Designing Hospitals According To NABH Standards

Dr. B. KrishnamurthyMD DA FRCA

Director, Acute Care Services, Kaveri Hospitals, Chennai.Principal Assessor , NABH

Lead Auditor, QMSLead Auditor, EMS

The Peter Principle

“In A Hierarchy Every Employee

Tends To Rise To His Level Of Incompetence”

IntentThe HCO Shall

Provide A Safe And Secure Environment For Patients , Their Families, Staff And Visitors.

Comply With Relevant Rules And Regulations, Laws And Bye Laws And Facility Inspection Requirements.

Plan For Emergencies Within The Facilities And The Community.

Intent- Contd.The HCO Shall

Plan For Safe Water, Electricity, Air-conditioning, Medical Gases And Vacuum Systems.

Plan For Management Of “HAZMAT”.Ensure the HCO Is A No Smoking Zone.Program For Clinical And Support Service

Equipment And Management.

NABH Standards• Access, Assessment and continuity of Care (AAC)

• Patient Rights and Education (PRE)

• Care of Patient (COP)

• Management of Medication (MOM)

• Hospital Infection control (HIC)

• Continuous Quality Improvement (CQI)

• Responsibility of Management (ROM)

• Facility Management and Safety (FMS)• Human Resource Management (HRM)

• Information Management System (IMS)National Accreditation Board for Hospitals

and Healthcare Providers 5

FMS Standards Summary

FMS Chapter• Standards 09• Objective Elements 43• To Get Full Accreditation

– No Individual Standard • Should Have More Than One Zero

– Average Score For The Individual Standard• Should Be More Than 5

– The Overall Average Score For All The Standards• Must Exceed 7

– Average Score For Individual Chapters • Should Be More Than 7

References • Relevant State & Local Body Regulations• Indian Standards

– IS 12433 Part I– IS 12433 Part II– IS 10905 Part I– IS 10905 Part II– IS 10905 Part III– IPHS ( Indian Public Health Standards )

• For PHCs• For 30 - 100 Beds• For 101 - 200 Beds • For 201 - 300 Beds• For 301 - 500 Beds

– IS 10500 ( For Potable Water )

• National Building Code• Manufacture, Storage & Import Of Hazardous Chemical ( Amendment ) Rules, 2000

Space Requirements As Per IS 12433 ( Part 2 ): 2001

IS-12433-basic Requirement For Hospital Planning Up To 100 Beds.

S. No Elements Requirements (Meter Square)

1 Carpet Area Per Bed 66.

2 Covered Area Per Bed 92.5

3 Total No. Of Beds 100 No.

4 Total Covered Area 9250

5 Assuming 3 Floors And Area Divided In To 40+30+30 %Ground Floor Carpet Area-9250x40%

3700

6 Ground Floor Covered Area Carpet Area X 4 Times 14800

For More Information About The Area Space Requirements ,Refer To IS-12433, Annexures

IS 10905 For Basic Requirements For General Hospital Buildings.

Suggests Minimum Of 7 Sq. Mt. Per BedInter Bed Distance

2.25 M From Centre To Centre1.2 M Edge To Edge.

200 Mm Clearance At Head EndEasy Trolley Movement Space For Bed Side Furniture For Patients.Privacy For Procedures.

• Hospitals Are Classified As Group C-1 In NBC• Corridors 2400 Mm / 7.8 Feet• Doors Width 2 Meters• Staircase Width 6.6 Feet / 2 Meters• Fire Exit Doors 3.35 X 2 Feet Width And 7.5

Feet In Height, Two Leaf, 30 Meters Distance For Travel, Open Outwards.

• Floor Indication Board 0.5m X 0.5m

National Building Code

NBC Of India Specifications ( 2005 )Part 4: Fire & Life Safety

180 Page Document• Classification Of Building As Per Fire Safety• Fire Zones• Types Of Construction• General Requirements • Life Safety• Fire Protection• Additional Occupancy - Wise Requirements • Annexures

– C . For High Rise Buildings – E. Fire Safety Plan

The HCO Needs To Have

• A Documented Fire Plan• Adequate Qualified Personnel• Fire Fighting Equipment & Maintenance

Records• Adequate Training Plans• Mock Fire Schedule Drills & Records • Well Displayed Exit Plans • Fire Exit Signages & Escape Lighting

Color Coding Of PipelinesIS 2379: 1990

Air Conditioning In OT - Standards Characteristics Super Specialty OT General OT

Temperature & Humidity 21 +/- 3 degrees C40 – 60 % RH

21 +/- 3 degrees C40 – 60 % RH

Air Quality HEPA 8’ x 6’2 Pre filters 1 Terminal filterClass 100

HEPA 6’ x 4’2 Pre filters 1 Terminal filter Class Class 1000

Air Change Per hour 30 25

Fresh Air Per Hour 5 4

Air Velocity 90 - 120 Similar

Positive Pressure +15 Pascal +15 Pascal

FMS Rounds Indicative list of things to look for:

• Entire building including terrace and basement• Fire exits• Diesel storage area• Liquid oxygen plant• Water treatment plant/RO plant• Sewage treatment plant• Gas manifold room• Diesel Generator set (s)• Vacuum and air compressor plant• Gas pipelines• Electrical yard/sub-station/receiving area• Lift machine room (s)• HVAC / Chiller plant

FMS Rounds Indicative list of things to look for:

• Signages• Provision of space• Patient and employee safety aspects

– Safety rails/Guard rails– Blind corners– Low ceiling– Open wires– Broken steps/ floor tiles

• Fire related– Fire alarms– Fire hoses and fire extinguishers– Smoke detectors

• Adherence to statutory requirements– Distance– Safety– Inspection reports

• Gas pipelines• Cigarette and beedi stubs!!!

FMS Rounds

FacilityFMS 1 a, c• Various Statutory Requirements

O Building O FireO Diesel StorageO Liquid Oxygen And Storage Of Medical Cylinders.O BoilerO Electrical Inspectorate Reports.O ETPO DG Sets

• Mechanism For Renewing Licenses

Rules, Regulations, Laws & By lawsS. No Elements

1 Building Permit (Land, Building, Electrical, Water, Sewage)

2 No Objection Certificate From The Chief Fire Officer

3 No Objection Certificate Under Pollution Control Act(License As Per Air Act 1981 )

4 Permit To Operate Lifts Under The Lifts And Escalators Act.

5 Explosive Act -1884, Gas Cylinder Rules 1981, Static And Mobile Pressure Vessels (Unfired) 1981.

6 License To Operate DG Sets And Permit To Store Diesel.

7 License For Boilers

8 License For Running A Canteen

9 Radiology Installation Approvals

Suggested Way• Designate A Management Functionary–Enlist All Laws & Regulations –Update As & When Needed– Identify Appropriate Individuals In HCO

Responsible For Each Law & Regulations –Direct, Coordinate & Control This

Activity

One Sample MechanismSl. No. Name Of License/

Approval/ Certification/ Authorization

Valid From

Valid Until

To Initiate Action For

Renewal By

Responsibility (Responsible

Person)

FMS Rounds Facility

FMS 2 a-g• Preventive And Break Down Maintenance Plan• Response Time• Up To Date Drawing, Layout, Escape Route• Signage• Provision Of Space • Designated Individual For Maintenance• Presence Of Staff Round The Clock For

Emergency Repairs

Preventive MaintenanceDAILY/WEEKLY/FORTNIGHTLY/ MONTHLY/QUARTERLY/

HALF YEARLY/ANNUALYS. No Examples S. No Examples

1 Lift 8 Electrical Installations

2 Air-conditioning 9 Plumbing Installations

3 D G Set 10 Fire Safety Equipments

4 Medical / LPG Gas Plants 11 Reverse Osmosis Plant

5 Sewage/Effluent Treatment Plant

12 Drinking Water Supplies And Outlets.

6 Water Sourcing Plant 13 Boilers If Any

7 Water Storage Areas 14 Solar Power Panels If Any

Breakdown MaintenanceROM -5 C

Management Ensures Implementation Of Systems For Internal And External Reporting Of Failures.

The HCO Maintains A Complaint Attendance Register.

Date And Receipt Of Complaint Allotment Of Job Completion Of Job Monitors Response Times

FMS.2b) Up-to-date Drawings Are Maintained Which Detail The Site Layout, Floor Plans And Fire Escape Routes.

FMS RoundsFacility

FMS 4 a-c• Availability Of Potable Water And Electricity• Alternate Sources And Their Checking• Water Quality Reports FMS 9 c-f• Safety Devices • Facility Inspection Rounds Twice A Year In Patient

Care Areas And Once In Non-patient Care Areas • Documentation Of Facility Inspection Report• Safety Education Program For All Staff

FMS RoundsFacility

HIC 2 h• Validation of OT air-conditioning• Change of HEPA filter (s)FMS 9 d• Staff Interview

FMS RoundsSafety

FMS 5 a-d• Documented plan for handling fire and non-fire emergencies

which includes exit plan • Signage pertaining to fire exits• Open and easily accessible fire exits without any obstruction• Mock drill schedule and record - Twice a year mock drill • Smoke detectors, fire alarms, fire alarm control panel etc.

(where applicable)• Safety Manual

FMS RoundsSafety

FMS 7 a-e• Potential emergencies (Community

emergencies, epidemics and disasters) identified

• Documented disaster management plan• Provision of supplies • Tested at least twice a year

List Of NFE Situations • Earth Quake • Flood • Bomb Threats • Hostage Situations • Civil Disorders Like Strikes• Sudden Failure Of Electricity, Gas, Vacuum• Hazmat Spills• Building Collapse• Bursting Of Pipelines, Boilers or Autoclaves • Antisocial Behavior By Patients, Relatives, Staff• Hysteric Fits By Patients, Relatives, Staff• Temperamental Disorders Of Staff• Invasion By Stray Animals Or Swarms Of Insects Or Pests

Disaster Management Plan Frame Work

• Documented Procedure• Clear Line Of Authority• Establishment Of Command Nucleus• Alert Code • Information & Communication• Readymade Action Cards For Each Category Of Staff• Resource Earmarking & Availability• Training • Mock Drills

FMS RoundsSafety

FMS 8 a-e• Identified hazardous materials• Hazardous materials identified have

documented procedure for sorting, storing, handling etc.

• Availability of MSDS for all such material• Spill management plan • Staff awareness

Hazardous Materials• The Hazardous Materials Could Be Identified

As Per Part II Of Manufacture, Storage And Import Of Hazardous Chemical (Amendment) Rules, 2000.

• In Addition Biological Materials Like Blood, Body Fluids And Microbiological Cultures; Mercury; Nuclear Isotopes; Medical Gases; LPG Gas; Steam; ETO, etc. Are Some Of The Other Common Hazardous Materials.

FMS RoundsSafety

FMS 9 a,b• Safety committee meeting minutes• Staff interview on their role in case of

emergencies and on safety aspects

Hazard Identification & Risk Analysis • What Are The Hazards?• Who Might Be Harmed And How ?– Probability– Severity– Impact– Risk Rating

• Control Measure– What Are We Doing Now?– What Do We Need To Do Further?

Thank You