert colors. The center focuses on providing highacuity services, and includes four operating rooms, one cath lab and a 22-bay emergency department. The hospital provides heart services, inpatient and outpatient surgery, medical services, and intensive care and emergency services while employing state-of-the-art diagnostic imaging and laboratory services as well. Efficient Rightsizing Striking a design balance between the vast program elements of the new Hualapai Mountain Medical Center facility and the budget required a well-choreographed process. The design team listened carefully to the client to provide a custom functioning hospital, but also contributed to the owner's efforts to save dollars without affecting functionality. This process started at the block planning phase and continued through the construction process. In order to produce a simple, elegant solution, the design team demonstrated its understanding of the challenges and complexities of healthcare operations and design scrutinizing the overall operational model of care, workflow analysis, patient throughput, staff efficiency and safety concepts. To optimize space at Hualapai, operational designs were analyzed allowing for wasteful space and processes to be removed prior to committing to floor-planning layouts. The design team's efforts were centered on giving the client the most value for its money.

HKS Architects and MedCath, Inc. led the planning effort from programming through schematic design, design development and construction. Corporate executives, physicians, key clinicians and community advocates were involved throughout the process to assure that the facility meets the projected demand, patient and staff needs, and community desires. Their prior experience helped when establishing lean design protocols and goals. Operational Lean Strategies The current standard in healthcare design is to provide a completely flexible space that can accommodate any critical scenario. This approach can result in over-programmed, excessive square footage rooms that have an extreme impact on the overall cost of the hospital. At Hualapai, the following lean concepts were applied, contributing to efficient space allocation: Âˇ Hualapai integrated inpatient/outpatient services within a

The right thing to do

A project of this scope and size usually takes 24 months to construct — instead, this project took 15.5 months. In addition, the owner saved approximately $75 per square foot construction cost when compared to similar projects. Situated serenely near the base of the Hualapai Mountains, the center welcomes patients and visitors to an oasis of healing featuring large open spaces, grand expanses of glass and soothing desert colors. The center focuses on providing highacuity services, and includes four operating rooms, one cath lab and a 22-bay emergency department. The hospital provides heart services, inpatient and outpatient surgery, medical services, and intensive care and emergency services while employing state-of-the-art diagnostic imaging and laboratory services as well. Efficient Rightsizing Striking a design balance between the vast program elements of the new Hualapai Mountain Medical Center facility and the budget required a well-choreographed process. The design team listened carefully to the client to provide a custom functioning hospital, but also contributed to the owner's efforts to save dollars without affecting functionality. This process started at the block planning phase and continued through the construction process. In order to produce a simple, elegant solution, the design team

Rooms used in the morning by pre-op patients can be used by post-op patients later in the afternoon Operational Lean Strategies The current standard in healthcare design is to provide a completely flexible space that can accommodate any critical scenario. This approach can result in over-programmed, excessive square footage rooms that have an extreme impact on the overall cost of the hospital. At Hualapai, the following lean concepts were applied, contributing to efficient space allocation: · Hualapai integrated inpatient/outpatient services within a single department to reduce duplicated key spaces and allowed for the sharing of support spaces. · A medical record, or electronic chart, protocol that facilitated a lean process was developed. This helped reduce waiting room time, thereby reducing waiting room space requirements. · A just-in-time delivery model for all support services was developed. The materials management department is smaller because the space needed to store supplies was greatly reduced; supplies are not stored onsite. · Caregiver-patient time was increased by reducing travel distances from support rooms and nurse stations to patient areas. · Similar rooms such as operating, imaging, ICU and acute care rooms were standardized to promote patient safety as well as to increase the ease and speed of construction. · Square footage was reduced by co-locating general lobby waiting with surgery and imaging waiting.

Rooms used in the morning by pre-op patients can be used by post-op patients later in the afternoon

· Pre-op and post-op patient rooms were combined. Rooms used in the morning by pre-op patients can be used by post-op patients later in the afternoon.

demonstrated its understanding of the challenges and complexities of healthcare operations and design scrutinizing the overall operational model of care, workflow analysis, patient throughput, staff efficiency and safety concepts.

· Separate circulation patterns were provided for staff,

To optimize space at Hualapai, operational designs were analyzed allowing for wasteful space and processes to be removed prior to committing to floor-planning layouts. The design team's efforts were centered on giving the client the most value for its money.

· Inpatient units were organized by patient acuity to improve

Successful architecture involves listening to client expectations and respecting architectural integrity while balancing budget and schedule. The Hualapai design team brought to the table a sound general knowledge of how basic design decisions affect construction cost, and successfully applied cost-saving concepts without affecting overall function.

patients and materials to improve workflow. This project used the "on-stage/off-stage" concept with separate public and staff corridors both staff efficiency and patient safety. Design Lean Strategies

On the Hualapai project, the owner realized cost savings when

spacing relative to the functional design, and the cost of concrete versus steel, as well as the availability of these materials. An appropriate structural system was then selected to increase the speed of construction, provide long spans for flexibility, enable better coordination between trades and provide flexibility above the ceiling for future changes. 路 The bed tower was suited to a concrete flat slab system due to the rigid layout of patient rooms and column spacing. This method reduced the overall building height and structural depth required. In addition, the MEP systems were easier to coordinate and quicker to install due to the absence of structural beams. 路 Over the diagnostic areas, a long span roof system provided a large column-free space for flexible floor plan layouts as well as increased the speed of erection to improve the construction schedule. Fast-Tracking at Hualapai A fast-track construction schedule is an essential part of a project's cost-saving strategy. On Hualapai, the design team established a working relationship with Lott Brothers Construction early in the design process to define documentissue milestones that melded with the construction schedule. The documents were issued using a just-in-time method to maximize coordination efforts, while at the same time keeping all of the contracting trades working as efficiently as possible without scheduling gaps between subcontract scopes. The contractor's early involvement facilitated feedback from subcontractors bidding on the job. Resulting revisions or changes to the design of building components or MEP systems cost less during design than in the field during construction. This fast-track schedule required close coordination of all team

members to keep the schedule on track and realize the maximum savings offered by a shorter schedule. The new Hualapai Mountain Medical Center is a distinct example of balancing operational effectiveness and rightsizing square footage without sacrificing the customer experience. Based on a patient- and family-focused design, the costeffectively designed hospital is committed to setting the standard for healthcare delivery in Kingman and northwest Arizona.

To know more, contact Gaurav Chopra at gchopra@hksinc.com, Gaurang Sheth at gsheth@hksinc.com or visit www.hksinc.com.

Intensively Planned ICUs Dr. Dattaraj Pendse, Facility Planner - Hosmac Projects, gives a rundown of the intricacies involved in building Intensive Care Units.

ICU (Intensive-Care Unit) refers to a highly-specified and sophisticated area of a hospital in terms of infrastructure, technology and manpower dedicated to the treatment of critically-ill patients with injuries or complications. Coupled with the highest order of quality control, education, training and research, an ICU operates with defined policies, protocols and procedures. In these changing times, the ICU entails a distinct team in terms of doctors, nursing personnel and other staff who are attuned to serving critical situations. These days, the trend is to have free-standing ICUs set up for individual modalities such as Neuro ICU, Cardiac ICU, Surgical ICU, Transplant ICU, Pediatric ICU, Neonatal ICU and the likes. Concept of ICU · Defining the standard of ICU-grade, such as Level-I, Level-II, Level-III or Tertiary Unit, is essential · The number of ICUs needed in an institution must coincide with the number of beds · Modalities to be included must be noted · Infrastructural settings such as location, space, placement of departments, extra space for support services need to be explored with the internal planning of ICU Inventory · Equipment Planning will depend on the number of beds, target level, and modalities of the ICU · Other important decisions must be taken considering the number of ventilated beds and availability of invasive monitoring

Setting up an ICU It is recommended that the total bed strength in an ICU should be between 8 to 12 and not below 6 or above 14 at one stretch. Ideally, the ICU should be divided into 3-4 cubicles of 4 beds each. This helps in separating patients on the basis of modalities and diseases, and in the treatment control of patients. It also diminishes the probability of cross infection. Effective steps and planning to control nosocomial infections must be taken. Protocols such as allowing visitors, footwear etc. inside ICU must be put in place. HVAC planning ICUs should be fully air-conditioned, which allows the control over temperature, humidity and air change inside the unit. Suitable and safe air quality must be maintained at all times. Air movement should always be from clean areas. It is recommended to have a minimum of six air changes per room within an hour, with two air changes per hour composed of outside air. Central air-conditioning systems and re-circulated air must pass through appropriate filters. It is recommended that all air should be filtered to 99% efficiency down to 5 microns. Heating/cooling should be provided with an emphasis on the comfort of the patients and the ICU personnel. For critical care units having enclosed patient modules, the temperature should be adjustable within each module to allow a choice of temperatures between 20 and 25 degree Celsius. The isolation rooms would need separate air handling units to maintain the air quality and pressure. Power back up in ICU is a serious issue. ICUs must have standalone power generators that automatically recoup in the

Event of a power failure. This power should be sufficient to maintain conditioned temperature and run the ICU equipment, though most of the essential ICU equipments have backup batteries. Voltage stabilization is also mandatory; hence, an Uninterrupted Power Supply (UPS) system is suggested for ICUs. Sound control The International Noise Council recommends that the noise level in an ICU must be maintained below 45 dBA in the daytime, 40 dBA in the evening and 20 dBA at night. Aperture settings Accessibility to outside natural light is recommended. It is known to improve the staff morale and patient recovery, also to save a patient from ending up into ICU psychosis. Natural lighting in the unit evidently minimizes power consumption, which is of the essence in India. Access to natural light also means that the patients have an access to view the external environment, which may be developed into a green and soothing vista. For general patient-care, the illumination should be bright enough to ensure adequate vision without eyestrain. The interior must be designed to best avoid glares created by reflecting lights. Higher frequency fluorescent lights and coated phosphorus lamps may be good for assessing the skin colour and tone for doctors. Floor lightings are important around the bedside and in the hallways at night to ensure the safety and comfort of patients. Black-out curtains or blinds must be installed on windows since patients often need rest during the daytime.

They must have clear access to the lifts and main corridors. Lifts, corridors and ramps should be spacious enough to provide smooth movement of a critically sick patient on his bed, trolley or wheel-chair. A thoroughfare is not required but there should be a single entry/exit point to the ICU that is manned at all times. However, emergency exit points are mandatory in case of a catastrophe. ICU bed designing and space planning While defining the area allocation for bed bay, the space required for the bed must also be recognized. Bedside lifesaving equipments like ventilator, dialysis machine, body warmer; mobile diagnostic equipments like USG/2-Echo machine, mobile X-ray machine; medical furniture, staff movement space around the bed, among others are also to be considered. These will ensure better and fast service at the time of emergencies as well as ease the movement of patients in and out of the bed bay. A separate procedure room should be allocated for the procedures like tracheotomy. It is advisable to set aside the provision of dialysis for atleast one or two beds in a mediumsized ICU. The planning should support one or two isolation rooms for the infected/immune-compromised patients. The isolation room will have one ante room in addition to the patient bed bay for the sink, change and writing. This room will also act as a pressure cut-off lobby for the isolation room.

Floor, wall and ceiling coverings In the Indian context, vitrified, non-slippery tiles are satisfactorily good. They can be fitted into reasonable budgets, are easy to clean and move on and may be stain proof. Ideally, hospital floors that absorb sound while enhancing the overall look and feel of the environment must be procured. Walls should meet the criteria of durability, ability to clean and maintain, flame resistance, mildew resistance, sound absorption and visual appeal. Door-stoppers and handrails should be placed well to reduce abuse and noise to minimum; it helps patient movement and ambulation. It is the ceiling surface that patients see the most when under treatment or bed-rest, sometimes for hours on end over several days or weeks. Hence, bright spotlights and fluorescent lights that cause eye-strain must be avoided. Ceilings must be prevented from soiling or fragmentation due to leakage and condensation. Rather than a plain back ground colour for the walls and ceilings, painting them with a medley of soft colours in patterns or murals would make the ambience more pleasingly for both, the patients and the staff. Disaster preparedness All hospitals should be designed in accordance with an established disaster management system. Within an ICU, measures must be inducted to overcome fire, accidents, infection and such unforeseen incidents. An emergency exit must be designed which can serve as a rescue point in times of an internal disaster. There should be a provision of a contingency room within the hospital, where critically-ill patients may be shifted temporarily. HDU may be the best place if beds are vacant. Adequate fire-fighting equipment must be present inside and outside the ICU. Location of ICU in Hospital Safe, easy, fast transfer of a critically sick patient should be set on high priority during the planning of an ICU's location. It should be located in close proximity to the emergency room, diagnostic department, operating rooms and trauma ward.

Conclusion Of late, ICUs have emerged as a separate specialty altogether, and can no longer be regarded purely as a part of anesthesia, medicine, surgery or such other area of expertise. The growth in the domain of ICUs is evident, but much needs to be done in area of infrastructure, human resource development, protocol, guidelines formation and research in accordance to Indian circumstances. Nevertheless, the scenario of ICU development is fast catching up in India. Acceptable guidelines must be adopted for making ICU designing guidelines which would be good for both rural and urban areas, as also for smaller and tertiary centers which may include teaching and non teaching institutes. Only sufficient groundwork and forethought can determine the blueprints of an efficiently managed Intensive Care Unit, which in turn can considerably impact a hospital's overall performance. The care and comfort that an ICU of any hospital provides to its patients ultimately establishes the value of that hospital. Hence, the designing and planning stage of an ICU surely deserves immense ICU-support before settlement.

The author can be reached at raj.pendse@hosmac.com.

Doctoring finance Narendra Karkera, Senior Advisor - Hosmac India, advises on how costing can be used as a tool by hospitals to improve the financial bottom line.

The fundamental framework of any profit-making organization attempts to escalate its financial bottom line. It refers to the difference between sales and expenses. The most constructive way to increase sales is to expand the activity volume (utilization and efficiency) of the Sales Department. However, this obvious approach is conceivably the most arduous of exercises in every organization. The elements that affect sales adhere to the universal demand and supply law. They can be notched up by way of discounts, charity, public relations, write-offs etc. There should be a defined authority to sanction and a laid down procedure for granting such concessions, since it directly affects the bottom

expenses including payment to doctors. In case this percentage reaches 40%, corrective measures to reduce it must be called for. A positive stratagem is to optimize employee utilization with efficiency, reallocation, multi-tasking and such other exploits. A negative approach would be to retrench or reduce salaries, though this is a very difficult process. Inversely, if the manpower is significantly remunerated and motivated, they would soon emerge as a magnanimous asset; but, if handled wrongly, would become a major difficult liability. Inventory Another equally important cost element is the inventory, which comprises of equipments and materials supply depots. These include pharmacy, surgical store, medical store and other material store. The control should start right from the request to buy up to the ultimate consumption. Here, both the price and quantity is required to be monitored based on the needs. The best price and quality supported bargain coupled with adequate market comparison is essential, as wrong purchases would result in cash loss. Overstocking at the main store or sub store would also block money and result in interest loss. There are other damages that may happen due to overstocking such as incurring wasteful inventory carrying cost, pilferage, expiry, breakages etc. Equipment

line. The process of sanction should be invariably difficult so as to discourage deductions from sales, which also come under the scanner of income tax authorities. As a last resort, organizations can even consider an increase in tariff in the worst case scenario, after having exhausted all other methods of improving sales. Insurance The revenue generated in Indian hospitals by way of insurance is only around around 10% of the total. However, in the near future, insurance would be a major source of income. Contrastingly if insurance processing is not handled properly, major cash losses are probable. Insurance companies normally favour cash-less provisions in order to attract clients, wherein they ask the Provider to send invoices in batch sizes of one month. This way, the clients give a pre-dispatch credit to insurance companies before the actual credit period ticks in. Once the credit period begins, claims are processed and the payments are to be cleared within the contracted credit period, but the probably of it is low. If there is a discrepancy/mistake in the claim then the whole batch is sent back for correction and the money gets blocked for a longer period than contracted. This results in an interest loss, and if the invoice itself is rejected then cash is lost. Under both circumstances, the bottom line suffers. Manpower Almost 35% of the hospital revenue is spent on manpower

To avoid wastage, equipments must be bought as per the hospital needs. Thorough negotiations must be dealt with. A complete maintenance contract for atleast the first ten years should be fixed at the time of purchase, as part of the negotiation. The required spare parts' prices should be frozen so that there are no surprises in future. Information technology IT is perhaps the most important of tools to reduce cost. Hospital operations have millions of transactions/entries, and if a good IT system is in place, performance will streamline with records. You can have less staff, more clarity and quality output. For instance, in Insurance invoice processing, if the Electronic Data Interface (EDI) is available then all transactions/reports will reach insurance companies on a realtime basis. Both the pre-dispatch credit and post-dispatch credit time is hence eliminated, and money flows in quicker, with the disallowance reduced to almost nil. Good Electronic Medical Records (EMR) would reduce the hassle of transferring tons of papers between various departments and doctors resulting in reduced cost and better quality work with quick response. If all the modules are interfaced, single source document would deduce the final results and statements - in short, no hassle of reentry which results in human error and additional work. Outsourcing Outsource some of the services as far as possible to professionals who specialize in hospitality, engineering, maintenance field and clinical areas. This would ensure quality service with less cost since these professionals deal with a larger volume, thereby reducing the administrative burden on the hospital management.

Breakeven point Normally, budgets are made for various elements of cost, revenue, cashflow, equipment activities etc. Targeting atleast a breakeven point year-on-year is a prudent approach, and if the budgeted breakeven point is lowered over the years,

utmost importance in any healthcare system and cannot be compromised. Quality checks aid in identifying process deficiencies which when revamped may result in cost reduction by doing away with unwanted processes. Quality checks and cost controls should go hand-in-hand in hospitals to ensure orderliness. Before services are price-tagged, it is necessary to study the processes involved. The next step would be to identify the process owners, whose definition of their respeective processes must be amalgamated with the established best practices. This study should clearly reveal under utilization and inefficiency, if any, with suggestions for corrective action. As per the best practices neither the under utilization cost nor the inefficiency cost of the organization should be passed on to the customer. Therefore it is advised to have a complete process revamp done to arrive at an accurate utilization and productivity (efficiency) analysis based on which a road map for the future can be created. With the entrance of health insurance, costing of the services has become even more essential. Insurance companies demand high quality service and a low tariff structure; for which, correct systems and procedures are required to be installed, which would result in lowering the cost. If the tariff does not match the quality, the hospital may be downgraded and a lower tariff should be granted.

pressure to improve revenue efficiency or reduce the cost is imperative. Liquidity Management Poor liquidity management is the result of blockage of funds in current assets. In turn, loss of interest on the blocked funds will be faced. Most importantly, if these current assets are not liquidated within the stipulated time, then there is a fear of losing them. Particularly, long term debtors would turn into bad debt; old inventory would become obsolete or expired. Similarly, better credit facilities from suppliers must be found, but this should not result in supply at a higher prices. However, in the event of suppliers not receiving their payments on time, credibility will markedly suffer. Cost Accounting There are several advantages of a proper cost accounting system, listed as below: · Cost awareness results in cost control and cost reduction · Auto internal audit of performance and cost facilitates controls on all cost centers · Generates MIS on cost comparison and performance for various periods ·

Aids in tariff fixation and inventory valuation

Facilitates budgeting exercise

Nevertheless, a costing exercise initiated by the management normally would be met with resistance from the staff, since it would lead to a number of revelations which would push them out from their comfort zones. These exercises may also be discounted as worthless and may be perceived as unwanted expenditure. But if the costing exercise is taken in the right spirit, it would be a boon to the hospital in improving its performance and result in cost reduction. The staff should be taken into confidence before the start of such an exercise in order to help them understand its importance alongwith its use in improving their individual and departmental efficiency. Such an exercise can also result in a financial turnaround and augment profitability. Another important point to be kept in mind while implementing cost accountancy is not to forego the quality. Quality is of

A nagging question that refuses to go away is that of the conventional costing system being good enough as on today. We have moved from the old system of Total Cost Approach (traditional) to Marginal Cost Approach (conventional), a couple of decades back. The need of the hour is a system that would give us accurate costing, namely, the Activity-based Costing System. In a hospital scenario, it is observed that the variable cost is very low i.e. around 40% (direct consumable, doctors charges etc.). A major portion of around 60% of the cost is fixed cost (overheads). Therefore, the contribution margin in hospitals are larger and may mislead in viability decision-making process of a service. Activity-based Costing reduces the contribution margin to a minimum by making majority of the cost direct. When the contribution margins are small, it puts a lot of pressure on the hospital to perform in order to get higher occupancy, thereby avoiding cash losses. This sort of pressure is good in the hospital industry, where breakeven point occupation is very high (65% to 75%). Under the conventional costing method, if the hospitals do not handle computation of overheads properly for the services, it would result in wrong costing and product pricing. Due to this very reason of non-capability to apportion the overheads appropriately under the conventional costing method, it is recommended that we move towards a more refined system i.e. Activity-based Costing. The benefit of implementing the Activity-based Costing method is that it results in accurate costing, focused approach to hospital overheads, conversion of indirect costs into direct and introduction of inter departmental billing. Further advantages of Activity-based Costing include equal importance to service centre like revenue centre; activities of the service centre is monitored continuously; under utilization and inefficiency of both revenue and service centre are highlighted; and self-discipline in both revenue and service centres. In short, each cost centre shall work like a strategic business unit, and would be seen as a profit centre, whereby reducing the burden of the hospital administrator in monitoring the day-to-day operations. Activity-based Costing has thus become a priority in all hospitals for their survival and future growth.

The author can be reached at narendra.karkera@hosmac.com.

Relax, breathe and heal

Vinay Pagarani, Development Manager — Hosmac Foundation, caught up with Dr. AM Joglekar, Surgeon Commander -Indian Navy (retired) and Specialist in Marine Hyperbaric Medicine, to ratify the word on the street about HBOT. A revelation so deserving yet so overdue — the hyperbaric medicine — has finally come into force in India. Found to be gratifying in the most unforgiving of cases, hyperbaric medicine has expeditiously unveiled its worth. About HBOT By definition, hyperbaric medicine, a.k.a. Hyperbaric Oxygen Therapy (HBOT), deals with physiological and therapeutic applications of barometric pressure more than sea level. Patients are subject to breathing 100% oxygen in a special chamber, which is how hyperbaric oxygenization is made possible. How it works A hyperbaric oxygen chamber is a sealed chamber, into which oxygen is pumped under a controlled amount of pressure. Hyperbaric Oxygen Therapy allows a patient to breathe up to more than four times the normal amount of oxygen, thereby greatly increasing the oxygenation of all of his/her organs,

efficiently and carry out their processes in an accelerated manner. Conditions HBOT can help cure This constructive therapy has gained immense value as a lifeand-limb saving measure in several medical and surgical conditions. Most commonly used for Diabetic wounds and severe crush injuries of limbs, HBOT proves effective in recovery of otherwise non-healing wounds. HBOT has evidently enhanced the healing process in conditions, such as: · Damage to soft tissue and bones due to radiation as a part of cancer therapy ·

Severe soft tissue infections including Gas gangrene

Resistant bone infection (Refractory Osteomyelitis)

· Select cases of severe fungal infections, thermal burns, carbon monoxide poisoning and smoke inhalation Decompression Sickness (DCS) after diving or compressed · air works · Plastic surgeons too find it convenient to provide HBOT to patients with compromised skin flaps and grafts Though, HBOT does add to treatment costs since it is coupled with a primary treatment, it also significantly reduces the overall hospitalization bills due to faster healing, besides bettering outcomes in the seriously ill or chronic and vexing disorders. HBOT at Godrej Memorial Hospital

tissues, and body fluids. It is the pressure in the chamber that allows for the much greater absorption of the oxygen provided. When a patient is in the chamber, the increased pressure causes the blood plasma and other liquids of the body to absorb much larger quantities of oxygen, greatly increasing oxygen uptake by the cells, tissues, glands, organs, brain, and all fluids of the body. The chamber becomes a “goldmine” of oxygen, which is utilized by the body for vital functions.

A multiplace chamber, such as the one at Godrej hospital, has several patient friendly features — the roomy interior provides adequate comfort. It allows up to six patients to either lie down or relax in a sitting position. A trained, in-chamber, medical attendant accompanies and monitors the patients during Treatment. The center is managed by a team of Hyperbaric

This increase in oxygen allows for increased circulation to areas, in spite of swelling or inflammation. At the same time, the increased pressure decreases the swelling and inflammation. The additional oxygen accelerates the healing process and enhances the white blood cells' ability to fight infection. It also promotes the development of new capillaries, the tiny blood vessels that connect arteries to veins. It also helps the body build new connective tissues. HBOT helps impaired organs to function better. By providing the cells with an abundance of oxygen, the cells react and are revitalized. They can now function more

Dr. AM Joglekar with the HBOT multiplace chamber at Godrej Memorial Hospital, Mumbai

physicians, anesthetists, and nurses, with experience in HBOT. 'Godrej' is perhaps the first private hospital in Mumbai to set up a multiplace chamber facility, to provide patients with Hyperbaric Oxygen, at its newly commissioned department of Hyperbaric & Diving Medicine. The department, headed by Dr. Joglekar, has helped many a critical patients through the most unrelenting of cases.

The roomy interiors of the chamber Extracts from the interview: VP: What are the costs involved in setting up an HBOT system? AMJ: Equipments and allied materials cost little over a crore of rupees. The total cost of building a multiplace chamber comes up to Rs. 2.5 crores. Monoplace chambers are comparatively cheaper but with much reduced capabilities. VP: What is the average duration required for a treatment? AMJ: HBOT is given in 'sittings' lasting 60-120 min. In acute conditions, healthy results are visible in 10-15 sittings; whereas chronic conditions call for 20-40 sittings. VP: Are there courses and training facilities to learn HBOT for staff? AMJ: A 2-year diploma course in HBOT Treatment, which covers training in hospital units, diving medicine, submarine medicine and shipboard medicine, is avaible at the Mumbai University. These Marine Medicine or Hyperbaric Specialsts form the core of the team, whereas Anaesthetists may be deployed for routine HBOT delivery. VP: Any message for the Indian healthcare industry? AMJ: India, being such a vast country, is still short of critical care hospitals. Every major city would do much better with 2-3 life & limb saving centres, attributed with an HBOT chamber. The HBOT service at Godrej Memorial hospital has undeniably proved to be an innovative gift to our patients. The Indian healthcare industry needs to explore new techniques such as the HBOT.

To know more about hyperbaric oxygen therapy, contact Dr. Joglekar at hospital@godrej.com.

Streamlining the lab setting

25 years since, management guru Peter Drucker's wellestablished theory holds water even today. â&#x20AC;&#x2DC;Profit may not be the primary goal, but it is an essential condition for a company's survival.â&#x20AC;&#x2122; Thus, although most hospitals are established to meet a social cause, the success of its sustenance and growth will largely depend upon how efficiently it manages its funds.

Research done by Hosmac India indicated the market average to be at almost 10-20 SqFt/Bed; though, international literature would put this at 20-30 SqFt/Bed. Some studies done by scientists like Dr. Rappaport state that the percentage area distribution for some of the sections in a lab is as follows:

The Department of Laboratory Medicine is recognized as one of the major revenue generating sources in a hospital setup. Laboratories today can even stand alone, if not within a hospital. Hence, it is imperative that the planning and management of lab services meets the challenge of ensuring a smooth flow of the 2 Ms: man and material. Adequate space for existing services and flexibility in design to allow future expansions must be intrinsic of this department's structure. Conventional laboratories essentially include multiple key components viz. Biochemistry, Haematology, Microbiology, Histopathology, Clinical Pathology and Serology/Immunology. Location and setting The daily operation of a laboratory fits the theoretical description of a semi-markov chain with job shop characteristics. This is because an order for multiple tests may require activity at several work stations; the procedure of scheduling tests is similar to that in a manufacturing unit that handles sundry small-scale customer-orders like a job shop. Hence, the facilities must be planned to facilitate this interdepartmental activity, and its smooth functioning in relation to other services of the hospital, keeping in mind its flexibility and expansion. Ideally, laboratory services must be located in close proximity to the inpatient area and outpatient department (OPD). Diagnostic tests requested from the OT, casualty or the intensive care units oftentimes require urgent diagnosis; hence, easy access to these rooms is also desirable. It is recommended that in situations where such an ideal location cannot be detected, there be at least a Blood Collection room at the OPD and a Stat lab, which is easily accessible from critical areas like OT, Casualty and ICU. The main laboratory may then be located at any suitable place in the premises. For planning and efficiently running a laboratory, it is also important to study the workflow of the department. Space Planning The total area required for a laboratory depends on many parameters such as the number of sections to be included; the bed size (which would, in turn, deduce the number of tests done); the workflow adopted; automated or manual etc.

Jagruti Bhatia, COO - Hosmac Consultancy Services illustrates on the laboratory medicine department, which has emerged as a prime revenue source in a healthcare setup.

During the planning stage, multidisciplinary factors such as the following must also be considered: · The size of equipment required to be set in the different sections · Storage space required · Movement of sample, reports, information and staff · Special requirements for interior design like the materials for table tops, flooring, planning for the electrical outputs, adequate lighting, temperature, furniture etc. These are to be specified in adequate detail like spaces near the microscopes have to either have enough natural light or as near the other work areas lighting of 500 lux. This is in contrast to the areas like the Biochemistry or Serology, where direct sunlight may cause untoward reactions in various chemicals or reagents. Thus, we can infer that the planning of this department will involve interweaving multifarious factors. But research has shown that a well-planned and equipped lab streamlines the staff time by almost 40 %, mainly attributed to the reduction of cri ssc ros sin

· What to buy · When to buy · What technology is best suitable · The size of the equipment (based on projections made by consultants for upcoming hospitals or depending on the existing workload requirements and the projected increase) · For what price to buy · At what terms to buy Manpower Planning and Staff Scheduling The manpower serving a laboratory calls for a class of talented and acute technical experts. Generally, high-end medical technologists would be recruited in shifts to run the lab, 24 by 7. Only this would ensure the availability of diagnostic facilities during emergency situations. The lab technician can be assisted by lab assistants and/or lab attendants. The manpower planning in the laboratory has to also bear in mind — productivity, to give an accurate evaluation of the efficiency in the lab. The productivity standard can thus be used for a dual purpose indicator: one, to check the efficiency level of the existing manpower and estimate whether there is adequate staff; second, to calculate the manpower required to touch a higher productivity benchmark. The American standard for a fully automated lab reaches 9,000 - 12,000 tests performed/technologist/year; and the Indian standard comes to about 7,500 tests/technologist/year. However, one leading private hospital in Mumbai has managed to exceed these standards, where the productivity is close to 11,000 tests/technician/year. This can be attributed to the high level of technology and automation put in place. In contrast, there are some public and charitable hospitals where this ratio is as low as 4,500 6,500 tests/technician/year. Revenue generator The department of laboratory medicine is rightly known as a 'cash cow' in hospitals. Whether as a single unit or a part of the hospital, the department's revenue generating capabilities are realized, almost instantaneously. Statistics show that a laboratory generates almost 20% to 29% of the hospital revenue in mediocre hospitals. In hospitals where this department forms a thrust area, as is the case with many of the leading hospitals, this percentage is much higher. Besides, the argument that the surgical section also generates considerable revenue for a hospital can be repealed with the fact that the expenditure involved in these departments is much higher, bringing down their net earnings.

g of events, thus ensuring a smooth workflow. Better working conditions also enhance productivity.

In recent years, the department of laboratory medicine has become an integral part of every hospital. This is owing to the fact that a patient is required to undergo clinical investigations to not only aid his diagnosis, but also monitor the progress of his treatment. With latest advances in science and technology, this field has undergone a sea change — shifting from manual to high levels of automation.

Groundwork for equipment Equipment planning in the laboratory is a complex process; since the technology involved ranges from low-end equipments like flame photometers to high-end equipments like automated electrolyte analyzers with attached monitors and printers. Simultaneously, the cost of these also varies with wide margins. A case in point is the chemistry auto-analyzers, which range from 3 lac INR to 60 lac INR; this cost variation persists for almost all the equipments. Hence, the decision making involves a complex exercise insisting for a team effort by Technical, Managerial and Financial experts. The points considered are:

The author can be reached at jagruti.bhatia@hosmac.com.

Flexibility in healthcare planning Hussain Varawalla, Mentor - Design Services - Hosmac India, touches upon the need for architects and planners to invest a design that sows the seeds of flexibility in a healthcare facility. Prior to the last 50 years, medical breakthroughs unearthed not more than a couple of times per decade. The '60s and '70s witnessed some evolution in the field of organ transplant, noninvasive surgery, synthetic antibiotics, and in related fields to healthcare delivery such as communication systems, automated material movement systems and building systems technology applied to healthcare facility construction. In the 1980s, major medical innovations came even more rapidly. With the '90s setting in, faster advances in medical technology were seen, together with new methodologies and mantras such as ‘patient-focused care’, ‘multi-skilled staff’ and ‘paperless medical record’.

· Reinforced emphasis on patient (self-)education in the hospital setting Based upon these more or less incomprehensible and exponential changes in clinical services, operational trends and advancements in technology, the diverse facilities — hailed as state-of-the-art two decades ago — are fast becoming obsolete long before the life of their building shell comes to an end. Narrow floor plans, too many solid walls and low floor-tofloor heights do not permit the expansion and renewal of healthcare facilities that is the need of the time. The Question Should the driving force be the cost of operating services rather than the cost of the building? The Planning Process While planning a healthcare facility — or any facility for that matter, there are the following broad phases of work: 1. Strategic Planning 2. Master Programming and Master Planning 3. Functional Programming In the traditional development process, this is followed by design development and contract documentation, but these aspects are beyond the scope of this feature story.

Today, the yoghurt has hit the HVAC system. Tannis Chefurka, Faith Nesdoly and John Christie write: · Decentralization of services and staff to patient care units, resulting in multidisciplinary care teams · Advances in communication/information systems for patient profiling and charting, for communications among staff, and between diagnostic services and patient charts · Continued clinical advances, many tending toward miniaturization and mobility · Increased acuity of both inpatients and ambulatory patients prevalent in the hospital setting · Increase in minimally invasive procedures, reducing the need for overnight admission · Expansion of outpatient clinics and creation of ambulatory ‘themes’ through selective clustering · Increased recognition of the family/caregiver's contribution to the healing process · Gradual acceptance of the benefits of non-traditional modes of therapy such as massage therapy and acupuncture · Expanded public awareness and access to information, fueling the consumers' desire for the latest in diagnostic techniques and treatments · Intensified point-of-care diagnostic testing · Magnified clinical research integrated into patient care settings

During these phases, all those concerned with the planning process are responsible for inspecting the ‘possibilities of the flexibility relevant to that phase’ and have a clear vision of what the following phase entails. The overall planning process, in this endeavor, rebuilds as the capital planning process, to which there is the operational planning process working in parallel. This, when linked to the facility planning process, will ensure that the planned facility is financially feasible. Flexibility in Strategic Planning Hospitals never develop into what we think they will. The corporate strategic plan, mission and vision statements will define the long term role of the organization, yet they ought to be fluid and changeable. They should anticipate changes in the program and service delivery. In short, the strategic plan is a living document. Consider the following questions during the strategic planning phase: Do we manage our way through changing service demands or design out of them? Historically, the approach to developing projections has been a straight-line graph. It never seems to plateau! New approaches focus on whether different service delivery approaches might allow the organization to gradually adapt with regard to demand. Do current trends create opportunities or barriers? A specialized service on a single site will create an opportunity to maintain and develop specialist expertise. But it can strike a discord, if the quality of service is not seen as worth going the extra mile to access the service.

Asked another way: Do alternate ways of clustering services within a facility create opportunities or limitations, in responding to long range demands and pressures? For example, will a pediatric strategic plan include pediatric rehabilitation, or will the rehabilitation plan include adult and pediatric rehabilitation? Where is the pressure for flexibility likely to be greater? The range of questions regarding flexibility will tend to recur in every phase, but the way in which this flexibility is to be achieved will become more narrowly defined and more tangible With each subsequent planning and design phase. Flexibility in Master Programming and Master Planning This is the first planning phase moving towards the design of the physical hospital plan. It is developed based on the strategic plan and describes programs and services at an outlining level, and it involves compiling basic workload and staffing projections. This information is then used to develop broadbrush estimates of space requirements and the relationships between them.

A functional program is a detailed document that describes the future functions and operations of a functional facility. At this stage of planning, the greatest flexibility needs to reside in the minds of the project planners to ensure that all relevant factors are considered. Flexibility-related issues in this phase include the following: 1. Operational trends — Consultants can provide benchmarking, but the staff needs to be up-to-date in these matters 2. Equipment choices — The location and selection of equipment are to be considered 3. Service consolidation — Operational efficiencies can be achieved by sharing support facilities

At the same time detailed information is gathered about possible site(s) for development of the facility. This site should be, among other things, of sufficient acreage to provide for any future expansion that may be necessary. Various other technical data about the possible site(s) is then compiled, which helps the architects and planners identify the constraints and opportunities offered by that site. A vade mecum to master plan the massing and construction phasing options, and preliminary capital cost estimates. A master plan is a living document and will require continual review and updating to make it functional as a planning guideline. There are the following issues to be considered in this phase: 1. The planning horizon — For how long into the future to plan for? 2. Single building v/s. healthcare campus — Single buildings will result in floor plates with substantially larger areas; the healthcare campus allows for progressive development towards an ultimate solution 3. Provision of support services — On-site or off-site? 4. Service growth and change — Placement of high growth services to allow for expansion 5. Building type — The location of space in specific building types may attract different design standards and unit costs 6. Vertical v/s. Horizontal expansion — Depends on a number of factors best addressed by the consultants Flexibility in Functional Programming

4. Utilization patterns — Spaces may be shared by accommodating different clinics on different days 5. Changes in hours of operation — This is an excellent option to accommodating additional workload, but the operating costs must be weighed against the capital cost of more space 6. Data communication capabilities — It is vital that this factor is provided adequately 7. Open concept planning — Allowing multiple uses and standardized service grids should be considered 8. Standardization of room sizes — Facilitates change in use more easily than custom-fitted room sizes 9. Flexibility at the patient bedside — The universal room concept 10.

Modular space planning — Using uniform planning units

Conclusion In the ideal world, the perfect balance is found between functionality of space and the generic parameters that afford its flexibility. Staff and patients will enjoy a pleasant and effective work/care environment. Construction dollars can be optimized. In the real world, this point of balance may seem elusive, but teamwork, attention to detail, and open communication throughout the planning and design process help us close in on our target. Planning a new healthcare facility affords an opportunity to create a dynamic and long-term solution in a manner that will allow the hospital to explore innovative and exciting ways to deliver healthcare to its community. An opportunity is provided to create a facility which delivers an inventive and flexible environment that will accommodate both the predictable and the unknown changes in a sustainable manner serving the organization, its patients and staff, their families, and the community, well into the future. The author can be reached at hussain.varawalla@hosmac.com.

Imagining the Imaging Department right

Anil Shastri, Senior Advisor - Hosmac Projects, advises on how the Imaging Department in any hospital or independent setup determines as a vital source of revenue generation. Where it all started On the 8th of November, 1895 medical imaging gained tremendous ground in hospital services. It was on this day that a physicist named Wilhelm Conrad Roentgen from the University of Wurzburg, Germany discovered an invention that would transform medical imaging history. His eyes were watching a luminous phenomena a faint, flickering, greenish illumination on a cardboard painted with fluorescent material in carefully darkened room. The rays emerging from Crookes' Tube penetrated the cardboard shield and fell upon the luminescent screen, thus revealing their existence in the darkness. The illumination was seen on the fluorescent screen due as with the invisible rays across the line of shadow. It was also observed that denser materials such as metals were lesser penetrable. The experiment was soon tried with humans, and it was discerned that human flesh were transparent but the bones opaque. The discoverer interposed his hands between the source of rays and the luminescent screen; consequently, his bones were visible excluding everything else on the screen behind. Later, the rays were named after their inventor, Roentgen (a.k.a. X-Rays). In 1901, Dr. Roentgen was honoured with the Nobel Prize for Physics, highlighting the pivotal milestone in the history of 'medical imaging'. The evident evolution Medical imaging has grown by leaps and bounds over the past century, assisted by modern advances in science and technology. Noteworthy innovations, coupled with myriad advances in applications and engineering fields, were seen. Holding high the rudimentary diagnostic tool of X-ray, many new inventions came about over the last century. Contrived

modalities such as Ultrasound, Nuclear Medicine, and Magnetic Resonance Imaging & Endoscopy were devised. Nonetheless, the quintessential X-ray diagnosis equipments form a backbone of the Imaging Department in any and every hospital, even

today. X-ray are still treated as the prime diagnostic tool, mainly due to its feasibility, whereas novel modalities such as the ones mentioned above are regarded as supplementary diagnostic procedures since they are relatively expensive. Be 'wary' careful Keep in mind that diagnostic modalities such as X-ray and nuclear medicine use ionizing radiations, which are hazardous to human tissue. And even though, these equipments are designed to shield the patient and working staff from unsafe exposures, their installations must support a regulated functioning. The Directorate of Radiation Protection (DRP), a branch of the Bhabha Atomic Research Center (BARC), has laid down some guidelines based on ICRP regulations to manufacture, market and install X-ray and nuclear medicine equipments. It is mandatory to adhere to the stipulated guidelines. Since ionizing radiations are harmful, some of the diagnostic procedures are even diverted to other modalities like Ultrasound, Endoscopy and Magnetic Resonance Imaging. Role of the Medical Imaging Dept

Assisting the clinician in diagnosis and treatment of diseases form the principal objective of the Imaging Department in any hospital setting. However, different types of hospitals, broadly, General and Super Specialty hospitals pose different workflows. General Hospitals They cater to the general masses, providing the vital facilities for diagnosis and treatment. Hospitals are further classified according to their modalities and respective bed strength.

CR System Modern Imaging Departments use this throughput technology. A CR system electronically captures the image on a plate to display on a monitor. Therefor, transferring or recording the image to another media is favourable. Upper: Quicker diagnosis Downer: Higher cost

路 Rural Hospitals (30 bedded) consist of the bare minimum basic requirements such as mobile X-ray equipment and minimal radiological system working on single phase mains supply in a dark room. Diesel generators serve as a back up to withstand power-cuts. Rural hospitals are set up remote from urban areas; oftentimes, they do not have qualified personnel radiologist. These hospitals are, however, equipped with mobile vans together with some basic radiological system for the chest and/or orthopedic X-ray to scan patients for diseases or injuries. 路 Cottage Hospitals (100 bedded) incorporate the standard prerequisites such as mobile X-ray equipment, 300mA hand operated X-ray equipment and back up diesel generators. These hospitals are located in small towns available with efficient radiographers. Uncomplicated procedures such as gastro intestinal studies are performed in such hospital. 路 District hospitals, (250 bedded) on the other hand, operate with more sophisticated equipments like motor operated X-ray tables with 40 KW X-ray generators. They help ease the load of chest, abdomen, ortho- X-rays as well as procedures such as GI, IVP etc. Dental X-ray equipments might also be a feature installed in some district hospitals. 路 Medical colleges, ordinarily, have a capacity of 300+ beds. They function on the Medical Council of India guidelines. These institutes carry high tech equipments such as motor-operated X-Ray tables, image intensifier television system. They enable the students to observe and study the entire procedure in a classroom. Recording facilities on electronic devices are also available, if needed. The number of X-ray equipments are dependent on the requirements of the hospital and institute. Super Specialty Hospitals The top of the line hospitals covering a large section of modalities such as Cardiology, Trauma, Nephrology, Ob/G, ENT, Ophthalmology, Cancer, Burns, Chest Diseases, Diabeties, Dental, among other, make the Super Specialty Hospitals. They are located in metro cities and cater to every type of patients Governed by a board of trustees, major super specialty hospitals fall under the research hospital category, where a certain percentage of beds are for free. In order to generate a diagnostic report, the Imaging Department needs a full-fledged dark room or a CR system. Dark room An integral part of the Imaging Department, this room is located adjacent to the X-ray rooms. Inside the completely darkened room, films are loaded in cassettes. Dark rooms demand a utility suit with drain board for mixing chemical solutions, as well as a water supply for the purpose of washing hands. An exhaust fan to ventilate the room and contain an uncontrolled spread of fumes from potentially harmful chemicals, is also essential. To obstruct light, a 'light lock', between the dark room and the exit, equipped with interlocking doors is essential. The room's walls and ceiling are painted black to brace the darkness. With an overall size of 100-150 sqft, the dark room is composed of a dry and wet section. Upper: Big investment Downer: Film processing takes about 30 minutes

Other Parameters Requirements of the power supply, space - area, skilled manpower and operating costs are considerably high for this department. Hence, efficient planning based on the needs and disease pattern of the hospital is of the pivotal to an adept outturn. Involvement of the hospital management, administration, engineering department must be summoned for forethought. As part of a pipe dream, the recommended size for an X-ray room should be of about 5.5m X 6m X 3m (L x B x H) dimension with a weight-bearing capacity of 1200 kg. Such a setting would allow upgradation of equipment and augmentation of services, as the future would demand from every Imaging Department in a hospital. A well-planned Radiology Department ensures an efficient flow of service, prompt scheduling and minimum movement of the patient. Almost 90% of the job, now-a-days, is done on conventional radiology equipments inclusive of radiography and fluoroscopy. The X-ray tube must be kept in check, as this diagnostic tool too expends ionising radiation. An expeditius option free of the major radiation trouble the multi-pulse high frequency X-ray generator is also available for those who take Green Healthcare more seriously. Specially designed to barricade radiation leakage as per the AERB guidelines, separate rooms for each department have to be maintained. The main electricity distribution transformer should be located close to the department, due to its heavy demand and low drops in voltage. Also, since most diagnostic units today are software-based, the requirement of airconditioning for diagnostic rooms is essential. Finally, the department can be classified into two main areas; namely, the Waiting Area and the Functional Area. Winding up Contemporary technology must be taken into account whilst planning the Imaging Department, since radical transformations have been seen in the department, lately. A scientifically-planned and designed Imaging Department, which is technologically upgraded, is essential to guarantee effective medical care to society. The author can be reached at anil.shastri@hosmac.com.

A role model for the healthcare industry In an intense tête-à-tête, Dr. T. Prabhakar, Director - UPRIMS & R, confuted the popular assumption that only private institutions can deliver quality healthcare facilities. Vinay Pagarani, Development Manager - HOSMAC Foundation reports. Located in the lush green plains of Etawah district deep within the state of Uttar Pradesh lays a small village by the name of Saifai, 250km away from the capital city of Lucknow. At a distance of another 20km from Etawah is Saifai village and is a government-run medical institution that has performed par excellence and beyond — behold the Uttar Pradesh Rural

and fellow doctors of UPRIMS & R have consistently ameliorated the public health scenario in all of the near-by villages. The man behind the entire operation of UPRIMS & R — Dr. T. Prabhakar, a specialist in neuro-anaesthesia and neuro intensive care — has turned the place around. He has served as a faculty for ten years in the Armed Forces Medical College (AFMC), He graduated from Andhra Medical College ,visakhapatnam, did post graduation from AFMC, Pune and did super specialisation from All India Institute. UPRIMS has been carved out solely following foresight of this visionary. Extracts of the interview: VP: How did the thought of setting up a grand institute such as UPRIMS in a village so underdeveloped as Safai emanate? TP: Shri Mulayam Singh Yadav wanted to alleviate these backward areas since back in the day. In 2005, when he was Chief Minister of Uttar Pradesh, he decided to commission a hospital and an institute under the NRHM scheme that would doctor Safai and its near-by areas. I joined in as the Director in August, 2006 to augment the strategy of the insitution.

Dr. T. Prabhakar, Director, UPRIMS & R Institute of Medical Sciences and Research (UPRIMS & R). In a short span of only five years, the institute which has an intake capacity of only 100 students per year has already equipped itself to take on the challenges of the next six years. Besides, efficaciously covering a radius of 30km, the students

In the initial days, our students were taken to a near-by village regularly to provide free medical assistance to one and all. We have gone well beyond medical checkups, even to the extent of learning and resolving social problems of our patients. Providing vaccinations, bleaching the wells and drains and creating health awareness amongst the public are continually done by our students on a regular basis. Today, we have covered each and every village in the Etawah distict and well beyond.

The Uttar Pradesh Rural Institute of Medical Sciences and Research is situated in Safai, 250km away from Lucknow in Uttar Pradesh

VP: In your words, which features of UPRIMS delineates it from the rest in the game? TP: Our OPD strength has crossed 2000 patients per day, who are provided tertiary care. The bed occupancy rate is above 100%. Financially, we are functioning above the breakeven point. Five years in the game, and we have already applied for preclinical and paramedical postgraduate accreditations alongwith the MBBS accreditation. We will be eligible for applying for clinical subject postgraduation next year. We are confident that the Medical Council of India will hesitate no inch in conferring them, next year. Intensively, we are already equipped with 60% of the infrastructure for super-specialities.

The government has been very cooperative in getting us finance and other approvals. Friends and well-wishers have also supported us well. Our ultimate goal to be recognized in the league of AIIMS is no more a distant dream. Possibly, in the next five years, we will be much ahead than most institutions in India. Before my tenure ends next year being a tenure appointment, we will have check-marked 70% of the list. The rest 30% of the objectives will pick up next year after our first batch graduates. VP: Please enlighten us with the strategies that are responsible for the success that UPRIMS is so extensively experiencing. TP: I have visited many a healthcare institutions in India as well as abroad. Taking note of the worthwhile examples, I have amalgamated their best practices to suit UPRIMS. I always plan 10 years ahead. The medical or electrical equipment we have purchased are covered with a 5 yearwarranty by default, and an additional 5 years by an arrangement we have made with the companies. This technique was a learning from my Army days.

The Govt of Uttar Pradesh has given permission to increase intake of medical students from 100 to 150 every year. We will be applying for approval of MCI accordingly. Despite the location and other constraints, we have achieved all this and more; so much so that the development outside the walls of UPRIMS were resultant from the operations inside. VP: Where have you reached in terms of the foreseen vision for UPRIMS? TP: The objective was to emerge UPRIMS into a premiere institution within the five years of my tenure of directorship. However, MCI regulations and the location constraint slowed us down. Either way, 60% of the checklist has already been fulfilled. As you know, we are delivering quality healthcare to the rural population, unlike any other. We run a number of viable government schemes such as the National Swasth Bhima Yojana, Establishment of DOTS centre, Running of rural health programmes, Prevention of blindness programme, Janani Suraksha Yojana, Family planning, Anti Retroviral therapy unit, ECHS for Ex servicemen and their families. In addition, Smile train program and â&#x20AC;&#x2DC;Health begins at homeâ&#x20AC;&#x2122; programme are run by our medical students..

Punctuality and discipline are two things, I have always advocated. I keep a watch on everything via CCTV cameras, placed at points of interest. Unless I am away, I take two rounds of two hours each in the entire institution every day. This gives my patients and staff a chance to confront me, face-to-face. My mobile contact number is freely available for anyone who wants a word with me. Besides, complaint books are placed and regularly inspected. VP: Any message for the Indian healthcare industry? TP: Healthcare institutions must be honest. Even if profitability is the primary objective of an institution, it must be brought about through good service, being a healthcare organization. Outdated equipments must never be purchased. Students as well as professionals must be updated with contemporary technical know-how. Cost-containment must be probed into and given adequate significance. Insurance companies must research more and provide better services to consumers, which are mutually beneficial. The Indian healthcare industry is on the rise. The ultimate objective of every institution must be linked to social service, thereby following an intensive approach to grow with the whole of the country. This perspective re-adjustment can have farreaching influences, and also impact the global order. To know more about UPRIMS & R, contact Dr. T. Prabhakar at prabhu4903@yahoo.com.

Hosmac turns 14! Isha Khanolkar, Asst. Manager - Operations - Hosmac India, recounts the commemoration of the 14th Hosmac Day. Fourteen years ago, a small outfit decided to make an impression on the entire healthcare scene in India. Hosmac set the ball rolling by questioning how hospitals operated and tended to their patients in India, and ergo challenged the way hospitals were planned and designed. Today, the then undersized outfit has evolved into a sizeable healthcareoriented company serving clients even in the international circles. On the 24th of June, this year, Hosmac wrapped up another year of excellence in the spaces of Healthcare Consulting, Design and Construction. Ever since the 10th year anniversary, this annual

11AM, Hosmacians were divided and equipped for a surprise race. Five teams were structured, each led by a group leader. The competition turned into an eventful mix of nature, adventure and recreation for the participants. Pit stops were arranged mid-way by the organizers to revitalize the teams with refreshments. After a two hour hike, most of the teams reached the base camp in record time and the winners were lauded with appreciation from all and a champagne bottle for keeps. The participants were then transferred to Citrus hotel in Lonavla, where they were to sojourn. Lunch ensued and a dog tired team took to mingling with their colleagues from around the country and the Middle East. Hosmac Day gives Hosmacians a chance to understand the distinct outlook with which their colleagues in the outspread regional offices carry on their Healthcare Consulting and Design Practices. A formal event for the evening was indicated, where Hosmac would announce its future objectives for the years to come. To add a formal flavor to the celebrations, the evening was rung in with the National Anthem and the auspicious lighting of the lamp ceremony. A recap of the year 2009 was captured in a video, made especially for the occasion. It showcased Hosmac's

Taking a closer look at healthcare in the lawns of Citrus Hotel, Lonavla celebration has been building up with gusto, year-after-year. This year's fĂŞte was perhaps the most resplendent yet. Hosmac India decided to celebrate its 14th Annual Day with a trip to the scenic locales of Lonavla. The Senior Management had always suggested the importance of engaging employees in team building activities. Towards this end, an early morning outdoor adventure trek was opted for, to motivate the Hosmac force. Aamby Valley's adventure zone, a.k.a. '18 degrees north', which holds many exciting outdoor recreation activities, like zorbing, rock climbing, was chosen for this purpose. Upon arrival before the starting line of the adventure zone at

L-R in foreground: Isha Khanolkar, Dr. Vivek Desai, Alvin Salhanda and Narendra Karkera Achievements in the areas of Healthcare Consulting and Projects. Snapshots of the new employees were also included in the video for introduction to personnel across regions. The evening saw presentations from the up and coming verticals of Management Consulting, Project Management and Healthcare Architecture.

Hosmacians listening intently to Alvin Saldanha (left)

Hosmac has always believed in the â&#x20AC;&#x2DC;kaizenâ&#x20AC;&#x2122; philosophy of continuous improvement. It decided to hold an intra division cum region 'Corporate Presentation' competition. Ideated by the Senior Management, it was included in the day's proceedings with the aim of placing the Company's most powerful communication tool in the hands of its employees. The room filled up with a sincere Hosmac-ial sentiment, which resonated among all. To Judge the competition, Hosmac had invited Alvin Saldanha, CEO, Idea Domain Communications; Dr Vivek Desai, MD, Hosmac India; and Narendra Karkera, Senior Advisor, Hosmac India.

Strong visuals, impressive new media and rock solid content filled the day with efforts from the fiercely competitive regions and divisions. Hosmac Projects bagged the Best Presentation title, for having used an innovative software to introduce instantaneous customization in the Hosmac Presentation based on the customer's needs. The annual Hosmac Awards, to honor the employees who displayed exemplary performance during the year, followed next. Announcements were made in the categories of Best Employees and Young Achievers in the respective divisions of Hosmac Projects, Hosmac Consultancy Services and Hosmac Common Pool as well as Support Services. Dr Vivek Desai then took over the proceedings of the evening by making a few special announcements that were to have a major impact on the Company. He motivated the teams to work harder and informed that Hosmac was facing a spurt in growth. That Hosmac had in fact grown over three folds in terms of revenue, as compared to last year. He pointed out poignantly to the example of how the Indian Government has placed its faith in the hands of Hosmac by awarding it with the prestigious remodeling project of Ram Manohar Lohia Hospital, New Delhi. Hosmac would be the only company that would be able to pull

Hosmac Projects’ personnel dacing to the beats of ‘Bollywood Night’ off the project in a short span of only one seventy days, just in time for the common wealth games. The announcements reinforced the emphasis that Hosmac has laid on professional management, focused vision and hard work. The evening was intersparsed with cultural performances from Hosmac personnel deployed onsite as well as the Accounts team. Their riveting performances left the audience asking for more and set the tone for the theme night that was to follow. Dressed in their best ‘Bollywood’ garb, the Hosmac glitterati descended upon the lawns of Citrus – Lonavala. ‘Bollywood Night’ saw Zeenat Aman, Anthonhy Gonzalves, Bobby and Chandini stealing the show with their perfect rendition of the yesteryear Stars. Dancing and Singing was dotted with individual performances as well as an impromptu fashion show. The DJ led the night with songs from all genres and made sure that everyone swayed with the music and had a good time. A near perfect day that was made possible by an event management company that has proven itself to be true to their word time and again at every Hosmac event. Maximus events that managed the Day's proceedings under the guidance of Managing Partner Reema Sanghvi executed the entire program flawlessly for seventy odd people. Mithila and Deepesh ensured that every need was attended to and that everything went as planned. Hosmac thanks them for their services.

Hosmac Day culminated with employees making new friends across regions and departments. It helped bind an already strongly knit team that will take on the new year with added confidence and poise. The dawn of another Hosmac Day will see the pioneering company completing 15 years of dedicated service of improving Healthcare Systems in India. With the Indian healthcare market set to grow by USD 75 billion in the next couple of years, the teams at Hosmac are preparing themselves to make a mark in India, and venture out into the world beyond to announce our arrival.

Hosmacians listening intently to Alvin Saldanha (left)

HOSMAC FOUNDATION

Head Office 120, Udyog Bhavan, Sonawala Lane, Goregaon East, Mumbai - 400 063, Maharashtra Tel : +91 22 6723 7000, Fax: +91 22 2686 3465

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