L E A R N I N G O B J E C T I V E S

After reading this chapter, the reader should be able to: enlist the components of healthy hospital environment. get an overview of planning and designing a hospital keeping in mind the components of healthy hospital environment.

4Healthy Hospital Environment: A Key to Safe HealthDr Sonu Goel, Dr Mahesh Devnani, Dr Parampreet Kaur Ahuja, Prof Anil Kumar Gupta and Dr Amarjeet Singh

“Patients of course give the highest priority to obtaining the very best available treatment; but they are also individual who merit respect, who may be frightened and need reassurance, and who are people with eye, ear and other senses, who need and deserve to receive pleasure from their environment.”

—Wickings

BACKGROUND

The hospitals must have humanising environment that can contribute positively to the health of patients as well as staff. It needs to heal and promote health. The objective should be to create a patient-focused and patient-centred environment by offering an atmosphere of safety, security, cleanliness and physical comfort.1 A clean hospital environment plays an important role in ensuring that best results are obtained for all kinds of medical care offered by it. Many factors, like the design of patient care areas, housekeeping services, air quality, water supply and laundry, etc. plays a significant role in this regard.2

In this context, sound environmental practices are impor-tant for improving hospital environment along with increas-ing efficiency, satisfying statutory requirements and reduc-ing costs. But, it is really unfortunate that the hospital administrators readily make cost-cutting compromises when called upon to meet environmental compliance standards. So, besides providing the curative services, and research and training facilities of high quality, hospitals also have to ensure that they practice ‘No Harm’ policy, i.e. human health should not be adversely affected due to impact of hospitals on local environment.

Health-promoting hospital (HPH) concept recognises that structure and function of hospitals are affected by the overall environment and hospitals themselves affect the environment.3 In order to minimise these environmental

problems, action should be taken to deal with pollution at source, for instance, waste should be segregated and concen-trated within healthcare institutions, and whenever possible it should be disposed-off safely. Also, due consideration must be given to the impact of hospitals on environment, especially to risk of pollution of water, air and soil, besides aesthetics.

For a healthy hospital environment, the hospital should ensure certain requirements like evidence-based design of hospital, floor space for beds, interbed space, safe water supply, proper sanitation and housekeeping, effective biomedical waste (BMW) management, adequate hand- washing facilities, isolation facilities, ventilation, etc. In addition regulation of traffic flow to minimise exposure of high-risk patients and facilitate patient transport, precau-tions to control rodents, pests and other vectors, good dietary services, utilisation of renewable energy sources, effective use of natural light, adequate waiting facility for patients and their relatives, disabled-friendly facilities inside the hospital, social and religious environment, and recre-ational and patient welfare activities, etc. are also important.

COMPONENTS OF HEALTHY HOSPITAL ENVIRONMENT

AestheticsAesthetics is now considered as an essential ingredient of healthy hospital environment. The hospital design should

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balance between function and aesthetics. Designing of a hospital should be done utilising knowledge of the latest and appropriate styles of architecture and furniture. This should be planned for the following dimensions: Physical aesthetics implies evidence based and well

planned. Psychological aesthetics, which includes happiness, joy

and pleasure. Spiritual aesthetics, which suggests hope, contentment

and peace. Intellectual aesthetics inspires interest and contemplative

delight.There is adequate access to natural light and fresh air at

all levels inside buildings of Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. For exam-ple, see-through windows from top to bottom in advanced eye centre provide eye-catching view in addition to provid-ing natural light and fresh air.

Air and VentilationThe ventilation systems of hospital should be designed and maintained to minimise microbial contamination. Certain high-risk areas such as operating rooms, critical care units and transplant units have special ventilation requirements. High-efficiency particulate air (HEPA) filters prevent recirculation of microorganisms. Unidirectional positive pressure laminar airflow systems are required in operating rooms.

The air-conditioning system of PGIMER Chandigarh is a centrally air-conditioned system with water-cooled recipro-cating type of chillers, as per the international norms. It runs 24 × 7 for 365 days a year, for more than 12 years, maintain-ing all the requisite parameters. It maintains a temperature of 23–27°C, relative humidity of 60% and 7–8 air changes in the ward areas, and a temperature of 20–22°C, relative humidity of 50–60%, and 15–24 air changes in operation theatre areas. Microvee Filters (fine filters that filter up to 0.03 μ of particles) are present throughout the system. Frequent maintenance/validation of efficacy of filters, ducts, diffusers and grills are done in accordance with manufac-turer’s requirements.

Safe WaterThe healthcare facility should provide safe water to patients, their relatives as well as to the staff. Sufficient number of water outlets depending on the requirement should be provided. If present, water storage tanks should be cleaned regularly and the quality of water should be sampled peri-odically to check for microorganism contamination. As water is now a scarce resource, there should be emphasis on water conservation. Health-promoting hospitals should have facilities for rainwater harvesting.

All the overhead tanks of PGIMER Chandigarh are regu-larly cleaned by sanitation and engineering wing of the hospital. The water samples of various tanks of PGIMER

Chandigarh are sent for testing and culture, and appropriate action, if required, is taken accordingly. Water coolers are provided at strategic sites throughout the hospital campus.

Sanitation and HousekeepingRoutine cleaning is important to ensure a clean and dust-free hospital environment which is important for quality patient care. ‘Patient-care areas should be cleaned by wet mopping, dry booming is not recommended. The use of a neutral detergent solution improves the quality of cleaning. Hot water (80°C) is a useful and effective environmental cleaner. Any areas visibly contaminated with blood or body fluids should be decontaminated and cleaned immediately with detergent and water. All horizontal surfaces and toilet areas should be cleaned daily. The housekeeping service is responsible for the regular and routine cleaning of all surfaces and maintaining a high level of hygiene in the facil-ity. The sanitation and housekeeping department is generally responsible for classifying the different hospital areas by varying need for cleaning and develop policies for appropri-ate cleaning techniques, adopting procedure (frequency, agents used, number of staff in area, etc.) for each type of area-from highly contaminated to the most clean-developing policies for collection, transport and disposal of different types of waste, informing the maintenance service of any building problems requiring repair (cracks, defects in the sanitary or electrical equipment, etc.) providing appro-priate training for pest control practices, establishing methods for the cleaning and disinfection of bedding (e.g. mattresses, pillows), etc.

The floors at all the areas in PGIMER hospital are wet-mopped two or three times per day (more in intensive areas and emergency). The emergency operation theatres are fumigated monthly. The sanitation and housekeeping staff is given regular training on different subjects like infection control, BMW management, etc. These programme stresses on personal hygiene, the importance of frequent and careful washing of hands and cleaning methods (e.g. sequence of rooms, correct use of equipments, dilution of cleaning agents, etc.).

Hospital Waste ManagementHospital waste (especially biological waste) potentially contains pathogenic microorganisms, and requires appro-priate and safe handling. There should be designated persons responsible for the management of waste collection, handling, storage and disposal. Waste management should be conducted in coordination with the infection-control team and waste management practices must meet legal and other statutory requirements.

At PGIMER Chandigarh biomedical waste (BMW) is handled and managed as per the provisions of BMW rules, 1998. The BMW is generated at various places in the insti-tute, viz. outpatient department (OPD), operation theatre

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(OT), inpatient department, intensive care unit (ICU), labo-ratories, etc. The BMW generation rate in PGIMER is approximately 1.5–2.5 kg/day/bed. The segregation and treatment of waste with 1% sodium hypochlorite solution for minimum 30 min is done at the source of generation. As 70–75% of waste generated in the hospital is nonhazardous or general waste, segregation reduces the quantum of waste that needs special treatment to only 25–30% of the total waste. The BMW is collected regularly 3–5 times/day from all the areas of generation and transported to a common refuse point in covered containers. The team for collection is earmarked and wears a special uniform with all protective gears. From refuse point, the noninfectious general waste in bags with proper tags/labels is transported to dumping area earmarked by Chandigarh administration for land filling. The incinerable waste is sent to the incinerator. The pretreated plastic is shredded in the shredder and again treated with 1% sodium hypochlorite solution for minimum 30 min. All the waste generated is finally disposed-off within 24 hours of generation.

Central Sterilisation Service DepartmentCentral sterile supply department (CSSD) of a hospital plays a major role in infection control. The responsibilities of the central sterilisation service are to clean, decontaminate, prepare for use, sterilise and store aseptically all sterile hospital supply. Its policies are developed in collaboration with the infection control committee and other hospital programmes.

The CSSD in charge of a hospital is responsible to oversee the use of different methods (physical, chemical and bacte-riological) to monitor the sterilisation process, supply sterile material (gauge, dressing material, procedure sets, gloves, vials) timely to the units/departments, ensure quality assur-ance of sterilisation by autoclave tape (on a daily basis) and by biological indicators and Bowie–Dick test pack (on weekly basis), reports any defect (supply, repair and mainte-nance, raw material, manpower and infection control) to Deputy Medical Superintendent, maintain complete records of each autoclave and steriliser run, communicate with vari-ous stakeholders (infection control committee, the nursing service, the operating suite, maintenance, and other appro-priate services on the matters of sterilisation in CSSD).

Dietary Services DepartmentThe dietary department of a hospital plays a direct role in promotion of health. The dieticians of a hospital provide consultations to patients on specific dietary requirements, define the criteria for the purchase of foodstuffs and other material, and maintain a high level of quality. In addition they issue written policies and instructions for hand-washing/clothing/staff responsibilities and daily disinfection duties, ensure the methods used for storing, preparing and distributing food that is devoid of contamination by

microorganisms, issue instructions for the cleaning of dishes after use, ensure appropriate handling and disposal of waste, and regular training of staff in food preparation, cleanliness and food safety.

Laundry Service DepartmentThe laundry department of a hospital plays indirect role in health promotion. The laundry manager of a hospital is responsible for participation in selection of fabrics for use in different hospital areas, developing policies for working clothes in each area and group of staff, maintaining regular supplies/distribution of working clothes, ensuring separation of ‘clean’ and ‘dirty’ areas, develop policies for the collection and transport of soiled linen, defining the method for disin-fecting linen, recommending washing conditions (e.g. temper-ature, duration), ensuring safety of laundry staff through prevention of exposure to sharps or laundry contaminated with potential pathogens, and periodic training of staff.

All the above-mentioned health-promoting activities are performed by laundry manager of PGIMER Chandigarh.

Social and Religious EnvironmentHospital is an indispensable community institution. Life patterns, value systems and ethics of the community served by the hospital should merit due consideration. The local architectural norms and traditions should be incorporated.

At PGIMER Chandigarh, many recreational and religious facilities are available for patients and staff in the institute. There are eye-catching fountains inside and outside OPD, besides flower beds and flower pots in and around campus. Religious sentiments of patients are also taken care of. There are temples, gurudwara and church inside campus. Celebrations are also held on various occasions like Diwali, Christmas, New Year, Fresher’s day, Saraswati puja, etc. Various self-help groups like Sewa Bharti are operating in PGI to help needy patients. There is a provision of meeting place for voluntary groups like alcohol anonymous, breath-free group within the hospital. Besides this, there is a blood bank society and a Thalassaemia Society to create awareness among patients.

Biological EnvironmentIt is a well-established fact that living plants (especially green) have a positive psychological effect on humans. Studies have shown that patients in healthcare settings experience have expressed improved satisfaction and speedy recovery when plants are present. Studies by National Aeronautics and Space Administration (NASA) and other scientists have also produced documented evidence that interior plants and their root-associated microbes can remove harmful chemi-cals from sealed chambers. Studies also show that interior plants may be beneficial in reducing the levels of microbes in the ambient air. Many hospitals in Japan have plants inside

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hospital to take advantage of their air-cleaning properties. Takenaka Garden Afforestation, Inc., Tokyo is adding ‘ecology garden’ in hospitals.4

During the last few years, many new centres and build-ings have come up in PGIMER campus. Despite this, PGIMER is adequately covered by trees throughout its campus. The area under green cover is 36% of the total area of the hospital campus. The department of horticulture in PGIMER has been a regular winner at city-level rose festival every year. The green lawns in the premises provide a comfortable place for patient’s relatives. The cattles and dogs are not allowed in the campus.

NoiseA hospital must ensure a quiet, calm environment for patients by providing a physical setting conducive to recov-ery. This requires an organisational culture that supports patients and families by not multiplying, through a noisy atmosphere, the stresses already being faced by the patients and their relatives due to illness, hospitalisation, medical visits, healing and bereavement.5 To accomplish this, hospi-tal administrator must identify internal and external noise factors, whether it is due to people themselves, the equip-ment or the building. They must also discern the noise sources that are controllable. The hospital must also measure and reduce the noise in patient rooms within the prescribed limits. Hospitals are meant to ensure a quiet and calm envi-ronment for patient’s early recovery. The noise levels limits during daytime at a hospital should not exceed 50 dB, as laid down by the noise pollution (regulation and control) rules 2000.6

Surprisingly, the noise level was found to exceed the laid down standards at the various locations in PGIMER. Since the unwanted sound produced in the hospital has an adverse impact on patients and their attendants, it is very necessary to curb the cause and adopt measures to reduce its impact. Noise causes sleep deprivation and leads to increased anxiety and stress on the patients and their relatives who are already in a stressful state. Noise also has an impact on the hospital employees. It leads to depression, irritability, reduced effi-ciency, decrease in productivity, and increased medical and nursing errors besides leading to hearing loss and adversely affecting cardiovascular health.5–7

A higher noise level in an institute could be attributed to unnecessary movement of people (patients/employees) in the hospital area, too many attendants and relatives of patients, mishandling of equipment, viz. trolleys and wheelchairs also produce rattling sound during the transfer of patients for various tests and checkups, reflection of sound from hard hospital walls/floors and ceiling, buzzers/beepers/monitors in ICU, telephone/mobile in patient-care areas, careless rattling of utensils and casual attitude of kitchen staff during distribution of food in the wards, unnecessary and avoidable enquiries of patients due to lack

of information boards, excessive student-to-patient ratio during clinical teaching and any renovation/construction activities in the campus.

Following steps would help to reduce the noise level in the hospital. All the equipment, viz. trolleys, wheelchairs, beds, etc. should be subjected to regular maintenance and oiling or be replaced, proper rubber padding should be present in the wheels of chair and beds to ensure smooth operations, the ceiling tiles can be changed from sound-reflecting to sound-absorbing tiles, an auditory impact query should be conducted for every equipment purchase/construction activity, light music can be played in wards to avoid noxious sounds, regular orientation of staff on the importance of maintaining appropriate noise levels, and proper signage and displays should be present for patients and their atten-dants to reduce their enquiries, reduced waiting lines in OPDs (online appointments, etc.). The signs/slogans such as ‘Silent Zone’, ‘Silent Zone Helps Healing Body’, ‘Silent Hospital Helps Healing’, etc. should be placed throughout the hospital, regular oiling of the doors of wards, renovation/repair activity should be done in a phased manner, reduction in the number of attendants accompanying the patients, recording of ambient noise levels in various areas through-out the day by sound meters (for informing policy makers/directors).

Traffi c Safety

A good traffic design in a hospital would ensure road safety of the patients and their relatives, besides providing pollution-free atmosphere. In PGIMER Chandigarh,multilevel parking facility near new OPD has been constructed to tackle heavy vehicular rush during peak hours. Speed level limit below 20 km is displayed at number of places inside campus for traffic safety. There is one-way traffic outside the hospital. Also signage boards are displayed at various locations in the complex.

Disabled-Friendly NatureA hospital should be a barrier-free structure that enables people with disabilities to move around safely and use the facilities within its premises.

Seating FacilityIn hospitals, patients are accompanied by their relatives. They have to wait for their turn for hours. Therefore, adequate seating facility should be provided for patients inside hospital and OPD.

Recreational and Health Educational Activities Recreational and health educational activities boost up the image of the hospitals. Therefore, posters and panels should be displayed inside hospital and OPDs for awareness of

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patients and their relatives. In PGIMER, there are eye-catching fountains inside and outside OPD that provide soothing effect to ailing patients. Besides this, flourishing flowerbeds and flowerpots in and around campus provide a relaxing atmosphere for everyone.

Workplace Health PromotionIn order to ensure minimum distraction of the employees from their household and other concerns, steps should be taken in their favour so that they devote their attention thor-oughly to the institute. Besides providing various facilities, strategies to reduce health risk to staff should also be in place. There should be a working women’s hostel, employee’s welfare canteens, community centre, a crèche for children of staff in the hospital premises. Besides this, to support employees financially in their hour of need, there is a provi-sion of employees welfare fund scheme, income-generating programme for families of staff (stitching of hospital linen and gowns by wives of hospital staff, vocational training for families for staff.

There is six-lane swimming pool inside PGIMER campus for staff and their families. Free yoga camps are also organ-ised for staff from time to time. There are two schools inside PGI campus for the children of staff. Besides this, there are many staff canteens providing nutritious food according to menu suggested by residents. There are milk booths near the hospital, which are quite popular among patients as well as hospital staff. A 1-week-long spring festival is celebrated every year inside PGIMER campus. February is celebrated as sports month every year. Various inter- and intradepartmen-tal as well as intercollege championships are organised.

The prime reason of a hospital is to provide patient care. Hence, the policies of hospitals have been primarily oriented towards the health and well-being of the patient. But lately hospitals have focused on environmental issues as well. It is essential that hospitals focus on environmental issues along with core patient care to provide clean, safe and quality patient care.8

Table 4.1 HPH score of PGIMER Chandigarh

Standards of HPH Maximum possible score

Observed score

Management policy 18 5

Patient assessment 14 5

Patient information and intervention 12 8

Promoting healthy work place 20 6

Continuity and cooperation 16 11

Total score 80 35

Each standard was classified into substandards comprising 13 in all. Each substandard was further supplemented by indicators quantifying substandards comprising 18 indicators in all. The results are shown in Table 4.1. The strengths were good intra- and intersec-toral collaboration of PGIMER with health and social care providers, patients being given follow-up instructions/rehabilitation plan on discharge, programmes like smok-ing cessation are successfully enforced, staff complies with health and safety requirements at work place, work-ing condition of employees comply with directives. However, hospital aims and mission as a health-promot-ing hospital was not formally declared, no specific exist-ing HPH policy document was available, no clearly labelled sets of health-promotion activities were in force, information on formal assessment for patient satisfac-tion was not available and there was no evidence that staff is involved in HPH policy making, audit and review. However, under WHO project for making PGIMER as a health-promoting hospital, all these activities were carried out in 2011–2012.

Case Study: PGIMER – A health-promoting hospital

PGIMER Chandigarh was evaluated for its ‘health-promoting hospital’ status based on World Health Organisation (WHO) self-assessment tools for health promotion in hospital. Interviews of healthcare providers, patients and their relatives were conducted. Observations for HPH indicators were also considered. The tool sought information on five standards (Table 4.1).

REFERENCES 1. Douglas CH, Douglas MR. Patient-friendly hospital environments:

exploring the patients’ perspective. Health Expect: 2004; 7: 61–73. 2. Gupta SK, Kant S, Chandrashekhar R, et al. Modern Trends in

Planning and Designing of Hospitals—Principles and Practice. New Delhi: Jaypee Brothers Medical Publishers; 2007.

3. Ottawa Charter for Health Promotion (http://www.who/int/hpr/ NPH/docs/ottawacharter hp.pdf). Ottawa: WHO; 1986.

4. Park SH, Mattson RH. Eff ects of fl owering and foliage plants in hospital rooms on patients recovering from abdominal surgery. Hort Technol: 2008; 18: 549–745.

5. http://www.thefreedictionary.com/noise. 6. Chatterjee A.K. Water Supply, Waste Disposal and Environmental

Pollution Engineering, New Delhi: Khanna Publishers; 1999. 7. www.benchmarksixsigma.com. 8. www.choate.com/media/pnc/1/media.471.pdf.

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