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.

Combining forces to better healthcare 3

The right thing to do 7

Intensively planned ICUs 11

Doctoring finance 13

Relax, breathe and heal 15

Streamlining the lab setting 17

Flexibility in healthcare planning

Imagining the Imaging Department right 2

A role model for the healthcare industry 2

Hosmac turns 14! 26

19

1

3

Editorial Board Table Of Content

Advisory Panel

Creative Consultant

Chief Editor

Narendr

Rakesh Mathur

Isha Khanolkar

Ipshita Dey

Amit Pandya

Vinay Pagarani

Paresh Gujrathi

a Karkera

narendra.karkera@hosmac.com

rakesh.mathur@hosmac.com

Isha.khanolkar@hosmac.com

paresh.gujrathi@hosmac.com

ipshita.dey@hosmac.com

amit@scarecrow.asia

vinay.pagarani@hosmacfoundation.org

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 plan individual departments. For instance, the fact

that the 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, H has teamed up with Heery International, USA to provide value-added hospital design services to projects at

large.

meticulously

room

osmac

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.

Executive's Note

Dr. Vivek Desai

Managing Director, Hosmac India Pvt. Ltd.

“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 super-

specialty, is not known to many. ”

1

Healthcare & India

Optimizing operations

Assimilation, of the essence

The Indian economy, predicted to be one of the world'semerging economies in the near future, has begun to rise with arobust pace of growth. Its healthcare sector is also growingrapidly, and is estimated to be worth US $75 billion by 2012. Thesector has shown momentous growth owing to the country'sgrowing middle class, which can afford quality healthcare.Additionally, high-quality healthcare facilities at competitivecosts have been instrumental in fetching hordes of foreignarrivals to the country, by way of medical tourism.

Taking things forward, US based Heery International, Inc. hasentered into a business teaming agreement with Hosmac IndiaPrivate Limited, a leading hospital design and managementconsultancy firm, to collectively pursue opportunities in India,alongwithAfrica and the Middle East.

Heery is a full service Architecture, Master Planning, InteriorDesign, Commissioning, Engineering, Construction and ProgramManagement firm with a history of stable leadership andfinancial strength. Throughout the years, Heery has expandedthrough a multitude of acquisitions. As a recent affiliate ofParsons Brinckerhoff, one of the world's leading professionalservices companies, Heery now operates as that firm's buildingsdivision. This new association gives Heery access todramatically increased resources, opportunities andinternational outreach.

One of Heery's primary focuses has been the delivery of superiorhealthcare design and planning services for specialty hospitalsand clinics, community and acute care hospitals, academicmedical centers, outpatient clinics and medical officebuildings. With nearly 60 years of US healthcare experience,Heery brings its extensive expertise, seasoned professionals,

and knowledge of healthcare design and planning to its newaffiliation with Hosmac. This enhances the team's ability toaddress various client situations and service requirements.

Understanding current and future requirements is integral toour healthcare facility design process. The best case scenario isone where we are afforded the opportunity to create a masterplan that addresses a variety of issues from current and futurebudgets, space and system requirements to trends inhealthcare, all of which impact future growth. When we lookfive or ten years out, we are not only considering how a spacewill grow, we are also focused on how to expand in a way thatmakes the most efficient and cost effective use of existinginfrastructure and equipment while maintaining the integrityof internal public and private circulation systems.

The greatest challenge in the healthcare industry is designingand constructing facilities that not only meet fiscal, functionaland environmental requirements, but exceed the needs ofpatients as well. Where does our healthcare planning anddesign process begin? By being collaborative. Defining a visionthat incorporates the needs and desires of key projectstakeholders, including administrators, physician leaders,nursing and support services, staff and even members of thecommunity is critical. This initial information gathering helps usestablish performance goals against which all decisions can bemeasured.

Clinical programming and planning revolves around suchperformance goals and layers in the agency and codehealthcare stipulations that dictate room type, function and

and minimum size per department. Departmental gross upfactors are utilized in conjunction with net room modulemethodology and the factors can vary per different facility type

Combining forces to better healthcare

In an exclusive report, , Vice President and , Project Architect of

Heery International illuminate on how a

healthcare facility can be streamlined.

Mark D. Johnson Bhavik H. Rao

announce their collaboration with Hosmac India, and

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

from lesser to greater in magnitude.

Key room adjacencies within each specific department arecritical in nature and help to properly 'zone' a department forproper staffing and patient care parameters. Also, key'department to department' adjacencies are very important interms of hospital efficiency and expedited patient care, serviceand safety.

Being attentive to patient and family requirements is vital tooverall facility success. Heery recently completed a state-of-the-art cancer center in Augusta, Georgia, where we invitedcancer survivors to play a critical role in the facility's planningand design process. Our goal was to understand their needs aswell as their desires. The flow of exam and fusion areas, amongother spaces, is based on their insightful input.

Many of Heery's projects embody the basic tenets of Planetree,a 'patient-centered care' healthcare philosophy rooted inpatient focused care. Curved hallways and non-institutionalfinishes with minimal overhead lighting help to enhance a“healing environment” for patients. Incorporating familyfriendly and specific places, which can range from centrallylocated family lounges to larger patient rooms, is of paramountimportance. These larger patient rooms are designed toaccommodate visitors comfortably without impeding staffduties. We certainly believe that families play an integral rolein the healing process.

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

carefully evaluating potential sustainable features at theproject's outset and weighing first costs against lifecyclesavings. It has been documented in studies that patients havebetter outcomes in comfortable, natural environments thanthey do in sterile, clinical settings. In addition, greenerfacilities enhance the working environment, which in turnimproves staff satisfaction and retention rates. Patients’average length of stay are also reduced.

Undoubtedly, our practice has embraced sustainability as one ofour primary focuses. Heery's long history and expertise in thearea of energy conservation puts the company in a strongposition to assist our clients in the delivery of sustainable andLEED certified buildings. Beginning in the late 1970s, Heerybegan researching and developing approaches to buildingdesign that enhanced energy conservation. Over the years, thisinitiative has expanded to include broader sustainability issues,including water management, building materials andoperational issues.

Heery has worked with clients to achieve sustainable designsolutions that:

Respect and contribute positively to local communities

Offer energy efficiency

Use renewable resources in preference to non-renewable

Use local and recycled materials where appropriate

Use water efficiently

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

Patient focused care

Sustainability is (ever)green

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

Preparing necessary submittals to the US Green BuildingCounsel for the certification process

Providing leadership to the project team in the developmentand delivery of the project in accordance with the establishedLEED and sustainable goals

To stand behind our commitment to sustainability, Heerydesigned Medical Center of the Rockies (MCR), a 595,000 Sq.Ft.tertiary care hospital in Colorado, which is currently the largestof three LEED Gold Certified hospitals in the US. Recently, MCRwas awarded the 2010 International Sustainable Design Award,one of the most prestigious awards given by the Design & HealthInternationalAcademy.

From the project's inception, the owner's intention was tocreate a sustainable facility that would enhance the health ofpatients, visitors and staff. It was incumbent upon everymember of the team to contribute the best ideas for bringingthis vision to life. MCR was designed and constructed in 32months using a fast track and integrated project delivery

method, involving architects, engineers, designers,construction team members, clinicians, and the owner'srepresentatives. Through this team process, every detail andmaterial selection was evaluated for its first cost versus life-cycle cost implications. Unlike most new hospitals built in theUS, MCR was planned for a 100-year life cycle, acknowledgingthe 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 selectionof materials and systems on those which provided the greatest

amount of value in terms of energy and raw materialconservation, durability, and performance over many years ofservice.

Together with the assistance of all selected contractors andsuppliers, the team managed the design and budget in real timeto a fixed budget amount. Not only does the end product exceedthe owner's and the community's expectations, but the projectwas completed for US $250 per square foot ($2550 per squaremeter), while still achieving LEED Gold.

Efficient medical planning and adjacencies resulted in areduced footprint that conserved materials. Designed as ahospital within a hospital, MCR houses the Heart Center of theRockies and the Trauma Center of the Rockies. While theseparate centers are clearly designated throughout thebuilding, they share key facilities, diagnostics and equipment,resulting in significant cost benefits and circulationefficiencies. Daylighting, a challenging feature to incorporatein hospitals, was not only woven into the patient rooms in anextensive way, where windows are larger than traditionalhospitals, but into traditionally darker zones of the hospital byvirtue of the hospital configuration and shape.

Equally important in the western United States is conservationof water. MCR earned several key LEED points for waterconservation in its design of landscaping and plumbing systems,and fixtures. Storm water from the 90-acre site is managed anddischarged from a newly created wetland zone on the site.Other sustainable elements include recycling 75% of theconstruction waste, maximizing recycled materials, orientingthe facility properly to increase daylight into the facility,storing information electronically to create a paper-litefacility, 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 achievedwith one attributable to Cooling Tower Efficiency and anotherpoint related to Floor Plan planning efficiency.

Heery sees a huge untapped opportunity in the delivery ofquality healthcare to the broader world. Our alliance withHosmac India will bring innovative planning and design to thehealthcare industry, and further the quality of healthcarewithin various nations.

We believe the collaboration between Heery, Inc. and HosmacIndia will benefit the world healthcare system and make a truedifference in the lives of many for the years to come.

An intensive approach

Footprint gambit

Beyond the horizon

To know more, contact Mark D Johnson at, Bhavik H Rao at , or

visit .mdjohnso@heery.com brao@heery.com

www.heery.com

At the heart of historic Route 66 in Kingman, Arizona is the newHualapai Mountain Medical Center an 180,000-square-foot, 70-bed general acute care Greenfield hospital. To make this aviable project, the design team implemented considerable leancost-saving strategies as well as significantly streamlined theschedule.

A project of this scope and size usually takes 24 months toconstruct — instead, this project took 15.5 months. In addition,the owner saved approximately $75 per square footconstruction cost when compared to similar projects.

Situated serenely near the base of the Hualapai Mountains, thecenter welcomes patients and visitors to an oasis of healingfeaturing large open spaces, grand expanses of glass andsoothing desert colors. The center focuses on providing high-acuity services, and includes four operating rooms, one cath laband a 22-bay emergency department. The hospital providesheart services, inpatient and outpatient surgery, medicalservices, and intensive care and emergency services whileemploying state-of-the-art diagnostic imaging and laboratoryservices as well.

Striking a design balance between the vast program elements ofthe new Hualapai Mountain Medical Center facility and thebudget required a well-choreographed process. The designteam listened carefully to the client to provide a customfunctioning hospital, but also contributed to the owner's effortsto save dollars without affecting functionality. This processstarted at the block planning phase and continued through theconstruction process.

In order to produce a simple, elegant solution, the design teamdemonstrated its understanding of the challenges andcomplexities of healthcare operations and design scrutinizingthe overall operational model of care, workflow analysis,patient throughput, staff efficiency and safety concepts.

To optimize space at Hualapai, operational designs wereanalyzed allowing for wasteful space and processes to beremoved prior to committing to floor-planning layouts. Thedesign team's efforts were centered on giving the client themost value for its money.

HKS Architects and MedCath, Inc. led the planning effort fromprogramming through schematic design, design developmentand construction. Corporate executives, physicians, keyclinicians and community advocates were involved throughoutthe process to assure that the facility meets the projecteddemand, patient and staff needs, and community desires. Theirprior experience helped when establishing lean designprotocols and goals.

The current standard in healthcare design is to provide acompletely flexible space that can accommodate any criticalscenario. This approach can result in over-programmed,excessive square footage rooms that have an extreme impacton 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

Efficient Rightsizing

Operational Lean Strategies

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The right thing to do

Gaurav Chopra Gaurang Sheth,, Practice Leader - South Asia Region and Senior

Designer at HKS, Inc. team up to unveil their rightsizing operation at The Hualapai

Mountain Medical Center, USA.

7

At the heart of historic Route 66 in Kingman, Arizona is the newHualapai Mountain Medical Center an 180,000-square-foot, 70-bed general acute care Greenfield hospital. To make this aviable project, the design team implemented considerable leancost-saving strategies as well as significantly streamlined theschedule.

A project of this scope and size usually takes 24 months toconstruct — instead, this project took 15.5 months. In addition,the owner saved approximately $75 per square footconstruction cost when compared to similar projects.

Situated serenely near the base of the Hualapai Mountains, thecenter welcomes patients and visitors to an oasis of healingfeaturing large open spaces, grand expanses of glass andsoothing desert colors. The center focuses on providing high-acuity services, and includes four operating rooms, one cath laband a 22-bay emergency department. The hospital providesheart services, inpatient and outpatient surgery, medicalservices, and intensive care and emergency services whileemploying state-of-the-art diagnostic imaging and laboratoryservices as well.

Striking a design balance between the vast program elements ofthe new Hualapai Mountain Medical Center facility and thebudget required a well-choreographed process. The designteam listened carefully to the client to provide a customfunctioning hospital, but also contributed to the owner's effortsto save dollars without affecting functionality. This processstarted at the block planning phase and continued through theconstruction process.

In order to produce a simple, elegant solution, the design team

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

To optimize space at Hualapai, operational designs wereanalyzed allowing for wasteful space and processes to beremoved prior to committing to floor-planning layouts. Thedesign team's efforts were centered on giving the client themost value for its money.

HKS Architects and MedCath, Inc. led the planning effort fromprogramming through schematic design, design developmentand construction. Corporate executives, physicians, keyclinicians and community advocates were involved throughoutthe process to assure that the facility meets the projecteddemand, patient and staff needs, and community desires. Theirprior experience helped when establishing lean designprotocols and goals.

The current standard in healthcare design is to provide acompletely flexible space that can accommodate any criticalscenario. This approach can result in over-programmed,excessive square footage rooms that have an extreme impacton 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 asingle department to reduce duplicated key spaces and allowedfor the sharing of support spaces.

Amedical record, or electronic chart, protocol that facilitateda lean process was developed. This helped reduce waiting roomtime, thereby reducing waiting room space requirements.

A just-in-time delivery model for all support services wasdeveloped. The materials management department is smallerbecause the space needed to store supplies was greatlyreduced; supplies are not stored onsite.

Caregiver-patient time was increased by reducing traveldistances from support rooms and nurse stations to patientareas.

Similar rooms such as operating, imaging, ICU and acute carerooms were standardized to promote patient safety as well asto increase the ease and speed of construction.

Square footage was reduced by co-locating general lobbywaiting with surgery and imaging waiting.

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

Separate circulation patterns were provided for staff,patients and materials to improve workflow. This project usedthe "on-stage/off-stage" concept with separate public and staffcorridors

Inpatient units were organized by patient acuity to improveboth staff efficiency and patient safety.

Successful architecture involves listening to clientexpectations and respecting architectural integrity whilebalancing budget and schedule. The Hualapai design teambrought to the table a sound general knowledge of how basicdesign decisions affect construction cost, and successfullyapplied cost-saving concepts without affecting overallfunction.

On the Hualapai project, the owner realized cost savings when

Efficient RightsizingOperational Lean Strategies

Design Lean Strategies

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The right thing to do

Rooms used in the morning by pre-op patients can

be used by post-op patients later in the afternoon

Rooms used in the morning by pre-op patients can

be used by post-op patients later in the afternoon

spacing relative to the functional design, and the cost ofconcrete versus steel, as well as the availability of thesematerials. An appropriate structural system was then selectedto increase the speed of construction, provide long spans forflexibility, enable better coordination between trades andprovide flexibility above the ceiling for future changes.

The bed tower was suited to a concrete flat slab system dueto the rigid layout of patient rooms and column spacing. Thismethod reduced the overall building height and structuraldepth required. In addition, the MEP systems were easier tocoordinate and quicker to install due to the absence ofstructural beams.

Over the diagnostic areas, a long span roof system provided alarge column-free space for flexible floor plan layouts as well asincreased the speed of erection to improve the constructionschedule.

A fast-track construction schedule is an essential part of aproject's cost-saving strategy. On Hualapai, the design teamestablished a working relationship with Lott BrothersConstruction early in the design process to define document-issue milestones that melded with the construction schedule.The documents were issued using a just-in-time method tomaximize coordination efforts, while at the same time keepingall of the contracting trades working as efficiently as possiblewithout scheduling gaps between subcontract scopes.

The contractor's early involvement facilitated feedback fromsubcontractors bidding on the job. Resulting revisions orchanges to the design of building components or MEP systemscost 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 themaximum savings offered by a shorter schedule.

The new Hualapai Mountain Medical Center is a distinctexample of balancing operational effectiveness and rightsizingsquare footage without sacrificing the customer experience.Based on a patient- and family-focused design, the cost-effectively designed hospital is committed to setting thestandard for healthcare delivery in Kingman and northwestArizona.

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Fast-Tracking at Hualapai

aurav Chopra atGaurang Sheth atTo know more, contact G

or visit .gchopra@hksinc.com,

gsheth@hksinc.com www.hksinc.com

9

ICU (Intensive-Care Unit) refers to a highly-specified andsophisticated area of a hospital in terms of infrastructure,technology and manpower dedicated to the treatment ofcritically-ill patients with injuries or complications. Coupledwith the highest order of quality control, education, trainingand research, an ICU operates with defined policies, protocolsand procedures. In these changing times, the ICU entails adistinct team in terms of doctors, nursing personnel and otherstaff who are attuned to serving critical situations.

These days, the trend is to have free-standing ICUs set up forindividual modalities such as Neuro ICU, Cardiac ICU, SurgicalICU, Transplant ICU, Pediatric ICU, Neonatal ICU and the likes.

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 coincidewith the number of beds

Modalities to be included must be noted

Infrastructural settings such as location, space, placement ofdepartments, extra space for support services need to beexplored with the internal planning of ICU

Equipment Planning will depend on the number of beds,target level, and modalities of the ICU

Other important decisions must be taken considering thenumber of ventilated beds and availability of invasivemonitoring

It is recommended that the total bed strength in an ICU shouldbe 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 bedseach. This helps in separating patients on the basis ofmodalities and diseases, and in the treatment control ofpatients. It also diminishes the probability of cross infection.Effective steps and planning to control nosocomial infectionsmust be taken. Protocols such as allowing visitors, footwearetc. inside ICU must be put in place.

ICUs should be fully air-conditioned, which allows the controlover temperature, humidity and air change inside the unit.Suitable and safe air quality must be maintained at all times.Airmovement should always be from clean areas. It isrecommended to have a minimum of six air changes per roomwithin an hour, with two air changes per hour composed ofoutside air.

Central air-conditioning systems and re-circulated air must passthrough appropriate filters. It is recommended that all airshould be filtered to 99% efficiency down to 5 microns.Heating/cooling should be provided with an emphasis on thecomfort of the patients and the ICU personnel. For critical careunits having enclosed patient modules, the temperature shouldbe adjustable within each module to allow a choice oftemperatures between 20 and 25 degree Celsius. The isolationrooms would need separate air handling units to maintain theair quality and pressure.

Power back up in ICU is a serious issue. ICUs must havestandalone power generators that automatically recoup in the

Concept of ICU

Inventory

Setting up an ICU

HVAC planning

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Intensively Planned ICUs

Dr. Dattaraj Pendse, Facility Planner - Hosmac Projects, gives a rundown of

the intricacies involved in building Intensive Care Units.

11

Event of a power failure. This power should be sufficient tomaintain conditioned temperature and run the ICU equipment,though most of the essential ICU equipments have backupbatteries. Voltage stabilization is also mandatory; hence, anUninterrupted Power Supply (UPS) system is suggested forICUs.

The International Noise Council recommends that the noiselevel in an ICU must be maintained below 45 dBA in thedaytime, 40 dBAin the evening and 20 dBAat night.

Accessibility to outside natural light is recommended. It isknown to improve the staff morale and patient recovery, alsoto save a patient from ending up into ICU psychosis. Naturallighting in the unit evidently minimizes power consumption,which is of the essence in India. Access to natural light alsomeans that the patients have an access to view the externalenvironment, which may be developed into a green andsoothing vista.

For general patient-care, the illumination should be brightenough to ensure adequate vision without eyestrain. Theinterior must be designed to best avoid glares created byreflecting lights. Higher frequency fluorescent lights andcoated phosphorus lamps may be good for assessing the skincolour and tone for doctors. Floor lightings are importantaround the bedside and in the hallways at night to ensure thesafety and comfort of patients. Black-out curtains or blindsmust be installed on windows since patients often need restduring the daytime.

In the Indian context, vitrified, non-slippery tiles aresatisfactorily good. They can be fitted into reasonablebudgets, are easy to clean and move on and may be stain proof.Ideally, hospital floors that absorb sound while enhancing theoverall look and feel of the environment must be procured.

Walls should meet the criteria of durability, ability to clean andmaintain, flame resistance, mildew resistance, soundabsorption and visual appeal. Door-stoppers and handrailsshould be placed well to reduce abuse and noise to minimum; ithelps patient movement and ambulation.

It is the ceiling surface that patients see the most when undertreatment or bed-rest, sometimes for hours on end overseveral days or weeks. Hence, bright spotlights and fluorescentlights that cause eye-strain must be avoided. Ceilings must beprevented from soiling or fragmentation due to leakage andcondensation.

Rather than a plain back ground colour for the walls andceilings, painting them with a medley of soft colours inpatterns or murals would make the ambience more pleasinglyfor both, the patients and the staff.

All hospitals should be designed in accordance with anestablished disaster management system. Within an ICU,measures must be inducted to overcome fire, accidents,infection and such unforeseen incidents. An emergency exitmust be designed which can serve as a rescue point in times ofan internal disaster. There should be a provision of acontingency room within the hospital, where critically-illpatients may be shifted temporarily. HDU may be the bestplace if beds are vacant. Adequate fire-fighting equipmentmust be present inside and outside the ICU.

Safe, easy, fast transfer of a critically sick patient should be seton high priority during the planning of an ICU's location. Itshould be located in close proximity to the emergency room,diagnostic department, operating rooms and trauma ward.

They must have clear access to the lifts and main corridors.

Lifts, corridors and ramps should be spacious enough to providesmooth movement of a critically sick patient on his bed, trolleyor wheel-chair. A thoroughfare is not required but there shouldbe a single entry/exit point to the ICU that is manned at alltimes. However, emergency exit points are mandatory in caseof a catastrophe.

I

While defining the area allocation for bed bay, the spacerequired for the bed must also be recognized. Bedsidelifesaving equipments like ventilator, dialysis machine, bodywarmer; mobile diagnostic equipments like USG/2-Echomachine, mobile X-ray machine; medical furniture, staffmovement space around the bed, among others are also to beconsidered. These will ensure better and fast service at thetime of emergencies as well as ease the movement of patientsin and out of the bed bay.

A separate procedure room should be allocated for theprocedures like tracheotomy. It is advisable to set aside theprovision of dialysis for atleast one or two beds in a medium-sized ICU. The planning should support one or two isolationrooms for the infected/immune-compromised patients. Theisolation room will have one ante room in addition to thepatient bed bay for the sink, change and writing. This room willalso act as a pressure cut-off lobby for the isolation room.

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 growthin the domain of ICUs is evident, but much needs to be done inarea of infrastructure, human resource development, protocol,guidelines formation and research in accordance to Indiancircumstances. Nevertheless, the scenario of ICU developmentis fast catching up in India.

Acceptable guidelines must be adopted for making ICUdesigning guidelines which would be good for both rural andurban areas, as also for smaller and tertiary centers which mayinclude teaching and non teaching institutes. Only sufficientgroundwork and forethought can determine the blueprints of anefficiently managed Intensive Care Unit, which in turn canconsiderably impact a hospital's overall performance. The careand comfort that an ICU of any hospital provides to its patientsultimately establishes the value of that hospital. Hence, thedesigning and planning stage of an ICU surely deserves immenseICU-support before settlement.

Sound control

Aperture settings

Floor, wall and ceiling coverings

Disaster preparedness

Location of ICU in Hospital

CU bed designing and space planning

Conclusion

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

The fundamental framework of any profit-making organizationattempts to escalate its financial bottom line. It refers to thedifference between sales and expenses.

The most constructive way to increase sales is to expand theactivity volume (utilization and efficiency) of the SalesDepartment. However, this obvious approach is conceivably themost arduous of exercises in every organization.

The elements that affect sales adhere to the universal demandand supply law. They can be notched up by way of discounts,charity, public relations, write-offs etc. There should be adefined authority to sanction and a laid down procedure forgranting such concessions, since it directly affects the bottom

line. The process of sanction should be invariably difficult so asto discourage deductions from sales, which also come under thescanner of income tax authorities.

As a last resort, organizations can even consider an increase intariff in the worst case scenario, after having exhausted allother methods of improving sales.

The revenue generated in Indian hospitals by way of insurance isonly around around 10% of the total. However, in the nearfuture, 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 inorder to attract clients, wherein they ask the Provider to sendinvoices in batch sizes of one month. This way, the clients give apre-dispatch credit to insurance companies before the actualcredit period ticks in. Once the credit period begins, claims areprocessed and the payments are to be cleared within thecontracted credit period, but the probably of it is low. If there isa discrepancy/mistake in the claim then the whole batch is sentback for correction and the money gets blocked for a longerperiod than contracted. This results in an interest loss, and ifthe invoice itself is rejected then cash is lost. Under bothcircumstances, the bottom line suffers.

Almost 35% of the hospital revenue is spent on manpower

expenses including payment to doctors. In case this percentagereaches 40%, corrective measures to reduce it must be calledfor. A positive stratagem is to optimize employee utilizationwith efficiency, reallocation, multi-tasking and such otherexploits. A negative approach would be to retrench or reducesalaries, though this is a very difficult process. Inversely, if themanpower is significantly remunerated and motivated, theywould soon emerge as a magnanimous asset; but, if handledwrongly, would become a major difficult liability.

I

Another equally important cost element is the inventory, whichcomprises of equipments and materials supply depots. Theseinclude pharmacy, surgical store, medical store and othermaterial store. The control should start right from the requestto buy up to the ultimate consumption. Here, both the price andquantity is required to be monitored based on the needs. Thebest price and quality supported bargain coupled with adequatemarket comparison is essential, as wrong purchases wouldresult in cash loss. Overstocking at the main store or sub storewould also block money and result in interest loss. There areother damages that may happen due to overstocking such asincurring wasteful inventory carrying cost, pilferage, expiry,breakages etc.

To avoid wastage, equipments must be bought as per thehospital needs. Thorough negotiations must be dealt with. Acomplete maintenance contract for atleast the first ten yearsshould be fixed at the time of purchase, as part of thenegotiation. The required spare parts' prices should be frozen sothat there are no surprises in future.

IT is perhaps the most important of tools to reduce cost.Hospital operations have millions of transactions/entries, and ifa good IT system is in place, performance will streamline withrecords. You can have less staff, more clarity and qualityoutput. For instance, in Insurance invoice processing, if theElectronic Data Interface (EDI) is available then alltransactions/reports will reach insurance companies on a real-time basis. Both the pre-dispatch credit and post-dispatchcredit time is hence eliminated, and money flows in quicker,with the disallowance reduced to almost nil. Good ElectronicMedical Records (EMR) would reduce the hassle of transferringtons of papers between various departments and doctorsresulting in reduced cost and better quality work with quickresponse. If all the modules are interfaced, single sourcedocument would deduce the final results and statements - inshort, no hassle of reentry which results in human error andadditional work.

Outsource some of the services as far as possible toprofessionals who specialize in hospitality, engineering,maintenance field and clinical areas. This would ensure qualityservice with less cost since these professionals deal with alarger volume, thereby reducing the administrative burden onthe hospital management.

Insurance

Manpower

nventory

Equipment

Information technology

Outsourcing

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.

Breakeven point

Liquidity Management

CostAccounting

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

pressure to improve revenue efficiency or reduce the cost isimperative.

Poor liquidity management is the result of blockage of funds incurrent assets. In turn, loss of interest on the blocked funds willbe faced. Most importantly, if these current assets are notliquidated within the stipulated time, then there is a fear oflosing them. Particularly, long term debtors would turn into baddebt; 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.

There are several advantages of a proper cost accountingsystem, listed as below:

Cost awareness results in cost control and cost reduction

Auto internal audit of performance and cost facilitatescontrols on all cost centers

Generates MIS on cost comparison and performance forvarious periods

Aids in tariff fixation and inventory valuation

Facilitates budgeting exercise

Nevertheless, a costing exercise initiated by the managementnormally would be met with resistance from the staff, since itwould lead to a number of revelations which would push themout from their comfort zones. These exercises may also bediscounted as worthless and may be perceived as unwantedexpenditure. But if the costing exercise is taken in the rightspirit, it would be a boon to the hospital in improving itsperformance and result in cost reduction. The staff should betaken into confidence before the start of such an exercise inorder to help them understand its importance alongwith its usein improving their individual and departmental efficiency. Suchan exercise can also result in a financial turnaround andaugment profitability.

Another important point to be kept in mind while implementingcost accountancy is not to forego the quality. Quality is of

utmost importance in any healthcare system and cannot becompromised. Quality checks aid in identifying processdeficiencies which when revamped may result in cost reductionby doing away with unwanted processes. Quality checks andcost controls should go hand-in-hand in hospitals to ensureorderliness.

Before services are price-tagged, it is necessary to study theprocesses involved. The next step would be to identify theprocess owners, whose definition of their respeective processesmust be amalgamated with the established best practices. Thisstudy should clearly reveal under utilization and inefficiency, ifany, with suggestions for corrective action. As per the bestpractices neither the under utilization cost nor the inefficiencycost of the organization should be passed on to the customer.Therefore it is advised to have a complete process revamp doneto arrive at an accurate utilization and productivity (efficiency)analysis based on which a road map for the future can becreated.

With the entrance of health insurance, costing of the serviceshas become even more essential. Insurance companies demandhigh 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 notmatch the quality, the hospital may be downgraded and a lowertariff should be granted.

A nagging question that refuses to go away is that of theconventional costing system being good enough as on today. Wehave moved from the old system of Total Cost Approach(traditional) to Marginal CostApproach (conventional), a coupleof decades back. The need of the hour is a system that wouldgive us accurate costing, namely, the Activity-based CostingSystem.

In a hospital scenario, it is observed that the variable cost isvery low i.e. around 40% (direct consumable, doctors chargesetc.). A major portion of around 60% of the cost is fixed cost(overheads). Therefore, the contribution margin in hospitalsare larger and may mislead in viability decision-making processof a service. Activity-based Costing reduces the contributionmargin to a minimum by making majority of the cost direct.When the contribution margins are small, it puts a lot ofpressure on the hospital to perform in order to get higheroccupancy, thereby avoiding cash losses.

This sort of pressure is good in the hospital industry, wherebreakeven point occupation is very high (65% to 75%). Underthe conventional costing method, if the hospitals do not handlecomputation of overheads properly for the services, it wouldresult in wrong costing and product pricing. Due to this veryreason of non-capability to apportion the overheadsappropriately under the conventional costing method, it isrecommended that we move towards a more refined system i.e.Activity-based Costing.

The benefit of implementing the Activity-based Costing methodis that it results in accurate costing, focused approach tohospital overheads, conversion of indirect costs into direct andintroduction of inter departmental billing.

Further advantages of Activity-based Costing include equalimportance to service centre like revenue centre; activities ofthe service centre is monitored continuously; under utilizationand inefficiency of both revenue and service centre arehighlighted; and self-discipline in both revenue and servicecentres. In short, each cost centre shall work like a strategicbusiness unit, and would be seen as a profit centre, wherebyreducing the burden of the hospital administrator in monitoringthe day-to-day operations. Activity-based Costing has thusbecome a priority in all hospitals for their survival and futuregrowth.

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

A revelation so deserving yet so overdue — the hyperbaricmedicine — has finally come into force in India. Found to begratifying in the most unforgiving of cases, hyperbaric medicinehas expeditiously unveiled its worth.

By definition, hyperbaric medicine, a.k.a. Hyperbaric OxygenTherapy (HBOT), deals with physiological and therapeuticapplications of barometric pressure more than sea level.Patients are subject to breathing 100% oxygen in a specialchamber, which is how hyperbaric oxygenization is madepossible.

A hyperbaric oxygen chamber is a sealed chamber, into whichoxygen is pumped under a controlled amount of pressure.Hyperbaric Oxygen Therapy allows a patient to breathe up tomore than four times the normal amount of oxygen, therebygreatly increasing the oxygenation of all of his/her organs,

tissues, and body fluids. It is the pressure in the chamber thatallows for the much greater absorption of the oxygen provided.When a patient is in the chamber, the increased pressure causesthe blood plasma and other liquids of the body to absorb muchlarger quantities of oxygen, greatly increasing oxygen uptakeby the cells, tissues, glands, organs, brain, and all fluids of thebody. The chamber becomes a “goldmine” of oxygen, which isutilized by the body for vital functions.

This increase in oxygen allows for increased circulation toareas, in spite of swelling or inflammation. At the same time,the increased pressure decreases the swelling andinflammation.

The additional oxygen accelerates the healing process andenhances the white blood cells' ability to fight infection. It alsopromotes the development of new capillaries, the tiny bloodvessels that connect arteries to veins. It also helps the bodybuild new connective tissues. HBOT helps impaired organs tofunction better.

By providing the cells with an abundance of oxygen, the cellsreact and are revitalized. They can now function more

efficiently and carry out their processes in an acceleratedmanner.

This constructive therapy has gained immense value as a life-and-limb saving measure in several medical and surgicalconditions. Most commonly used for Diabetic wounds andsevere crush injuries of limbs, HBOT proves effective inrecovery of otherwise non-healing wounds.

HBOT has evidently enhanced the healing process inconditions, such as:

Damage to soft tissue and bones due to radiation as a part ofcancer 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 compressedair works

Plastic surgeons too find it convenient to provide HBOT topatients with compromised skin flaps and grafts

Though, HBOT does add to treatment costs since it is coupledwith a primary treatment, it also significantly reduces theoverall hospitalization bills due to faster healing, besidesbettering outcomes in the seriously ill or chronic and vexingdisorders.

A multiplace chamber, such as the one at Godrej hospital, hasseveral patient friendly features — the roomy interior providesadequate comfort. It allows up to six patients to either lie downor relax in a sitting position. A trained, in-chamber, medicalattendant accompanies and monitors the patients during

Treatment. The center is managed by a team of Hyperbaric

About HBOT

How it works

Conditions HBOT can help cure

HBOT at Godrej Memorial Hospital

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Relax, breathe and heal

Dr. AM Joglekar with the HBOT multiplace chamber at

Godrej Memorial Hospital, Mumbai

Vinay Pagarani — , Dr. AM Joglekar, Development Manager Hosmac Foundation caught up with ,

Surgeon Commander -Indian Navy (retired) and Specialist in Marine Hyperbaric Medicine, to ratify

the word on the street about HBOT.

physicians, anesthetists, and nurses, with experience in HBOT.

'Godrej' is perhaps the first private hospital in Mumbai to set upa multiplace chamber facility, to provide patients withHyperbaric Oxygen, at its newly commissioned department ofHyperbaric & Diving Medicine. The department, headed by Dr.Joglekar, has helped many a critical patients through the mostunrelenting of cases.

Extracts from the interview:

Equipments and allied materials cost little over a crore ofrupees. The total cost of building a multiplace chamber comesup to Rs. 2.5 crores. Monoplace chambers are comparativelycheaper but with much reduced capabilities.

HBOT is given in 'sittings' lasting 60-120 min. In acuteconditions, healthy results are visible in 10-15 sittings; whereaschronic conditions call for 20-40 sittings.

A 2-year diploma course in HBOT Treatment, which coverstraining in hospital units, diving medicine, submarine medicineand shipboard medicine, is avaible at the Mumbai University.These Marine Medicine or Hyperbaric Specialsts form the coreof the team, whereas Anaesthetists may be deployed forroutine HBOT delivery.

India, being such a vast country, is still short of criticalcare hospitals. Every major city would do much better with 2-3life & limb saving centres, attributed with an HBOT chamber.

The HBOT service at Godrej Memorial hospital has undeniablyproved to be an innovative gift to our patients. The Indianhealthcare industry needs to explore new techniques such asthe HBOT.

VP: What are the costs involved in setting up an HBOTsystem?

AMJ:

VP: What is the average duration required for a treatment?

AMJ:

VP: Are there courses and training facilities to learn HBOT forstaff?

AMJ:

VP: Any message for the Indian healthcare industry?

AMJ:

To know contact Dr.Joglekar at .

more about hyperbaric oxygen therapy,hospital@godrej.com

The roomy interiors of the chamber

16

25 years since, management guru Peter Drucker's well-established theory holds water even today. ‘Profit may not bethe primary goal, but it is an essential condition for a company'ssurvival.’Thus, although most hospitals are established to meeta social cause, the success of its sustenance and growth willlargely depend upon how efficiently it manages its funds.

The Department of Laboratory Medicine is recognized as one ofthe major revenue generating sources in a hospital setup.Laboratories today can even stand alone, if not within ahospital. Hence, it is imperative that the planning andmanagement of lab services meets the challenge of ensuring asmooth flow of the 2 Ms: man and material. Adequate space forexisting services and flexibility in design to allow futureexpansions must be intrinsic of this department's structure.

Conventional laboratories essentially include multiple keycomponents viz. Biochemistry, Haematology, Microbiology,Histopathology, Clinical Pathology and Serology/Immunology.

The daily operation of a laboratory fits the theoreticaldescription of a semi-markov chain with job shopcharacteristics. This is because an order for multiple tests mayrequire activity at several work stations; the procedure ofscheduling tests is similar to that in a manufacturing unit thathandles sundry small-scale customer-orders like a job shop.Hence, the facilities must be planned to facilitate thisinterdepartmental activity, and its smooth functioning inrelation to other services of the hospital, keeping in mind itsflexibility and expansion.

Ideally, laboratory services must be located in close proximityto the inpatient area and outpatient department (OPD).Diagnostic tests requested from the OT, casualty or theintensive care units oftentimes require urgent diagnosis;hence, easy access to these rooms is also desirable. It isrecommended that in situations where such an ideal locationcannot be detected, there be at least a Blood Collection roomat the OPD and a Stat lab, which is easily accessible from criticalareas like OT, Casualty and ICU. The main laboratory may thenbe located at any suitable place in the premises.

For planning and efficiently running a laboratory, it is alsoimportant to study the workflow of the department.

The total area required for a laboratory depends on manyparameters such as the number of sections to be included; thebed size (which would, in turn, deduce the number of testsdone); the workflow adopted; automated or manual etc.

Research done by Hosmac India indicated the market averageto be at almost 10-20 SqFt/Bed; though, internationalliterature would put this at 20-30 SqFt/Bed.

Some studies done by scientists like Dr. Rappaport state thatthe percentage area distribution for some of the sections in alab is as follows:

Location and setting

Space Planning

Streamlining the lab setting

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 thefollowing must also be considered:

The size of equipment required to be set in the differentsections

Storage space required

Movement of sample, reports, information and staff

Special requirements for interior design like the materials fortable tops, flooring, planning for the electrical outputs,adequate lighting, temperature, furniture etc. These are to bespecified in adequate detail like spaces near the microscopeshave to either have enough natural light or as near the otherwork areas lighting of 500 lux. This is in contrast to the areas likethe Biochemistry or Serology, where direct sunlight may causeuntoward reactions in various chemicals or reagents.

Thus, we can infer that the planning of this department willinvolve interweaving multifarious factors. But research hasshown that a well-planned and equipped lab streamlines thestaff time by almost 40 %, mainly attributed to the reduction ofc r is scross i n

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

Equipment planning in the laboratory is a complex process;since the technology involved ranges from low-end equipmentslike flame photometers to high-end equipments like automatedelectrolyte 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 rangefrom 3 lac INR to 60 lac INR; this cost variation persists foralmost all the equipments. Hence, the decision making involvesa complex exercise insisting for a team effort by Technical,Managerial and Financial experts. The points considered are:

What to buy

When to buy

What technology is best suitable

The size of the equipment (based on projections made byconsultants for upcoming hospitals or depending on the existingworkload requirements and the projected increase)

For what price to buy

At what terms to buy

The manpower serving a laboratory calls for a class of talentedand acute technical experts. Generally, high-end medicaltechnologists would be recruited in shifts to run the lab, 24 by 7.Only this would ensure the availability of diagnostic facilitiesduring emergency situations. The lab technician can be assistedby lab assistants and/or lab attendants.

The manpower planning in the laboratory has to also bear inmind — productivity, to give an accurate evaluation of theefficiency in the lab. The productivity standard can thus beused for a dual purpose indicator: one, to check theefficiency level of the existing manpower and estimatewhether there is adequate staff; second, to calculate themanpower required to touch a higher productivitybenchmark. The American standard for a fully automatedl a b r e a c h e s 9 , 0 0 0 - 1 2 , 0 0 0 t e s t sperformed/technologist/year; and the Indian standardcomes to about 7,500 tests/technologist/year. However,one leading private hospital in Mumbai has managed toexceed these standards, where the productivity is close to11,000 tests/technician/year. This can be attributed tothe high level of technology and automation put in place.In contrast, there are some public and charitable hospitalswhere this ratio is as low as 4,500 6,500tests/technician/year.

The department of laboratory medicine is rightly known asa 'cash cow' in hospitals. Whether as a single unit or a partof the hospital, the department's revenue generatingcapabilities are realized, almost instantaneously.Statistics show that a laboratory generates almost 20% to29% of the hospital revenue in mediocre hospitals. Inhospitals where this department forms a thrust area, as isthe case with many of the leading hospitals, thispercentage is much higher. Besides, the argument that thesurgical section also generates considerable revenue for ahospital can be repealed with the fact that theexpenditure involved in these departments is much higher,bringing down their net earnings.

In recent years, the department of laboratory medicinehas become an integral part of every hospital. This is owingto the fact that a patient is required to undergo clinicalinvestigations to not only aid his diagnosis, but alsomonitor the progress of his treatment. With latestadvances in science and technology, this field has

undergone a sea change — shifting from manual to high levels ofautomation.

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Groundwork for equipment

Manpower Planning and Staff Scheduling

Revenue generator

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

18

Prior to the last 50 years, medical breakthroughs unearthed notmore than a couple of times per decade. The '60s and '70switnessed some evolution in the field of organ transplant, non-invasive surgery, synthetic antibiotics, and in related fields tohealthcare delivery such as communication systems,automated material movement systems and building systemstechnology applied to healthcare facility construction.

In the 1980s, major medical innovations came even morerapidly. With the '90s setting in, faster advances in medicaltechnology were seen, together with new methodologies andmantras such as ‘patient-focused care’, ‘multi-skilled staff’and ‘paperless medical record’.

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 patientprofiling and charting, for communications among staff, andbetween diagnostic services and patient charts

Continued clinical advances, many tending towardminiaturization and mobility

Increased acuity of both inpatients and ambulatory patientsprevalent in the hospital setting

Increase in minimally invasive procedures, reducing the needfor overnight admission

Expansion of outpatient clinics and creation of ambulatory‘themes’ through selective clustering

Increased recognition of the family/caregiver's contributionto the healing process

Gradual acceptance of the benefits of non-traditional modesof therapy such as massage therapy and acupuncture

Expanded public awareness and access to information, fuelingthe consumers' desire for the latest in diagnostic techniquesand treatments

Intensified point-of-care diagnostic testing

Magnified clinical research integrated into patient caresettings

Reinforced emphasis on patient (self-)education in thehospital setting

Based upon these more or less incomprehensible andexponential changes in clinical services, operational trendsand advancements in technology, the diverse facilities — hailedas state-of-the-art two decades ago — are fast becomingobsolete long before the life of their building shell comes to anend. Narrow floor plans, too many solid walls and low floor-to-floor heights do not permit the expansion and renewal ofhealthcare facilities that is the need of the time.

Should the driving force be the cost of operating services ratherthan the cost of the building?

While planning a healthcare facility — or any facility for thatmatter, 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 bydesign development and contract documentation, but theseaspects are beyond the scope of this feature story.

During these phases, all those concerned with the planningprocess are responsible for inspecting the ‘possibilities of theflexibility relevant to that phase’ and have a clear vision ofwhat the following phase entails.

The overall planning process, in this endeavor, rebuilds as thecapital planning process, to which there is the operationalplanning process working in parallel. This, when linked to thefacility planning process, will ensure that the planned facility isfinancially feasible.

Hospitals never develop into what we think they will. Thecorporate strategic plan, mission and vision statements willdefine the long term role of the organization, yet they ought tobe fluid and changeable. They should anticipate changes in theprogram and service delivery. In short, the strategic plan is aliving document.

Consider the following questions during the strategic planningphase:

Do we manage our way through changing service demands ordesign out of them?

Historically, the approach to developing projections has been astraight-line graph. It never seems to plateau! New approachesfocus on whether different service delivery approaches mightallow the organization to gradually adapt with regard todemand.

Do current trends create opportunities or barriers?

A specialized service on a single site will create an opportunityto maintain and develop specialist expertise. But it can strike adiscord, if the quality of service is not seen as worth going theextra mile to access the service.

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The Question

The Planning Process

Flexibility in Strategic Planning

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.

Asked another way: Do alternate ways of clustering serviceswithin a facility create opportunities or limitations, inresponding to long range demands and pressures?

For example, will a pediatric strategic plan include pediatricrehabilitation, or will the rehabilitation plan include adult andpediatric rehabilitation? Where is the pressure for flexibilitylikely to be greater?

The range of questions regarding flexibility will tend to recur inevery phase, but the way in which this flexibility is to beachieved will become more narrowly defined and more tangible

With each subsequent planning and design phase.

This is the first planning phase moving towards the design of thephysical hospital plan. It is developed based on the strategicplan and describes programs and services at an outlining level,and it involves compiling basic workload and staffingprojections. This information is then used to develop broad-brush estimates of space requirements and the relationshipsbetween them.

At the same time detailed information is gathered aboutpossible site(s) for development of the facility. This site shouldbe, among other things, of sufficient acreage to provide for anyfuture expansion that may be necessary.

Various other technical data about the possible site(s) is thencompiled, which helps the architects and planners identify theconstraints and opportunities offered by that site. A vademecum to master plan the massing and construction phasingoptions, and preliminary capital cost estimates.

A master plan is a living document and will require continualreview and updating to make it functional as a planningguideline.

There are the following issues to be considered in this phase:

1. The planning horizon — For how long into the future to planfor?

2. Single building v/s. healthcare campus — Single buildingswill result in floor plates with substantially larger areas; thehealthcare campus allows for progressive development towardsan ultimate solution

3. Provision of support services — On-site or off-site?

4. Service growth and change — Placement of high growthservices to allow for expansion

5. Building type — The location of space in specific buildingtypes may attract different design standards and unit costs

6. Vertical v/s. Horizontal expansion — Depends on a number offactors best addressed by the consultants

A functional program is a detailed document that describes thefuture functions and operations of a functional facility. At thisstage of planning, the greatest flexibility needs to reside in theminds of the project planners to ensure that all relevantfactors are considered.

Flexibility-related issues in this phase include the following:

1. Operational trends — Consultants can providebenchmarking, but the staff needs to be up-to-date in thesematters

2. Equipment choices — The location and selection ofequipment are to be considered

3. Service consolidation — Operational efficiencies can beachieved by sharing support facilities

4. Utilization patterns — Spaces may be shared byaccommodating different clinics on different days

5. Changes in hours of operation — This is an excellent optionto accommodating additional workload, but the operatingcosts must be weighed against the capital cost of more space

6. Data communication capabilities — It is vital that thisfactor is provided adequately

7. Open concept planning — Allowing multiple uses andstandardized service grids should be considered

8. Standardization of room sizes — Facilitates change in usemore easily than custom-fitted room sizes

9. Flexibility at the patient bedside — The universal roomconcept

10. Modular space planning — Using uniform planning units

In the ideal world, the perfect balance is found betweenfunctionality of space and the generic parameters that affordits flexibility. Staff and patients will enjoy a pleasant andeffective work/care environment. Construction dollars can beoptimized.

In the real world, this point of balance may seem elusive, butteamwork, attention to detail, and open communicationthroughout the planning and design process help us close in onour target. Planning a new healthcare facility affords anopportunity to create a dynamic and long-term solution in amanner that will allow the hospital to explore innovative andexciting ways to deliver healthcare to its community. Anopportunity is provided to create a facility which delivers aninventive and flexible environment that will accommodateboth the predictable and the unknown changes in a sustainablemanner serving the organization, its patients and staff, theirfamilies, and the community, well into the future.

Flexibility in Master Programming and Master Planning

Flexibility in Functional Programming

Conclusion

The author can be reached at.hussain.varawalla@hosmac.com

Where it all started

The evident evolution

Be 'wary' careful

Role of the Medical Imaging Dept

On the 8th of November, 1895 medical imaging gainedtremendous ground in hospital services. It was on this day that aphysicist named Wilhelm Conrad Roentgen from the Universityof Wurzburg, Germany discovered an invention that wouldtransform medical imaging history. His eyes were watching aluminous phenomena a faint, flickering, greenish illuminationon a cardboard painted with fluorescent material in carefullydarkened room. The rays emerging from Crookes' Tubepenetrated the cardboard shield and fell upon the luminescentscreen, thus revealing their existence in the darkness. Theillumination was seen on the fluorescent screen due as with theinvisible rays across the line of shadow. It was also observedthat denser materials such as metals were lesser penetrable.

The experiment was soon tried with humans, and it wasdiscerned that human flesh were transparent but the bonesopaque. The discoverer interposed his hands between thesource of rays and the luminescent screen; consequently, hisbones were visible excluding everything else on the screenbehind.

Later, the rays were named after their inventor, Roentgen(a.k.a. X-Rays). In 1901, Dr. Roentgen was honoured with theNobel Prize for Physics, highlighting the pivotal milestone in thehistory of 'medical imaging'.

Medical imaging has grown by leaps and bounds over the pastcentury, assisted by modern advances in science andtechnology. Noteworthy innovations, coupled with myriadadvances in applications and engineering fields, were seen.

Holding high the rudimentary diagnostic tool of X-ray, manynew inventions came about over the last century. Contrived

modalities such as Ultrasound, Nuclear Medicine, and MagneticResonance Imaging & Endoscopy were devised. Nonetheless,the quintessential X-ray diagnosis equipments form a backboneof 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 asthe ones mentioned above are regarded as supplementarydiagnostic procedures since they are relatively expensive.

Keep in mind that diagnostic modalities such as X-ray andnuclear medicine use ionizing radiations, which are hazardousto human tissue. And even though, these equipments aredesigned to shield the patient and working staff from unsafeexposures, their installations must support a regulatedfunctioning. The Directorate of Radiation Protection (DRP), abranch of the Bhabha Atomic Research Center (BARC), has laiddown some guidelines based on ICRP regulations tomanufacture, market and install X-ray and nuclear medicineequipments. It is mandatory to adhere to the stipulatedguidelines. Since ionizing radiations are harmful, some of thediagnostic procedures are even diverted to other modalitieslike Ultrasound, Endoscopy and Magnetic Resonance Imaging.

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.

Assisting the clinician in diagnosis and treatment of diseasesform the principal objective of the Imaging Department in anyhospital setting. However, different types of hospitals,broadly, General and Super Specialty hospitals pose differentworkflows.

They cater to the general masses, providing the vital facilitiesfor diagnosis and treatment. Hospitals are further classifiedaccording to their modalities and respective bed strength.

Rural Hospitals (30 bedded) consist of the bare minimumbasic requirements such as mobile X-ray equipment andminimal radiological system working on single phase mainssupply in a dark room. Diesel generators serve as a back up towithstand power-cuts. Rural hospitals are set up remote fromurban areas; oftentimes, they do not have qualified personnelradiologist. These hospitals are, however, equipped withmobile vans together with some basic radiological system forthe chest and/or orthopedic X-ray to scan patients for diseasesor injuries.

Cottage Hospitals (100 bedded) incorporate the standardprerequisites such as mobile X-ray equipment, 300mA handoperated X-ray equipment and back up diesel generators. Thesehospitals are located in small towns available with efficientradiographers. Uncomplicated procedures such as gastrointestinal studies are performed in such hospital.

District hospitals, (250 bedded) on the other hand, operatewith more sophisticated equipments like motor operated X-raytables with 40 KW X-ray generators. They help ease the load ofchest, abdomen, ortho- X-rays as well as procedures such as GI,IVP etc. Dental X-ray equipments might also be a featureinstalled in some district hospitals.

Medical colleges, ordinarily, have a capacity of 300+ beds.They function on the Medical Council of India guidelines. Theseinstitutes carry high tech equipments such as motor-operatedX-Ray tables, image intensifier television system. They enablethe students to observe and study the entire procedure in aclassroom. Recording facilities on electronic devices are alsoavailable, if needed. The number of X-ray equipments aredependent on the requirements of the hospital and institute.

The top of the line hospitals covering a large section ofmodalities such as Cardiology, Trauma, Nephrology, Ob/G, ENT,Ophthalmology, Cancer, Burns, Chest Diseases, Diabeties,Dental, among other, make the Super Specialty Hospitals. Theyare located in metro cities and cater to every type of patientsGoverned by a board of trustees, major super specialtyhospitals fall under the research hospital category, where acertain percentage of beds are for free.

In order to generate a diagnostic report, the ImagingDepartment needs a full-fledged dark room or a CR system.

An integral part of the Imaging Department, this room is locatedadjacent to the X-ray rooms. Inside the completely darkenedroom, films are loaded in cassettes. Dark rooms demand autility suit with drain board for mixing chemical solutions, aswell as a water supply for the purpose of washing hands. Anexhaust fan to ventilate the room and contain an uncontrolledspread of fumes from potentially harmful chemicals, is alsoessential.

To obstruct light, a 'light lock', between the dark room and theexit, equipped with interlocking doors is essential. The room'swalls and ceiling are painted black to brace the darkness. Withan overall size of 100-150 sqft, the dark room is composed of adry and wet section.

Big investment

Film processing takes about 30 minutes

Modern Imaging Departments use this throughput technology. ACR system electronically captures the image on a plate todisplay on a monitor. Therefor, transferring or recording theimage to another media is favourable.

Quicker diagnosis

Higher cost

Requirements of the power supply, space - area, skilledmanpower and operating costs are considerably high for thisdepartment. Hence, efficient planning based on the needs anddisease pattern of the hospital is of the pivotal to an adept out-turn. Involvement of the hospital management,administration, engineering department must be summonedfor forethought.

As part of a pipe dream, the recommended size for an X-rayroom should be of about 5.5m X 6m X 3m (L x B x H) dimensionwith a weight-bearing capacity of 1200 kg. Such a setting wouldallow upgradation of equipment and augmentation of services,as the future would demand from every Imaging Department ina hospital.

Awell-planned Radiology Department ensures an efficient flowof service, prompt scheduling and minimum movement of thepatient. Almost 90% of the job, now-a-days, is done onconventional radiology equipments inclusive of radiographyand fluoroscopy.

The X-ray tube must be kept in check, as this diagnostic tool tooexpends ionising radiation. An expeditius option free of themajor radiation trouble the multi-pulse high frequency X-raygenerator is also available for those who take GreenHealthcare more seriously.

Specially designed to barricade radiation leakage as per theAERB guidelines, separate rooms for each department have tobe maintained. The main electricity distribution transformershould be located close to the department, due to its heavydemand and low drops in voltage. Also, since most diagnosticunits today are software-based, the requirement of air-conditioning for diagnostic rooms is essential.

Finally, the department can be classified into two main areas;namely, the WaitingArea and the FunctionalArea.

Contemporary technology must be taken into account whilstplanning the Imaging Department, since radicaltransformations have been seen in the department, lately. Ascientifically-planned and designed Imaging Department,which is technologically upgraded, is essential to guaranteeeffective medical care to society.

General Hospitals

Super Specialty Hospitals

Dark room

Upper:

Downer:

CR System

Upper:

Downer:

Other Parameters

Winding up

�

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The author can be reached at .anil.shastri@hosmac.com

Located in the lush green plains of Etawah district deep withinthe state of Uttar Pradesh lays a small village by the name ofSaifai, 250km away from the capital city of Lucknow. At adistance of another 20km from Etawah is Saifai village and is agovernment-run medical institution that has performed parexcellence and beyond — behold the Uttar Pradesh Rural

Institute of Medical Sciences and Research (UPRIMS & R).

In a short span of only five years, the institute which has anintake capacity of only 100 students per year has alreadyequipped itself to take on the challenges of the next six years.Besides, efficaciously covering a radius of 30km, the students

and fellow doctors of UPRIMS & R have consistentlyameliorated the public health scenario in all of the near-byvillages.

The man behind the entire operation of UPRIMS & R — Dr. T.Prabhakar, a specialist in neuro-anaesthesia and neurointensive care — has turned the place around. He has served asa 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 didsuper specialisation from All India Institute. UPRIMS has beencarved out solely following foresight of this visionary.

Shri Mulayam Singh Yadav wanted to alleviate thesebackward areas since back in the day. In 2005, when he wasChief Minister of Uttar Pradesh, he decided to commission ahospital and an institute under the NRHM scheme that woulddoctor Safai and its near-by areas. I joined in as the Director inAugust, 2006 to augment the strategy of the insitution.

In the initial days, our students were taken to a near-by villageregularly to provide free medical assistance to one and all. Wehave gone well beyond medical checkups, even to the extentof learning and resolving social problems of our patients.Providing vaccinations, bleaching the wells and drains andcreating health awareness amongst the public are continuallydone by our students on a regular basis. Today, we havecovered each and every village in the Etawah distict and wellbeyond.

Extracts of the interview:

VP: How did the thought of setting up a grand institute suchas UPRIMS in a village so underdeveloped as Safai emanate?

TP:

A role model for the healthcare industry

In an intense tête-à-tête, , Director - UPRIMS & R, confuted the popular assumption that only private

institutions can deliver quality healthcare facilities. , Development Manager - HOSMAC Foundation reports.

Dr. T. Prabhakar

Vinay Pagarani

The Uttar Pradesh Rural Institute of Medical Sciences and Research is situated in Safai,

250km away from Lucknow in Uttar Pradesh

Dr. T. Prabhakar, Director, UPRIMS & R

VP: In your words, which features of UPRIMS delineates itfrom the rest in the game?

TP:

VP: Where have you reached in terms of the foreseen visionfor UPRIMS?

TP:

VP: Please enlighten us with the strategies that areresponsible for the success that UPRIMS is so extensivelyexperiencing.

TP:

VP:Any message for the Indian healthcare industry?

TP:

Our OPD strength has crossed 2000 patients per day, who areprovided 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 pre-clinical and paramedical postgraduate accreditationsalongwith the MBBS accreditation. We will be eligible forapplying for clinical subject postgraduation next year. We areconfident that the Medical Council of India will hesitate no inchin conferring them, next year. Intensively, we are alreadyequipped with 60% of the infrastructure for super-specialities.

The Govt of Uttar Pradesh has given permission to increaseintake of medical students from 100 to 150 every year. We willbe applying for approval of MCI accordingly.

Despite the location and other constraints, we have achievedall this and more; so much so that the development outside thewalls of UPRIMS were resultant from the operations inside.

The objective was to emerge UPRIMS into a premiereinstitution within the five years of my tenure of directorship.However, MCI regulations and the location constraint slowed usdown. Either way, 60% of the checklist has already beenfulfilled. As you know, we are delivering quality healthcare tothe rural population, unlike any other.

We run a number of viable government schemes such as theNational Swasth Bhima Yojana, Establishment of DOTS centre,Running of rural health programmes, Prevention of blindnessprogramme, Janani Suraksha Yojana, Family planning, AntiRetroviral therapy unit, ECHS for Ex servicemen and theirfamilies. In addition, Smile train program and ‘Health begins athome’programme are run by our medical students..

The government has been very cooperative in getting usfinance and other approvals. Friends and well-wishers havealso supported us well. Our ultimate goal to be recognized inthe league of AIIMS is no more a distant dream. Possibly, in thenext five years, we will be much ahead than most institutions inIndia.

Before my tenure ends next year being a tenure appointment,we will have check-marked 70% of the list. The rest 30% of theobjectives will pick up next year after our first batchgraduates.

I have visited many a healthcare institutions in India as wellas abroad. Taking note of the worthwhile examples, I haveamalgamated their best practices to suit UPRIMS.

I always plan 10 years ahead. The medical or electricalequipment we have purchased are covered with a 5 year-warranty by default, and an additional 5 years by anarrangement we have made with the companies. Thistechnique was a learning from myArmy days.

Punctuality and discipline are two things, I have alwaysadvocated. I keep a watch on everything via CCTV cameras,placed at points of interest. Unless I am away, I take two roundsof two hours each in the entire institution every day. This givesmy patients and staff a chance to confront me, face-to-face.My mobile contact number is freely available for anyone whowants a word with me. Besides, complaint books are placed andregularly inspected.

Healthcare institutions must be honest. Even ifprofitability is the primary objective of an institution, it mustbe brought about through good service, being a healthcareorganization. Outdated equipments must never be purchased.

Students as well as professionals must be updated withcontemporary technical know-how. Cost-containment must beprobed into and given adequate significance. Insurancecompanies must research more and provide better services toconsumers, which are mutually beneficial.

The Indian healthcare industry is on the rise. The ultimateobjective of every institution must be linked to social service,thereby following an intensive approach to grow with the wholeof the country. This perspective re-adjustment can have far-reaching influences, and also impact the global order.

To know more about UPRIMS & R, contact Dr. T. Prabhakar at.prabhu4903@yahoo.com

Fourteen years ago, a small outfit decided to make animpression on the entire healthcare scene in India. Hosmac setthe ball rolling by questioning how hospitals operated andtended to their patients in India, and ergo challenged the wayhospitals were planned and designed. Today, the thenundersized outfit has evolved into a sizeable healthcare-oriented company serving clients even in the internationalcircles.

On the 24th of June, this year, Hosmac wrapped up another yearof excellence in the spaces of Healthcare Consulting, Design andConstruction. Ever since the 10th year anniversary, this annual

celebration has been building up with gusto, year-after-year.

This year's fête was perhaps the most resplendent yet. HosmacIndia decided to celebrate its 14th Annual Day with a trip to thescenic locales of Lonavla. The Senior Management had alwayssuggested the importance of engaging employees in teambuilding activities. Towards this end, an early morning outdooradventure trek was opted for, to motivate the Hosmac force.Aamby Valley's adventure zone, a.k.a. '18 degrees north', whichholds 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

11AM, Hosmacians were divided and equipped for a surpriserace. 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 werearranged mid-way by the organizers to revitalize the teamswith refreshments.

After a two hour hike, most of the teams reached the base campin record time and the winners were lauded with appreciationfrom all and a champagne bottle for keeps.

The participants were then transferred to Citrus hotel inLonavla, where they were to sojourn. Lunch ensued and a dogtired team took to mingling with their colleagues from aroundthe country and the Middle East. Hosmac Day gives Hosmaciansa chance to understand the distinct outlook with which theircolleagues in the outspread regional offices carry on theirHealthcare Consulting and Design Practices.

A formal event for the evening was indicated, where Hosmacwould announce its future objectives for the years to come. Toadd a formal flavor to the celebrations, the evening was rung inwith the National Anthem and the auspicious lighting of thelamp ceremony. A recap of the year 2009 was captured in avideo, made especially for the occasion. It showcased Hosmac's

Achievements in the areas of Healthcare Consulting andProjects. Snapshots of the new employees were also included inthe video for introduction to personnel across regions. Theevening saw presentations from the up and coming verticals ofManagement Consulting, Project Management and HealthcareArchitecture.

Hosmac has always believed in the ‘kaizen’ philosophy ofcontinuous improvement. It decided to hold an intra divisioncum region 'Corporate Presentation' competition. Ideated bythe Senior Management, it was included in the day'sproceedings with the aim of placing the Company's mostpowerful communication tool in the hands of its employees.The room filled up with a sincere Hosmac-ial sentiment, whichresonated among all. To Judge the competition, Hosmac hadinvited Alvin Saldanha, CEO, Idea Domain Communications; DrVivek Desai, MD, Hosmac India; and Narendra Karkera, SeniorAdvisor, Hosmac India.

Hosmac turns 14!

Isha Khanolkar, Asst. Manager - Operations - Hosmac India, recounts

the commemoration of the 14th Hosmac Day.

L-R in foreground: Isha Khanolkar, Dr. Vivek Desai,

Alvin Salhanda and Narendra Karkera

Hosmacians listening intently to Alvin Saldanha (left)

Taking a closer look at healthcare

in the lawns of Citrus Hotel, Lonavla

Strong visuals, impressive new media and rock solid contentfilled the day with efforts from the fiercely competitive regionsand divisions. Hosmac Projects bagged the Best Presentationtitle, for having used an innovative software to introduceinstantaneous customization in the Hosmac Presentation basedon the customer's needs.

The annual Hosmac Awards, to honor the employees whodisplayed exemplary performance during the year, followednext. Announcements were made in the categories of BestEmployees and Young Achievers in the respective divisions ofHosmac Projects, Hosmac Consultancy Services and HosmacCommon Pool as well as Support Services.

Dr Vivek Desai then took over the proceedings of the evening bymaking a few special announcements that were to have a majorimpact on the Company. He motivated the teams to work harderand informed that Hosmac was facing a spurt in growth. ThatHosmac had in fact grown over three folds in terms of revenue,as compared to last year. He pointed out poignantly to theexample of how the Indian Government has placed its faith inthe hands of Hosmac by awarding it with the prestigiousremodeling project of Ram Manohar Lohia Hospital, New Delhi.Hosmac would be the only company that would be able to pull

off the project in a short span of only one seventy days, just intime for the common wealth games. The announcementsreinforced the emphasis that Hosmac has laid on professionalmanagement, focused vision and hard work.

The evening was intersparsed with cultural performances fromHosmac personnel deployed onsite as well as the Accountsteam. Their riveting performances left the audience asking formore and set the tone for the theme night that was to follow.

Dressed in their best ‘Bollywood’ garb, the Hosmac glitteratidescended upon the lawns of Citrus – Lonavala. ‘BollywoodNight’ saw Zeenat Aman, Anthonhy Gonzalves, Bobby andChandini stealing the show with their perfect rendition of theyesteryear Stars. Dancing and Singing was dotted withindividual performances as well as an impromptu fashion show.The DJ led the night with songs from all genres and made surethat everyone swayed with the music and had a good time.

A near perfect day that was made possible by an eventmanagement company that has proven itself to be true to theirword time and again at every Hosmac event. Maximus eventsthat managed the Day's proceedings under the guidance ofManaging Partner Reema Sanghvi executed the entire programflawlessly for seventy odd people. Mithila and Deepesh ensuredthat every need was attended to and that everything went asplanned. Hosmac thanks them for their services.

Hosmac Day culminated with employees making new friendsacross regions and departments. It helped bind an alreadystrongly knit team that will take on the new year with addedconfidence and poise. The dawn of another Hosmac Day will seethe pioneering company completing 15 years of dedicatedservice of improving Healthcare Systems in India. With theIndian healthcare market set to grow by USD 75 billion in thenext couple of years, the teams at Hosmac are preparingthemselves to make a mark in India, and venture out into theworld beyond to announce our arrival.

Hosmac Projects’ personnel dacing to the beats of ‘Bollywood Night’

Hosmacians listening intently to Alvin Saldanha (left)

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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HOSMAC Middle East FZ LLC

PO Box 505064, DHCC, Dubai, UAE

Tel : +9714 4298345

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Gurgaon - 122 002 Haryana

Tel : +91 124 3240 677

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Tel : +91 80 2520 4141

East Region

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Kolkatta - 700 101 West Bengal

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Uturn, Guwahati - 781003 Assam

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