Speaker 1: He is a great figure in the eye care standard NABH and he don't need much introduction but still I have to introduce as a part of my MC role. So he is a medical director of Nirmal Eye Hospital Chennai. He is also a principal assessor of NABH, executive committee member OTSI and member legal cell AIOS. He is a mentor and advisor TNOA, General of Ophthalmic Science and Research, GIMA. He is a chairman academic committee IMA, TNSB and co-chair national IMA PDB. He is a vice president TNOA and is also a president IMA, TAMARAM. Sir, over to you Nirmal sir.

Speaker 2: Thank you Swetha for that nice introduction and thank you Gagan for setting the tone for the meeting and as usual a wonderful talk with a lot of insights into how we started the eye care standards journey and also what we can look forward. So good afternoon ladies and gentlemen. Thank you for joining us for this continuing quality education series on ophthalmology standards and so my talk is about infrastructure and facility requirements in eye center. So whenever we have a program on NABH, people have a lot of questions related to the infrastructure and what relevance it has to the quality process. So generally we quantify the goodness in health care based on the three things, the structure, process and outcomes. So unless we have good structure, particularly the infrastructure, the staffing facilities and policies, there will be deficient processes and outcome may not be as expected. So every system is perfectly designed to achieve the results it gets. As you all know, there are three dimension to quality of care, the structure where the inputs are there, the material, the staff and the organizational structure. So good structure increases the likelihood of good process and good process increases the likelihood of good outcome. So good outcome means not only the visual outcome, what we aim at in ophthalmology, but also patient satisfaction and employee satisfaction. So this quote highlights the importance of having good infrastructure because it's much more than architecture or the aesthetics in a building. So what exactly you mean by the infrastructure? So any hospital will have a structural component, okay, the beautiful building here and non-structural component for providing medical facilities, lifeline facilities and certain aesthetic facilities. So these are the architectural edifice. And the most important in hospital or healthcare institution is the lifeline facilities apart from the aesthetic and the infrastructure part. So what are these? These are emergency exit system, the fire system, the electricity system, water supply, medical gas and communication. So not only the main lifeline facilities, but since this is very critical, we also need to have alternative for these systems. So this sums up the requirement for a safe hospital. So the structure not only leads to good process, but also can take a mediation path and directly impact the outcome. So how do we do that? So many hospitals, when we have a discussion, they say this particular facility had this, so that's why we incorporated in our small hospital. So that teaching institution where I graduated had a HIPAA filter and laminar outflow. It was a big setup with big layout. Should I have all this for my small single practitioner? So you should not compare orange with apple. So you need to design and build your infrastructure as per the scope of services. The good starting point for planning your infrastructure is the scope of services and the application form you fill up before going for accreditations. So you have to define your scope of services and also see what is not in the scope at present and what support and auxiliary services you are going to provide. So based on this, you have to plan your infrastructure. The second moot point would be the regulatory requirement in your state. In India, health is a state subject and various states have different regulatory norms. So you have to comply with the regulatory norms like the Clinical Establishment Act and your state healthcare acts. And don't compare yourself with other organizations, maybe because each organization will have a different scope of services and accordingly, they would have planned their infrastructure. And last important thing is the form and functions. So based on your scope of services, you need to plan the form of your practice and what all functional elements required you have to incorporate in your infrastructure. So I thought I'd take this talk based on the frequently asked question in many of our accreditation related meetings. So these are some of the common questions asked. What are the NIVH norms for hospital building? Is there any reference? We are only a daycare. Should we have an ambulance, emergency services, or casualty? Should we have a pharmacy, lab, or opticals? And then the question go towards the infection control and OT related. So what is the minimum size? I'm planning to expand my OT, how should I plan or re-design? Is AHU module? I think this is one of the oft repeated questions in many of our accreditation meetings. So to answer this, let me first. So this is the first question. So what are the NIVH norms for a hospital? Very often NIVH, instead of taking the bouquet, gets brick bags from the stakeholders because they think all the requirements, stringent requirements are given by NIVH. No. Many of the requirements are regulatory requirements and India, the healthcare standards are based on Indian standards, the IPHS standard, Indian public health standard, and the National Building Code. This National Building Code is the Bible for architects and engineers because so this publication described the every aspect of building construction as well as safe practices. So here the hospitals are classified as Group C1 in the National Building Code and they have prescribed these limitations in terms of the corridor size, the door width size, the staircase width, the ramp requirement, as well as the evacuation requirements. And HVAC, heating, ventilations, air conditioning system is also incorporated in the fire and life safety of the National Building Code. So according to this, there are various fire zones and the type of construction is prescribed to the hospitals. So, and if there are high-rise building, again, there are prescribed norms for the hospital in high-rise buildings. And the third important regulation is the Clinical Establishment Act and this has been amended in various states, a lot of draft amendments are there. So you take up the last approved document from your state and that is also given various requirements on the size as well as the operation data requirements. And these are the minimum requirements for a procedure room. And if you are going to build a procedure room, you can build according to the space requirement given in this CEA Act. And the fourth one is the NABH standard, particularly Hospital Infection Control Standards and Facility Management and Safety Standards. So the intent of NABH standard is for providing safe and secure environment for patients and plan for emergencies within the facilities and also establish a program for the clinical and support service, equipment and management. So what is the minimum size? Let me go through this. And before planning or planning to redesign your structure or upgrade it, so you have to answer these questions, is your existing facility or system working well? If it is working well, how will the proposed change make a difference to the existing infrastructure? So why or who will get benefited and what will improve? And if you are going to ask these kinds of questions to your consultants or anyone suggesting a modular OT or asking to change your requirement just for the sake of accreditation, ask the last question, who will get benefited out of this infrastructure change and what will improve? Whether is it because of government norms you are fulfilling the regulations? For example, the ramp was a regulation recently introduced and whether the hospital and surgical team will get benefited because of this improved structure and whether the patient will get better outcomes because of the improved structure. And also, is it absolutely necessary, whether we can do it now or later or if there is any alternative available? So let me briefly go take you through the OT requirements because this is the commonest question asked in many of our meetings. The first requirement in a hospital, particularly in a critical care area like operation theater is it should do the sick no harm. And this is another reference or resource material apart from what Gagan listed. So this is a review article published in our TNOA journal by me and Kumaran. It has probably one of the widely cited and most popular articles, 61,000 downloads so far. And that gives various aspects of the design and requirement. And in hospital OT design, there are different challenges. The three different functions has to come in this single space. One, it has to provide safe, comfortable, and calming area for the patient and the providers. And the providers have to navigate the space quickly and efficiently, particularly in an emergency situation. And third, the most important aspect is infection control and how you need to understand the zoning, equipments, ventilation, the unidirectional flow, and particularly in ophthalmology because of the small OT areas, incorporating all of this is a serious challenge. And of course, architects are now discovering innovative ways to incorporate all these challenges in a small area. These things are really important apart from the location, the equipment you choose, the patient safety and infection control requirements, the various goals, and how you're going to utilize this space in terms for the patient benefit as well as utilization of the space. So whenever you are designing or redesigning a project, write down your requirements for the data, not only your present requirement in terms of number of patients or the number of surgeries or a type of surgery, you also need to take into consideration your future prospects, say after five years or after 10 years, because you can't keep on redesigning your data. The second step is make a requirement, area requirement, and also add 30% to the circulation space and then add various requirements, the requirements for the equipment. So there are good softwares now available, which can calculate the space requirement as well as the cost of these things. Then zoning is an important concept, not only in a single OT, but also in multiple OT structures. You need to have four well-defined zones, protective, clean, sterile, and disposal. And these are the things that will come under, I will not go into the details, but these are the areas that will come into the four important zones. And it's always better to have a disposal zone because the biomedical wastage guidelines are a bit stringent on this, and PCB always keeps reviewing this requirement. So this is the OT design, and for ease of understanding this, you can also color code it. The disposal area is obviously the red zone, the sterile areas are the green zone, the transition zone is in the pink, and then the outer zone is in the light brown color. And you also need to understand, you need to have a proper workflow. Ideal is to have a unidirectional workflow and no mixing of dirty and the clean products. So this is the ideal way for a CSSD, or this is the important area, a good layout is important for cleaning, disinfection, and sterilization. And you also need to have good equipment for cleaning the equipments. And the important aspect in CSSD and OT is the engineering control, because this plays a major role in large volume practices and also critical surgery practices. You also need to ensure that the air and water supply is filtered air and good quality water. The AC ducts have to be maintained properly and plumbing lines have to be properly integrated and maintained. It's always better to have a disinfection room and the cleaning areas. So not only hand wash basin, discharge table with flusher disinfectant as well. And the OT walls, ideal is to have the dustproof, moisture proof walls. The corners have to be cold and door ideal to have two leaf itself closing device. Natural lighting in ophthalmic setup, natural or general lighting is essential. And you also need to plan up for these scrub up and sterilization areas. These are modular door, stainless steel, 304, it should not rust. And flooring, you can have hard, any hard material with less joints, not necessarily the PVC promoted by your vendor. You can also have a marbonite, hard marbles, epoxy, as well as PVC. Then surgical scrub area, ideal to have a fabricated one. So that maintenance is easier. It can be fitted with sensor tab and pass back can make this zoning easy. And again, it will also help in proper maintenance of the zoning and also less movement of men material resources. And modular OT, this is again, I offer repeated questions, modular OT really helps to reduce the operation date and maintenance in the long run. And it's also cheaper because the size of the panels are standardized and it will be easily available. And if you want to, in the long run, it is cost effective and maintenance is easier. And modification also would be easier because these are standardized sites. A word about the HVAC requirement, this is also a mandatory statutory requirement, again, mentioned in the national building code, the design, noise, vibration, various types of air conditioning system, the energy conservation installation, everything has been mentioned in the national building code section eight. And this is a revised guideline issued by NABH based on the working relationship, various meetings with the quality experts, manufacturers, engineers, and technical committee. And this is the classification super speciality OT with different norms for the air changes, the general OT and daycare center OT. And these are the basic assumptions that have been kept in view for the OT standards. And generally air conditioning systems like window AC and split are not recommended because they are basically recirculation units and there will be convenient pockets for microbial growth, which can be sealed. And these are the three important components of HVAC system, heating, ventilation, and air conditioning. India is a vast country. So we have varied climates and different climates across the year. So we need to have these provision to have safe operation theater with all these facilities. So how do HVAC system help in improving air quality by dilution, by ventilation and air quality is improved by filtration and reduce exposure time of the bugs, because you keep on removing the bugs through the air change and pressure differential, there is an optimal temperature. So once you have an optimal temperature in OT, the bugs cannot survive. And this is the ideal humidity. So with good Laminar air flow systems and filtration units, you can maintain the humidity system and we reduce the viability of the organism by UV treatment. So all in all, HVAC system really helps in maintaining a sterile environment for our healthcare related work. So these are the various AHUs, I will not go into the details, but this OT Laminar air flow unit with a filtration really ensures a good air quality in our theater. And why humidity control, there's an important, you need to understand this low relative humidity is suitable for Klebsiella and high humidity enhances growth of Pseudomonas aeruginosa. So we can keep on doing a root cause analysis for many of our cluster infections and their humidity also plays a major role because of the high humid conditions, we have Pseudomonas infections more in our clustered end of cases, right? So overall operation theater requirements is a legal requirement. It's a requirement to satisfy empowerment standards. It reduces medical and surgical error, better infection control, maintenance, easy and cheap and saves you from medical legal cases. So a well-designed planned OT is essential as a basic infrastructure requirement for application and medical legal safety. There are a few other questions I would like to answer. So we are only a daycare, should we have an ambulance or emergency services and managing medical emergency is another critical medical legal aspect of managing a high care facility. So you need to have certain vital equipment for CPR. It is essential not only for patient care, but also for medical legal reasons. So you can have a cylinder or you can have a manifold. You also need to have a crash cart. And along with the crash cart, it's very, very important to maintain a list of medicines and also consumables that is needed for doing CPR. So this is the crash cart. And if you are not able to get a crash cart, you can also maintain a small adult crash box, which all the relevant emergency medications and consumables. And the word about the ambulance requirement, it should be commensurate with the scope of services. If you don't have an ambulance in your scope or needed, you can have an MOU with the appropriate agency, but the ambulance should be there with all these facilities for transfer of your critical patients. And few other requirements, infrastructure equipment for accretion, the signages, whether it's a mandatory signages or not, and what all the equipments needed and the medical gases. So this is the overview of FMS standard or facility management and safety standards. And these are the regulations required. You need to maintain an Excel sheet to know about the various laws and also the requisite facility inspection requirements for maintaining the pollution control board license, CA Act, all these things are needed. And you also need to have good signages with scope of services in bilingual language. And also these are the different signages that are required for accretion. The statutory signage to give statutory information. Like x-ray or lasers and identification signage to identify facilities provided by your hospital. And then the information signage to provide information and also direction signage. In case of evacuation, this should be a well-lit board so that this is also a fire safety requirement. And the next infrastructure requirement is the infrastructure and manpower adequate to provide as per defined scope of services. Suppose you are having a retina service, you need to have a fundus camera or OCT and then FFA. So either your facility should have, or you need to have an arrangement with the outsource agency in the form of a MOU. And of course, based on the quality assurance system. And you also need to do infrastructure change as per the risk assessment. And how do you do the risk assessment in high risk areas? What are the equipment as well as space required? You need to have this disabled friendly requirements, particularly toilets and also access to your building and safe water, electricity, medical gas and vacuum system. If you are functioning 24 seven, you need to have this access 24 by seven and medical gases. Again, if you are not able to have a proper integrated system, you need to have cylinders in the critical care areas. And apart from having the equipment, you also need to have a proper inventory breakdown and preventive maintenance plan for this. And fire emergency is a major requirement for not only small, big hospitals, but also for small hospitals. You need to have smoke detectors and also a trained multi-disciplinary team to handle such emergencies. So basically safe hospital is not only the structural component, but also the life and facilities like the critical system, emergency care, fire safety, communication system. And recently our state has made fire lifts and ramp mandatory for all facilities for all hospitals. So you also need to take care of your state requirement and you have to integrate all these things for seamless patient flow and also ensure that proper registers are maintained about the inventory as well as the maintenance aspect. It's ideal to not only have good infrastructure, but also maintain them over a period of time with your facility inspection rounds. So it's important that, so if people are falling over the edge of a cliff and sustaining injuries, the problem could be dealt with by stationing ambulances at the bottom or erecting a fence at the top. Unfortunately, we put far too much effort into provision of ambulances, but far too little into the simple approach of erecting fences. So this is what quality standards advice to focus on essential and preventive aspect with good infrastructure to get good outcome and processes. Thank you so much for your kind attention.