NABH accreditation guidelines for patient-friendly hospital design

Deepak Venkatesh Agarkhed, General Manager –Engineering, Facilities & Quality, highlights the importance of designing hospital infrastructure as per NABH guidelines

The Hospital X-Ray room wall was redone during hospital construction phase as room wall thickness was not 9 inch. A new air-conditioning unit added at pharmacy as temperature was more than 25o. NABH assessment pointed out that there is no child play area in hospital during assessment.

The above examples point out deficiencies in hospital infrastructure. The biggest challenge for any operating hospital to secure accreditation is modification in infrastructure. The hospital project planning team normally takes inputs from various stakeholders like architects, service consultants and user team but tend to miss out on design considerations on NABH compliance with respect to infrastructure. In few cases the hospital planners try to justify their stand on facility requirement to hospital by using NABH as guidelines which may or may not be true.

As mentioned in the NABH website, accreditation results in high quality of care and patient safety. Adoption of NABH standards related to infrastructure will help hospitals to achieve an environment conducive for patient safety. It is advised to go through the accreditation standards as part of hospital design and implement infrastruture requirements during the hospital construction phase.
The necessary infrastructural requirements in NABH accreditation guidelines are divided in three categories.

Statutory requirements:

There are some mandatory requirements for accreditation of a hospital. NABH team invariably reviews all documents pertaining to legal compliances during their audit.

• The areas of imaging services like X-Ray, CT scanner unit should adhere to Atomic Energy Research Board norms. The AERB website provides the details on facility planning.
• The blood bank should have 100 sq m for operations of blood bank, 50 sq m for preparation of blood components and 10 sq m for Apheresis are to be considered

Explicit requirements based on standard interpretation:

These requirements are given in the NABH guidebook as
interpretation of standards and often accessed by NABH assessors to provide scores of particular standards.

• The space for each clinical service should be based on either national (like IPHS) or international standards, except in cases where directives of government agencies like AERB are laid out.
• The laboratory area, CSSD and rehabilitative service
  infrastructure should have adequate space to meet the defined scope of services.
• Patient rooms should consider the following

1. The optimal space between two patient beds should be one to two meter.
2. There should be clean utility area in wards and ICU to keep medicines in clean, safe and secure environment. There should be a utility room in patient care areas to keep all types of wastes.
3. A negative pressure isolation room should be provided for airborne cases like measles.

• Patient safety alarms i.e. both visual and auditory like nurse call bells, medical gas alarm units should be installed at designated locations in hospitals. Fall prevention measures for elderly like anti-skid tiles   and grab bars, ramps with railings for disabled should be provided for   safe & secure environment to vulnerable patient group. The handicap toilets for physically challenged people should be available.
• The paediatric service should be child friendly and should include playroom for children, breast feeding room. The CCTV camera should be installed in paediatric services to present child/ neonate abduction.
• The space of worship for patients and their relatives is to be provided.
• The operating theatre should have  facilities for pre-op holding, separate changing rooms for males and females, hand-washing area, operating rooms, waiting area for relatives, storage area, collection area for waste and linen and recovery room. The layout of the theatre should be such that the mix of sterile and unsterile patients does not happen or if it is not possible the mix is reduced to the bare minimum. The operating theatre should have dedicated AHU and three stage/ two stage air filter depending on type of OT.
• The ambulance parking should have demarcated space and access for is to There should be communication system between hospital and ambulance.
• The central storage area for medical supplies and consumables should be as per manufacturer’s guidelines with provision to keep high risk medicines like narcotics and hazardous materials in safe manner.
• The hospital kitchen should  kept away from the traffic. There should be a separate storage area to keep cleaning supplies away from food. The re should be a dedicated food preparation area provided in hospital kitchen.
• Hazardous material storage, central waste collection area for keeping biomedical wastes should be provided.
• The engineering plant should have sufficient spaces for alternate sources like DG, compressor or vacuum plants.
• Infrastructure for fire emergencies like fire water tanks, fire exit routes etc. should be planned as per NBC norms
  depending on the height of the  hospital building.
• The following signages as mentioned below should available.

1. Bi-lingual signages about clinical services provided by the hospital.

The services not provided should also be clearly indicated.

1. Bi-lingual signage display of patients’ rights and responsibilities in strategic locations like entrance/ lobby of hospital, registration, billing, OPD and IPD area.
2. Safety signage for imaging services, as required by regulatory authorities.
3. Bi-lingual fire signage like fire exit/ no smoking etc. as
   per the requirement by statutory bodies should be provided.
4. Hand washing signage as per WHO guidelines near hand washing area.

Implicit requirement based on standard interpretation:

• The provision of curtains in all examination rooms in OPD, treatment rooms to ensure patients’ privacy and dignity.
• The patients in a temporary holding area should have
  provision of oxygen, suction provision and a few electrical sockets.
• Energy efficiency measures should be in corporated into infrastructure design like low power consumption LED lights, solar energy utilisation, rain water harvesting pits, variable frequency drives for AHU, water and electrical meters at various locations and creation of landscaping gardens.

Modern day patients expectations from hospitals go beyond clinical outcomes and comprise various aspects including hospital infrastuture. Hence, hospital infrastructure planning and execution with due consideration on accreditation points should no longer be considered as a wish list. It must be a mandatory part of  any hospital design.