MINIMUM REQUIREMENTS - FACILITIES

FACILITIES REQUIRED

C. Physical Facilities

C.1 Space requirement

C.1.1 Minimum area required for establishing the facility. 20 m²/bed

C.1.2 Functional space planning of the facility like reception area, waiting area, (m²)

AreaSqft

Reception, MRD 1000

(Entrance zone)

Casualty / Emergency 200

Examination room125

Laboratory 150

OT 150

Labour room (if any)150

Pharmacy 125

Records room 200

Wards 75 sqft/bed

References

  1. Tamilnadu Government Minimum norms for private clinical establishments
  2. Clinical establishments (control and regulation ) Rules, 1994, Orissa
  3. The Karnataka Private Medical Establishments Act, 2007
  4. IS 10905 (Part 2)

C.1.4 Basic signage

A signage within or outside the facility should be made available containing the following information in two languages

C.1.4.1 Name of the care provider with registration number

C.1.4.2 Fee structure – Basic data

C.1.4.3 Timing of the facility

C.1.4.4 Services provided

C.1.4.5 List of consultants with availability days

C.1.4.6 List of holidays

C.1.4.7 Directional signages for Emergencies, Departments, etc

C.1.4.8 Florescent Fire Exit

C.1.4.9 Safety, hazard and caution signs (Eg. X-ray, Scan room)

C.1.4.10 Mandatory information (RTI, PNDT, MTP etc)

C.2 Furniture & Fixtures
This will entail the details about the furniture and sundry items commensurate to the services delivery requirements.

C.2.1 Furniture / Fixture Requirements . . . as required

C.2.2 Sundry Articles Requirement . . . as required

C.2.3 Others

C.3 Facilities Engineering Requirements.

C.3.1 Civil Engineering

Building plans to be approved by local authorities

C.3.2 Mechanical Engineering

HVAC – Air conditioners should be provided for operating theaters and intensive care units (IS 12433 Part II,Pg.28)

Medical Gas

Medical gas such as Oxygen, Nitrous Oxide should be made available in cylinders.

C.3.3 Electrical Engineering

Standby generator should be provided for essential and critical areas of the hospital (OT / ICU, etc)

C.4 Public Utilities

C.4.1 Safe drinking water – as per IS 12433 Part I, 2001, 20.3, IPHS Standards

10,000 litres/day shall be available

C.4.2 Sanitary Requirements – as per IS 12433 Part I, 2001, 15.5.7

Toilets-1 for 8 beds

Bathrooms -1 for 12 beds

C.4.3 Others – Fire protection IS 12433 Part I, 2001, 20.4

Manually operated fire alarm shall be available

Fire extinguishers shall be available in accordance with fire safety norms prescribed by the local authority

D. Equipments / Instruments

D.5 Sterilizing Equipments

Steam autoclave 1

Sterilizer 2

E. Human resources

This includes the minimum number of people required in the facility.

E.5 Administrative Staff

Office incharge- 1

Accountant - 1

Record Clerk - 1

Peon – 1

Cashier – 1

Store Keeper – 1

Security / House Keeping– Outsourced or as per requirement

Others (as per need)

H. Licenses

This includes the minimum statutory compliance applicable as per the central or state government along with licensing body.

S.No / Licenses and Statutory Obligations in Hospital / Y/N
1 / Building permit (from municipality) / Y
2 / No objection certificate – chief fire officer / Y
3 / Bio-medical waste (management & handling) rules 1998 / Y
4 / No objection certificate under pollution control Act
5 / Radiation protection certificate in respect of all X-ray and CT scanner from BARC / Y
6 / Atomic energy regulatory body approvals (AERB) / Y
7 / Excise permit to store spirit / If spirit stored
8 / Income tax PAN / Y
9 / Permit to operate the lift under lift and escalator Act / As applicable
10 / Narcotics and psychotropic substances Act / As applicable
11 / Sales tax registration certificate (VAT) (Optical shop,etc) / As applicable
12 / Vehicles Act 1988, Vehicle registration certificate for Ambulance / Y
13 / Retail drug license / Y
14 / Wireless operation certificate from Indian Post and telegraphs / As applicable
15 / Air & Water (Prevention and control of pollution) Act, 1981 / Y
16 / Arms Act, 1950 / As applicable
17 / Indian Boilers Act 1923 & Indian Boiler Regulations 1950 / As applicable
18 / Cable television network Act, 1995 / As applicable
19 / Central sales tax Act, 1956 / N
20 / Consumer protection Act, 1986 / As applicable
21 / Contract Act, 1982 / As applicable
22 / Customs Act, 1962 / As applicable
23 / Dentist regulations, 1976 / As applicable
24 / Drugs and cosmetics Act, 1940 / Y
25 / Electricity rules, 1956 / Y
26 / Employees provident fund Act, 1952 / Y
27 / Employees’ State Insurance Act, 1948 & Employees’ State Insurance (General) Regulations, 1950 / As applicable
28 / Employment exchange Act, 1969 / As applicable
29 / Environment protection Act, 1986 / Y
30 / Equal remuneration Act, 1976 / As applicable
31 / Explosives Act, 1884 (? 1984) / As applicable
32 / Hire purchase Act, 1972 / As applicable
33 / Income tax Act, 1961 / Y
34 / Indian Lunacy act 1912 / As applicable
35 / Indian medical council Act and code of medical ethics, 1956 / Y
36 / Indian nursing council Act, 1947 / Y
37 / Indian trade unions Act, 1926 / As applicable
38 / Industrial disputes Act, 1947 / As applicable
39 / Lepers Act / As applicable
40 / Maternity benefits Act, 1961 / Y
41 / MTP Act, 1971 / As applicable
42 / Minimum wages Act, 1948 / Y
43 / National building code / Y
44 / National holidays under shops Act / Y
45 / Payment of bonus Act, 1965 / N
46 / Payment of gratuity Act, 1972 / Y
47 / Payment of wages Act, 1936 / Y
48 / Persons with disability Act, 1995 / As applicable
49 / Pharmacy Act, 1948 / Y
50 / PNDT Act, 1996 / Y
51 / Prevention of food adulteration Act, 1954. Rules 1961 (If canteen is available) / As applicable
52 / PPF Act, 1968 / Y
53 / Registration of births and deaths Act, 1969 / Y
54 / Tax deducted at source Act / Y
55 / Sales tax Act / N
56 / License for blood bank / As applicable
57 / Workers compensation Act, 1923 / Y
58 / Water Supply Sewage Act 1978 / As applicable
59 / Food and drugs act / As applicable
60 / Gas cylinder rules 1981 / Y
61 / Code of medical ethics / Y
62 / Part II of manufacture, storage and import of hazardous chemical rules 2000 / As applicable
63 / Right to information act 2005 / N
64 / IT act 2000 for computer base record. / As applicable
65 / Rehabilitation Council of India Registration / As applicable

I. Basic Processes

I.1 Registration

I.1.1 All patients treated by the organization shall receive a unique registration number (Hospital number, OPNO, MRNO, etc)

I.1 Assessment

I.1.1 All patients treated by the organization shall undergo an basic initial assessment in accordance to the levels of care

I.3. Infection Control

I.3.1 Adequate hand washing /hand rub facilities shall be available

I.3.2Sterile supplies shall be used for surgeries and in intensive care areas

I.3.3All sterile supply shall have a defined expiry period

I.3.4A sterilization register shall be maintained containing date of sterilization, expiry date, batch number

I.3.5Operation theater environment shall be subjected to microbiological surveillance periodically

I.3.6Operation theater complex shall have atleast three zones (Dirty area, Clean area, Sterile area)

I.3.7Monitoring the level of sterilization of surgical packs / kits shall be done using indicators (thermal)

I.3.8Filters of air conditioners in Operation theaters, ICUs shall be cleaned and disinfected periodically (atleast once in 15 days)

Specific infection control practices shall be followed as prescribed by the respective regulatory bodies (Such as NPCB)

I.4 Safety

I.4.1 All patients undergoing surgeries shall undergo a pre-operative check list which includes, correct patient, correct procedure, and correct site

I.4.2 Sharps shall be disposed as per the BMW management guidelines

I.4.3 All newborns shall have an identification tag

I.5 Clinical records

I.5.1A medical record shall be maintained for all in-patients

I.5.2Medical records of inpatients shall be retained for atleast 5 years. Records of MLC shall be maintained as per the legal requirements

I.5.3All patients undergoing a surgery, invasive procedure shall give a written informed consent

I.5.4A record of surgeries shall be maintained

I.6 Discharge

I.5.1Patients discharged from the hospital shall receive a discharge summary containing reasons for admission, treatment given, medication and follow-up advice

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