SPECIALIZED SURGICAL CENTER FOR ELECTIVE SURGERY IN PORT HARCOURT RIVERS STATE

ABSTRACT

Globally,   healthcare   systems   are  experiencing   increasing   fiscal  demographic   and consumer pressure. There have been metamorphic changes in the recent past in terms of healthcare delivery.  The planning,  design and final architectural expression in health care is reflective of the gradual shift in outlook of healthcare institutions from merely treating the sick to a concerted approach to harness healthy living. This has been triggered by globalization,  increased expectations of seekers and providers of healthcare,  emphasis on ambulatory/daycare  services,  enhanced standards of care and the participation  of private players in the health sector.

Healthcare facilities { in the larger picture Hospitals}  are the largest and most complex of all modem institutes.  To add to these complexities are the major transformations that are occurring in the delivery of health care worldwide.   It is thus essential that hospitals are planned  and  designed  to  meet  the  requirements   of today  and  tomorrow.  Winston Churchill had commented “first  we shape our buildings  and thereafter  they shape us”. This is certainly true for healthcare facilities.

Existing best practices for healthcare facilities include- emerging trends/concepts  such as integrated  health  care  facilities,  value  added  services,  expandability,  green  hospitals, healing architecture, life enhancing designs, assisted living facilities, patent focused architecture and humanizing environment.

This exercise is a documentation of the research into this branch of medical specialty and its architectural design,  emphasizing on the study of an expandable medical facility.  The

facts, figures and standards  of the project  were extracted  from authoritative  sources and presented  in  this  small  volume.  For  the  ease  of understanding,  this  write-up  basically consists of the definitions,  introducing reports explaining the project context including  its background/historical  reviews,  the aim and objective of the project and the analysis of the choice site location and geographical conditions.

This work also highlights functional components  and technical information on the design of a surgical center and an analytical review  of existing projects  of the same kind in the form of case studies.  A space program was arrived at in order to elucidate the summ ation of the whole efforts  in the research and design of the proposed surgical center.

This project write-up is believed to offer a design guide to future surgical center planners and  designers,  who  may need  information for the  expansion  of already  existing  health facilities or planning of new ones.

CHAPTER 1

1.0  INTRODUCTION

Ambroise  Pare, a 16th century French surgeon, stated that there were five reasons  to perform  surgery:  “To  eliminate that which is superfluous, restore  that which has been dislocated,  separate that which has been united,  join  that which has been divided and repair the defects ofnature.  (Bishop  1960)

The aforementioned reasons for surgery are all aimed at improving healthcare and health standards which are not exactly the order of the day in this part of the world. The essence of a specialist center which is particularly aimed at addressing a specific group of health requirement  has become a paramount  necessity  in this country.  Such specialist  centers that may include ambulatory care, diagnosis and treatment services are typically provided to a diagnostic service backed up by treatment for referred patients.  Because such centers do not handle the unpredictable  emergency cases, they are able to deal efficiently with referred  elective  cases,  where  the  patient   is  able  to  move  around  the  center  for consultation, diagnosis and treatment in one visit.

This specialist surgical center will be developed through a flexible expandable concept, the facility which will accommodate  growth and change, will also improve on patient• focused care (PFC) in Nigeria.  The patient-focus  care (PFC) concept originated  in the USA as a reaction to the impersonal nature of hospital care. Such specialist  center  which  deal only with  elective  cases will  also typically  deal with mainstream   procedures   that  may  involve   in-patient  services  such  as  hip  and  knee replacement. The referred patients that will receive improved health care treatment in this facility may not necessarily book-in themselves,  they will in most cases be booked-in by a medical practitioner or specialist that requires the advanced medical care, treatment technology and equipments available at such a center.

1.1  GENERAL BACKGROUND  INFORMATION

The Government of Rivers state is dedicated to improving  healthcare in its state,  where the citizens ofNiger Delta and other Nigerians will benefit from its health care and health improvement  schemes and programs. In a bid to improve health care, the Rivers State Government  has  approved  the  design  and  construction  of 105  health  centers  spread around  all  local  government  areas  in  the  state.  This  step  has provided  a  lot  of job opportunities for medical practitioners in the country.

In another bid to improve standard ofliving in the state for both indigenes, non-indigenes and foreign investors,  the state government has also mandated a commission known as the Greater Port Harcourt City Commission to take charge of the Greater Port Harcourt Development Project which is estimated to kick off with the phase one in May 2010.

This project is to be located in an area known as “Greater Port Harcourt” in Rivers State. The location of this project was inspired by the Government of Rivers State when it first came up with the “Greater Port Harcourt City Development  Project”.  In the master plan  of the greater  Port Harcourt phase one project,  provisions  are being  made  for a Waste   water  treatment  plant,   a  Power   generation   plant,   an  Integrated   solid  waste treatment,  a  water  abstraction  and  treatment  plant,  a  specialists  hospital,  a  general hospital and a lot more.

The development  of a specialized  surgical center through  a flexible expandable  concept will in the future save the Rivers  State Government the trouble and finance involved in demolishing  and rebuilding  health facilities.  By virtue of the location  of a project  in the Greater Port Harcourt City,  it is to a reasonable extent sustainable.

PROJECT BACKGROUND

Surgical centers  are sometimes  classified  as either hospital-associated  or freestanding. Hospital associated surgical centers are those surgical centers that operate with the administration  of a particular  hospital they are attached  to,  all surgical  cases here are hospital cases. Freestanding surgical centers are those surgical centers that operate independently, without being attached to any particular  hospital. This research work is dealing with the freestanding  surgical center. Surgical centers have been defined as “a facility primarily  organized  or  established  for the purpose  of performing  surgery  for outpatients and a separate identifiable entity from any other health care facility.” More recently,  some  surgical  centers  have  sought  institutional relationships  with  academic medical  centers,  hoping  to  benefit  from  the  prestige  associated  with  teaching  and research.

The concept of a surgical center is a new idea to medical delivery in Nigeria, but has been in existence  and in full practice  in other  developed  countries  of the world.  This new concept  in referral  health  delivery  is geared  at  improving  and  fulfilling  the  demand

functions of healthcare.  As technology  develops, medical understanding  progresses  and their  combined  application  expands.  Social demand and expectations  are also correspondingly  enhanced.  In times past,  health facilities were focused on care of the sick rather than preventing  illness. This is not the case in recent times as there is a change of demand  due  to  increase  in  life  expectancy,  health  becoming  a  norm  and  healthcare focusing  on prevention  and  intervention rather  than treatment  of diseases.  Emphasis  in healthcare is also shifting from in-patient to day care.

Surgery   centers   should   not   be   misconstrued   with   outpatient   centers   that   provide diagnostic services or primary health care,  such as urgent care centers,  community health centers,  mobile diagnostic units,  or rural health clinics.  Surgical centers are distinguished from  these  other  health  care  facilities  by  their  use  of a referral  system  for  accepting patients  and  their  maintenance  of  a  dedicated  operating  room.  The  first  characteristic (which is the referral system) means that any patient who wants to be treated in a surgical

center must first consult their primary health care provider,  or PCP,  and choose to have

their condition treated by surgery rather than an alternative approach. The second feature (dedicated operating  room) means that the surgical facility must have at least one room (depending on the size ofthe surgical center) that is used only for operations.  (Aker 2001)

Traditionally, surgical centers have been designed as a single static entity, but another approach is to use a flexible expandable concept which allows for growth. It is possible to develop plans which permit ordered growth and change, and which enable various departments to be added to from time to time, without cutting traffic routes or invading space already used for other purposes.  The construction  of a surgical center should be such that it  can easily be extended  in consonance  with expansion  of the function and acquisition  of equipment  in  the  hospital.  It  has to  be  acknowledged  that  building  and function life span differs. The golden architectural principle  of indeterminacy should be followed which enables a “building  to grow with order and change with calm”.  In order to  combat  obsolescence   in  such  facilities,  the  building  should  thus  be  adaptable  to changing requirements.

Buildings  have a considerable  life span. Even lightly constructed  modem  buildings  will last,  so far as structural  soundness  is concerned,  approximately  about  50 to  100  years. Over such a period we must expect many changes in use.  It has sometimes been argued that we ought to try to put up hospitals in a very temporary  form,  designed to last only a short period.  However desirable this may be,  it is not possible; building structures have to be designed to stand up against certain maximum  stresses imposed by climate. We must therefore  try  to  design  hospitals  which,  although  structurally  long-lived,  are  flexible enough to remain efficient under changing use.  (Digest 1998)

1.2  STATEMENT OF ARCHITECTURAL PROBLEM

As the world evolves,  so do the needs of people change,  and this change in human needs has a direct “change in requirement”  effect on the economic and social cultural life of the people. All these changes in tum have a tremendous  effect on lifestyle and taste in all aspects of life and especially in buildings.

Changes require that a substantial amount of new health facilities and hospitals should be built to replace many which are hopelessly out of date and uneconomic. Nevertheless, health facilities that are built today with an acclaimed modem standard will tomorrow be outdated;   therefore  the  ability  for  a  medical  center  to  be  expandable  is  a  critical consideration  in the design  of such  facilities.  Architectural  problems  synonymous  with health facilities today are the inability to expand them when the need arises.

From the study of existing hospitals in and around Rivers State,  it has been observed that there  is  normally  no  initial  planning   for  expansion;  therefore  when  the  need  for  an increase  in space or upgrade of facility arises,  in the most cases the trend is that the old or existing  structure  has  to  be  demolished  in  other  to  accomm odate  change  in  terms  of facility  and space and to  increase the number  of patients  that  can be attended  to  in the facility.  A  very  recent  example  is the  demolition  of the  old  teaching  hospital  by  the Rivers  State government  who is proposing  to  erect a specialist hospital worth  about  98 million dollars.

In  line with  the  aforementioned  reason,  it  is therefore  important that  a surgical  center with an expandable concept be developed.

1.3 AIM AND OBJECTIVES

This primary  aim of this work is to carry out an in-depth  study on the planning of an expandable medical facility that will accommodate growth over a period of time.

The objectives are therefore to:-

•    Identify  and  analyze  functions  of a health  facility  that  restricts  it  from being expandable.

•     Generate a concept that will meet the demand and function of a modem  surgical center   as   well   as   being    flexible   enough   to   accomm odate    change   with advancement in technology and health requirements.

•     To  create  a  facility  and  an  environment  to  improve   on  patient  focused  care through the new concept in referral health delivery.

1.4 MOTIVATION

Sitting in the waiting area of a theatre unit in one of the major teaching hospitals located somewhere in the Niger Delta, waiting to deliver a message to a theatre nurse, came a physician  that made an announcement  implying  that patients  in the waiting  area who were scheduled to have surgery that day should revisit the hospital in two weeks because there  was a problem  with  a surgical  equipment  which may not be rectified  any time sooner than two weeks; this incident induced in me the idea of a specialist surgical center that would offer speedy and improved health care to patients.

Also having a father with a medical condition which specialist say operations to rectify cannot  be  performed  in  Nigeria  because  of lack  of some  technicalities  and  special equipments  also reinforced  in me that a facility of such importance  is required  in the country.

Furthermore,  with  a  general  look  at  the  obtaining  surgical  care  especially  in  non emergency cases,  it is a point of observation that most people who can afford to,  fly out of the country to obtain special health care.  This further reinforced  my opinion on the need for such a facility in this country.

1.5  SIGNIFICANCE OF PROJECT

This  specialized  surgical  center  for  elective  surgery  is  of great  significance  to  Rivers State as it will bring about development. The location of this project as ear marked by the State  Government  is to  shift  infrastructure to the New  Greater  Port  Harcourt  to  attract developers  to  the  area.  This  project  is  also  a bold  step  by  both  the  Government  and members   of the  private   sector  to  harness  public-private   partnership,  as  the  project construction  will be handled  and sponsored by a Canadian  firm called Clinotech.  Under the arrangement,  Governor Amaechi  explained,  the contractor  would provide the money to finance the project  while the State Government  would pay back the money after five years.

This specialized  surgical  center  for elective surgery  on completion  will be beneficial  to Rivers  people,  Niger  Deltans  and  Nigerians  at  large  in  taking  care  of some  of their medical needs as well as provide employment  for indigenes.

The  significance   of this  project   impacting  on  patients  and  surgeons  are  detailed  as follows:

•   Cost. In many cases,  an outpatient procedure  done in a surgical centers costs between one-half and  one-third   as  much  as  the  same  procedure   done  in  a  hospital.  It  is important,  however,  for patients  to  compare  costs  carefully,  because  some  surgical centers procedures  may cost as much as or even more than hospital-based  procedures. For  example,   the Medicare  Payment  Advisory  Commission found  that  whereas  a

cataract operation cost only $942 at a surgery center in 2001  as opposed  to $1334 at a hospital,  after-cataract laser surgery cost $429 at the surgical center versus $246 at a hospital.  Figuresfor an endoscopy and biopsy ofthe upper digestive tract were $429 and $359 respectively; for  a diagnostic colonoscopy,  $429 and $401; andfor epidural anesthesia,  $320 and $183.  (Rank 2003)

•   Convenience.  There  is  much  less  administrative  paperwork  and  “red  tape”  at  an

ambulatory  surgical  center  compared  to  the  admissions  process  at  most  hospitals. Patients also like the fact that they can leave a surgical centers relatively quickly after their surgery, which translates into less time lost from work.

•  Presence of family and friends.  Whereas most hospitals keep patients recovering from a surgical procedure  in separate rooms,  in a surgical center the patient  can usually spend the recovery period after surgery with their loved ones.

•   Greater efficiency.  This advantage is particularly important to surgeons.  It takes much less time to prepare  an operating room in a specialized  surgical center  for the next patient  than in a standard hospital.  Improved  efficiency  allows the surgeon to treat more patients  in the same amount of time than he or she would be able to do in a hospital;  some  surgeons  maintain  that  they  can  do  three  times  the  number   of procedures in a surgical center as they could in a hospital setting.

•   Greater  control  over procedures  and standards.  Many  doctors  prefer  working  in  a surgical  center  because  they  can set the  standards  for staffing,  safety precautions, postoperative care, etc., rather than having these things decided for them by a hospital manager.

Medical services and emerging health facility planning  is an emerging sector of health infrastructure development. There are certain impacts on the provision of healthcare and they include-Medical technology, health transition, consumer’s expectations, epidemiological    and   demographic   changes.    The   advancement    in   scientific   and technological research has taken the healthcare skills and facilities up to a state-of the art   level.   The   improvements   in   qualitative   aspects   of  healthcare,   the   exponential escalation  in  the  cost  of  construction  of  hospitals  and resource  constraints,  offer  new challenges in effective utilization  and conservation of resources.  It is thus imperative that

planning and designing of healthcare facilities are done holistically and scientifically.

This project  is also significant  in curbing the effects  of emerging changes that will be detailed as follows:

Enhanced expectations of patients: the patients have become more quality conscious as well as price sensitive.  They expect clinical,  administrative  and supportive  services as well as design of facilities to be conducive to their requirements.

Epidemiological and demographic changes: there has been a cascading pattern in the incidence oflifestyle diseases and geriatric related healthcare problems.

Emphasis on ambulatory/day  care:  hospital  stay is gradually being programmed  for high  dependency  in-patient  care  and  for  other  cases  emphasis  is  on  shorter  stay  in hospitals.

Enhanced standards:  there has been an upgrading  of the standards and norms in the delivery ofhealthcare.

Changing function of hospitals:   hospitals are an evolving system. Apart from curing the  sick,  they  have  the  added  function  of maintenance   and  prevention   of health, biomedical research and providing community outreach services. The focus in health is gradually shifting from treating illness to creating wellness.

Advancement  In medical sciences:   this dictates or changes the paradigm of healthcare delivery.  The advent of futuristic dimensions in molecular biology,  pharmaceuticals  and surgical interventions has changed management modalities of diseases.

Outsourcing:  this is being gainfully utilized  and services such as laundry,  kitchen and

CSSD are being outsourced to appropriate agencies.  (Gupta 2001).

1.6      PROJECT SCOPE

The  scope  of this project  will be  limited  to  a detailed  study  on the planning  of an expandable medical facility. Ultimately a designed will be produced which will house the following functions:-

■        General surgery

■        Gynecology

■        Cosmetic surgery

■        Dental surgery

■        Cardio surgery

■        Orthopedic and sport medicine

There are other impacting factors that will guide us during the execution of the scope of this project and these include-

Socio-economic  profile  of community- this aspect  has imminent bearing on the space determination and also the expected standards of the hospital. Existing  medical  facilities-  this  will  directly  impact  the  size  and  type  of healthcare facility to be planned for.

Health profile of the region- the varying disease pattern of different regions will affect the requirements of the various departments/ services.

Vernacular  architecture-  this term  also known  as the local  traditional  architecture  has a role  to  play   in   the  planning   of  medical   facilities   of that  particular   region.   Local architecture  is  a  result  of age-old  construction  methods  which  take  into  account  the climatic  conditions,  seasonal  variations  and  other  aspects  with  special  emphasis  on locally  available material.  While providing the new facilities,  this aspect should be taken into account so that the built forms blend with the local surroundings. Suitable variations could be  made to utilize  new  materials  and the requirements  dictated  by the  emerging technologies and trends.

Local regulations- governing bodies and local bodies from region to region have different type  of policies/  guidelines/  rules  related  with  the respective regional  planning  norms, thus affecting the spatial relationship  of health planning.

Choice of technology-  this depends on the type of facility being planned  for the specific level  of healthcare,  financial  availability,  and  the  type  of equipment  that  are  to  be provided for the specific healthcare unit.

Climatic  zones-  design  and  space  parameters  are  influenced  by  the  type  of climatic conditions.  The  impact  of climate  in  space  norm  varies  in  different  situations,  e.g.  a volume of space in a consultants room or ward in a cold region will have lesser openingand will be compact  in nature  whereas the same in a coastal region  like ours will have more window area and open type of planning for cross-ventilation.

1. 7 RESEARCH METHODS

The  research  methodology  to  be  adopted  in  this  research  will  include  pnmary  and secondary data collection.

PRIMARY DATA COLLECTION

In primary data collection,  information /data are collected personally using methods such as interviews and questionnaires.  The key point here is that the data you collect is unique to you and your research and, until you publish, no one else has access to it.

There are many methods of collecting primary data and the main methods include:

o   Questionnaires o   Interviews

o    Focus group interviews o Observation

o    Case-Studies o     Diaries

o   Critical incidents and o   Portfolios.

SECONDARY DATA  COLLECTION

Secondary   data  is  collecting  and  possibly   processing   data  by  people   other  than  the researcher in question.  Secondary  data  is collected  by others  but utilized  or used  by the researcher.

Secondary  data is data that has already been collected  and collated by somebody  for some reason  other than the current  study.  It can be used to get a new perspective on the current study,  to  supplement   or  compare  the  work  or to use  parts  of it,  as another  study  may prove  costly and time consuming  e.g. the census.

Secondary    data   can   further   be   divided   into   two   parts.   Qualitative    data   includes biographies, personal letters, diaries, records, documents, published  material, computer database, policy  statements,  etc.  Quantitative  data  would  have  market  research,  census, and Economic  documents, planning  documents  or specimens.  The list is endless  and once the type of secondary  data is identified,  it becomes  easy to locate the source.

Since  the  data  has been  collected  for another  purpose  by somebody  else,  it may not  be fully useful, the context  could have changed  or data could have been doctored.

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