Here’s how to Design a Hospital which is NABH compliant

Healthcare experts believe that it’s timely and challenging for the promoters to design a hospital according to NABH guidelines. An HE report.

NABH is an integral part of healthcare insurance today. But tales of hospitals show that it’s not always easy to design according to NABH.

Designing a hospital according to NABH regulations is no small feat. It requires the ability to interpret the guidelines mentioned in NABH handbook, share the data with the hospital management team, visualise to make sense of everything— all at an extreme level of detail that would be an overkill for a small player.

Probably, that’s the reason, why only a small percentage of hospitals in India are NABH compliant. So, what’s NABH?  National Accreditation Board for Hospitals and Healthcare Providers (NABH) is a constituent board of Quality Council of India, set up to establish and operation accreditation programme for healthcare organisations.

“NABH standards are not prescriptive and are subject to interpretation, and that’s why there’s confusion. Management often focuses only on revenue-generating departments like cardiology or oncology. So other departments get step-motherly treatment. For example, typically in a hospital, you will have separate circulation areas for outpatient, inpatient, staff and services. If you don’t provide enough space, then there will be an intersection of movement of various providers. As is the case with any other regulation, NABH is no silver bullet. There are already several regulations, and if you follow the law of the land, it will be easier to design an NABH compliant hospital. What’s more Indian Public Health Standards can also be a good guide regarding the design of a public health facility,” says Dr Sachin Wagh, an independent healthcare consultant.

NABH Standards for hospitals comprises of a set of three books-NABH Standards, Guide Book and Annexure and can be procured for Rs. 3500.

“The standards provide a framework for quality assurance and quality improvement for hospitals. It focuses on patient safety and quality of care. Further, the standards call for continuous monitoring of sentinel events and comprehensive corrective action plan leading to the building of a culture of quality at all levels and across all the functions,” states the official website of NABH.

The 10 chapters in the standard reflect two significant aspects of healthcare delivery, i.e. patient-centred functions (chapter 1-5) and healthcare organisation-centred functions (chapter 6-10).

Sameer Mehta, Director Projects, Hosmac, points out that the role of the NABH is to ensure a minimum level of quality of healthcare design, and it involves not just infrastructure, but also operations— how you operate your facility. “The FGI Guidelines for Design and Construction of Hospitals is the design standard most often employed by medical planners, designers, and owners of hospitals and outpatient facilities abroad. When it comes to Joint Commission International (JCI) accreditation, one can always refer to FGI guideline. In contrast, NABH doesn't refer to any particular document. It calls for compliance with the laws of the land, seeks to question how the objectives of patient safety, infection control are achieved and tends to become open-ended. That's where the confusion arises in terms of what's the baseline to be considered,” he explains.

Mehta points out that the two aspects of hospital management need to focus on are facility management and operations. “Quality depends on not just setting up infrastructure, but also operating it. Often old hospitals make design changes to integrate qualities like patient safety, caregiver safety. For one of the hospitals in Mumbai, then newly done had all the patient toilet doors inwards. All the doors had to be redone, as these must open outwards in the interest of patient safety,” he recalls.

Realising that smaller players find it tough to stick some of its size norms, NABH has eased its stipulation for OT rooms. “In all fairness, not all surgeries really called for the erstwhile minimum 400 sq ft. However, they still insist on engineering standards for OTs, that often doesn't add up,” Mehta explains.

So if NABH doesn’t give you clear instructions, then what’s the next option? Indian designers usually refer to the National Building Code. The National Building Code of India (NBC), a comprehensive building code, is a national instrument providing guidelines for regulating the building construction activities across the country. It serves as a model code for adoption by all agencies involved in building construction works be they public works departments, other government construction departments, local bodies or private construction agencies.

Grey Areas

Mehta points out that while sprinklers are ubiquitous, there are spaces in hospitals where you cannot use a conventional sprinkler system. “There are solutions such as gas-based suppression systems that can douse a fire, and this agent won't affect the patient adversely. However, out here is a matter of voluntary compliance, and very few hospitals have gone for this, as it is expensive. Moreover, NBC code doesn't insist on this,” he explains.

In terms of patient safety, there are various technology solutions, like the medical grade isolation transformers which ensures safe and continuous power to vital devices and departments, However, Kerala is the only state which has officially mandated this technology. These add to cost, but there can be no concessions, when it comes to patient safety.

How do NABH guidelines differ from that of other regulations?

“Interpretations of NABH could always vary. There are no clear guidelines, so many designers rely on the American Institute of Architecture guidelines and NBC for credible references. For projects in the Middle East, it's necessary that designers are compliant with FGI guidelines, even before we start the construction. It's easier, as we have clear instructions,” Mehta adds.

So, is NABH meant only for big players and tertiary care chains? No.

There are different levels of NABH accreditation for healthcare organizations like there is entry level and separate set of standards for small healthcare organizations, opthal facilities, IVF centres etc. It is beneficial for smaller organizations, as it is often difficult to comply with accreditation norms overnight, as there could be constraints of space and finance. It also raises the largest question surround NABH. Is it a growing trend? Mehta notes that the trend is set to grow, as insurance companies prefer hospitals which are NABH compliant.

Make no mistake— NABH is not a fad. It represents a whole new way of designing hospitals by turbocharging the existing trends of patient-centric design. “There is no replacement for safety in a hospital. NABH accreditation will be one of the major forces for the healthcare of the next decade. However, it is a journey, and the healthcare sector has made a start,” he concludes.