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D u v o i J T A 3 Â K J u n e , 1 S S Ü

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HEALTH FT-'iCIL I TIES DESIOiM US I MB COMPUTER AIDED LAYOUT TECHNIQUES:

AN APPLICATIDI'J

SUBMITTED TO THE DEPARTMENT OF MANAGEMENT AND THE GRADUATE SCHOOL OF BUSINESS ADMINISTRATION

OF BILKEMT UNIVERSITY

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FDR THE DEGREE OF

MASTER OF BUSINESS ADMINIS I'RATION

Bv

DUYGIJ TABAK June?, 1990

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TS

. і и г .

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certify that I have read this tliesis and that in my opinion it is fully adequate, in scope and quality, as a thesis for the degree of Master of Bi.isiness Administration.

A s s i s t - P r o f . E) i 1 e k Y e 1 d a, n

I certify that I have read this thesis and that in my opinion it is fully adequate, in siCDpe and quality, as a thesis for the de(3ree of Master of Business Administration.

I certify tfiat I have read this thesis £\nd that in my opinion it is fully adeqt.iate, in scope a\nd quality, as a thesis for the degree of Master of Business Administration.

Assist. Prof. Elrdal Erel

Approved for the Graduate School of Business Administration

---Prof. Dr. Süibidey Togan

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ACI<NGWLEDGENENT

;i: wiBh t o th«unk Dr« Dilek Ye İd an« Dr« Can Bımçîa,, Dr« Erdal li" r e 1 *f a r t h e i r a d v i. ^ g u i. d a n c: e ^ a n d e n c o u r a g e m e n t

(■;.11r o u g h c:^u t t h e c o ıx r üüe o f t l"ıi. «iü t. h e s ;i. s «

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ABSTRACT

HEALTH F A C I L r n E S DESIGN USING COMPUTER AIDED LAYOUT TECHNIQUES;

AN APPLICATION

DUYGU TABAK

Maist.er in Bui-jirie Ad m i n i B t r“ a t i on Supervisors Assist. Prof. Dilek Yeldan

June, 1990, 62! Paoes

Health Facilities Planning is one of the most significant fields of study for increasing the efficiency of operations in hospitals. In this study demand for health services is analysed and a planning procedure is developed for the layout of health facilities. An application is given for the city of Ankara using a computer aided layout technique.

Key Words; Health facility,· computer aided layout techniques, facility design

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ÖZET

BİLGİSAYAR DESTEKLİ TASARIM TEKNİKLERİ İLE SAĞLIK t e s i s l e r i n i n PLANLANNAEİI :

b i r u y g u l a m a

DUYGU TABAK

Is idaresi. Yüksek Lisans

D e n e t. c i 2 Y r d - D o c . D r « D i .1 e I·:; Y e 1 (i a n ¿\ z i I'“ a riı 1 9 9 ( . ) 6 2 s a y T ¿\

iü>a Q 1 ;l k t e s i s 1 e r i ■ t a s a r ;ı.m .ı. 1·)a s t a h a n e 1 e r d e I·.·: i i. s 1 e m 1 e r" i n V e I'“i /î) I i 1 i 0 i n i. n a r 11 :ı r :i 1 n) a üi>ı n d a k u 1 i. a n 1 1 a n ö n e m 1 i. . ç a 11 ş /îîa a 1 a n 1 a r ı n cj a n b i r i cJ i r » B l.i ca 1 ,ı.i*>/îia d a *·■;>a Q .11 1·:; h i m e 1 1 e r i n e o 1 a n talep incelenmiş ve bir "saQlık tesisleri tasarlama yöntemi" g e 1 i s t i. r i 1 m i s t i r « B i 1 g i.i·:··;a y a r d e s t e k 1 i t as a r ı /n te k n i Q x k u 11 a n X 1 a r a k An k a r a s e I"·»r i. i.c i.n b i r l\y g u 1 a îî»a v e r i. 1 m i s t i r u

Anahtar Bö^rcük 1 er: SaQlık t e s i s i b i l g i s a y a r destekli t a s a r" 1 m t e k n i. k* 1 e r" i. m t e s i.b t a s a\ r- 1 n ı,x

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TABLE OF CONTENTS

CHAPTER 1. INTRODOCTION

CHAPTER 2. DEMAND FOR HEALTH CARE 2 . .1,, 0 p e r a t i o n s ;L n a H o s p .11. a 1

2 1.1 . Dernand in Hospital Operations 2.1.2 . T h e 0 e n e r a t i o n o f D e m a n d

2-1.2.1. Demand for Medical Care 2.1.2.2. Medical Caxre Process 2 . 1.2.3. The Role of The Hospital 2.2 . F o r e c a s t i n g

2.2.1. F o r ·e c a s t i n g T e c h rt i q i.ie s

2.2.2. Approaches to Forecasting for The Health Care Field 2.2.3'. A Forecast of TTie Number of Beds Resquired for Ankara

CHAPTER 3. HOSPITAL FACILITIES PLANNING PROCESS 3.1. Engineering Design F'^rocess

3.2. Health F-ac i 1 i ties Planning F-·roc ess 3!l.2!. 1 .Defining Health Needs

~ S , 2 . 2 . Specifying The Medical Services to Satisfy The Health Needs

35.2;.-3. Determining the Interrelationships F-or All Services 3Î. 35. Flow Anal у s x s

3.3.1. F'low F\attern'3 Betwe?en Departments of a Hospital 35.3'.2?. Measurement Of F"low Between Departments

Z . 35.2.. 1. Con cl u s i on

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3.4. ‘Space Requiremen ts 3. S . C on c 1 u s i o rt

CHAF--TER 4. HEALTH FACILITIES LAYOUT AMD AM APPLICATIOM FOR THE CITY OF AMKARA

4,, .1. M Approaches To Computer Aided Layout 4.1.1. Craft

4.1.2. Corelap

4.1.3. An Advanced Version of Core;·lap

CHAPTER 5. EVALUATIOM OF THE PLAMS 5.1. Evaluation of First Floor

5.2. Evalucition of Ground Floor

5.3. Evaluation Of Underground Floor 5.4. Modification of The Layouts

CHAPTER 6

.

COMCLUSIOM

RE p' E REM C E! S

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CHAPTER 1- INTRODUCTION

The development of health services in a societv is a m a j o r f a c t o r" i n p r o m o t i n g t. h e *.:>o c i a 1 w e 1 f a r e o f t h a t s CD c j.e t y - C o n B c ;i.e n t i. cdus a n d a ci e c] i..ia t e p 1 a ri n ;i.n cdf h e a 11 h f ac i 1 i ties « par"ticu 1 ar 1 y cDf hospi ta 1 s j, increases the efficiency and productivity of health servicres in a scDciety.

T h e Li iii>e o f· g e ri e r a 1 s t a n d a r d i n bt e a cJ cdf p 1 a rin i. n g i.n accordanc:e with needs and objectives leads to inefficient a n d i n e f f e c:; t i v e d e s i g r i o 'f f a c i 1 i t i e s . T h i iii> i. s the r e a s o n w h y a gcDCDd layout is essential for a productive and efficrient

<:» y s t e in . I n t l-ii i t h e i::> i s h cdtiii-p i t a l B are c: o n £> i cl e r~ e d a s production systems which are service-oriented. A study on t i I e h CD <::>p 11 a 1 1 a y cdut i s i ri t r o <J u c e d w i t h a n a p p 1 i c a t. i o n f cdr a

hypothtstical hospital to be built in 1992 in Ankara. Assuming that the construetion starts in the present year 1992 is a reascDnable ei-jpectation for the completion of the wcDrk

-T I'D;i.s s t u d y w i. 11 b e a s t a r t i n g p cdi n t f cdr" d e s i g n e r s who

a re tCD (1) determi.ne 11*ie depar tmenta 1 re 1 a t ionships in hospitals,, (2) set an initial plan to start vjith« The p r o p CD s e d pD 1 a I'is ( g i v e n i n C h a p t e r· V ) c a n b e m o d i. f i. e d a ri d a 11 e r ■e cl a c c o r ci i. ri g t cd t li e s p e c: i f ;i c ide c-dd s a n cJ r e q ix i r e m e n t s w h i c |·) t Ide d e s i cj n e r s s h cdu 1 d sat i s f y . Fur t h r m cdre, detailed hospDital plans cc^n be drawn changing and relaxincj some of

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the aBsumptiona made in thii·;·:; study. Availability of such a plan will ease the work of the deBignters¡, Scive time and increase the efficiency of the plana to be drawn further.

As demand is the major factor in determining the capacity requirementB of a hospital. demaod analysis for a. hospital and health service*» is given in the second chapter. Thi'B analysis is done from the management point of view, con'sidering thei operations in a hospital. Consequently, various approache*» to forecasting in the health care field are given and a forecaist of ho'spital beds requirement, for the year JL992 i» done for the city of Ankara. This forecast is made baised on the increase in the number of the ©Kisting bed's in hospitals in Ankara. Such a forecast is necessary as a starting point in determining the number of beds and space requirements the hypothetical hospital in Ankara should hawe. Though ci more accuraite forecast can be? done by using the demaind figures for the hospital beds or number of patients aipplying to hospitail's every day, this was not feasible because of the lack of relevant data , in this *sub;ie?ct. Demand analysis given in Chapter II provides •support for the activities described in Chapter III in which a health facility planning process is developed referring to the Systematic Layout Planning (SLP) approach by Mundell The information gathered in the second and third chapters will be the inputs for the computer aided layout technique used in Chapter IV. This chapter will conclude the

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!study developing an initial plan for the hypothetical hospital suggested for the city of Ankcira»

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CHAPTER 2.

DEMAND FOR HEALTH CARE

2,1 ..OPERATIONS IN A HOSPITAL

A hospital can ' be described as a collection of functional service units in which every unit performs on© specialised task. The departmental organisational structure nursing, dietary, radiology, laundry, etc." is in fact built this way. In a typical hospital there may be more than twenty functional units performing a specialised task. The actual functions these units pe^rform vary widely from removing waste to psychiatr-u:· counselling. However, from a management viewpoint, all of these units can be represented as a feedback loop. In each unit there is a supervisor or a group of siupervisors whose job is to s

,1. establish specific expectahions and/or goc>ls for the operations including both quantity and quality of performance,

2. order the arrangement of resources (i.e., labour, material, and fcicilities) in the system that are designed to reach these expectations and control the system to improve the achievemen t of the expec tc\tions. These basic operations that exist in every functional unit in a hospital can be represented as shown in Figure 2 ~ 1 .

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Fs’esources : Labour И cl ter ia 1 Fac ill ties

Service

Monitor : Compares p e r f Q r rn a n c: e ^ against prior e>:pec tat ion s

\1/ ЕЕи pec tuitions : F D 1 i. c: i 0iiii· a n d siit a n d a r d ï f о r I")e rf о r iïia n c e Performance! Quantity Qualitv F’igure 2-"I

Operations of a Functional Unit in a Hospital

M o «:> L". s L\ p 0r vis o r s i i“i ti c) !:»p i t a 1 s o r 1 s e w h e r *e a p e r ate roughly in the manner suggested in Figure 2-1. They may not liave quantitative or even objective ex pec talions or measures of performancej, but they and their workers have personal and s u b j e c: t i v e f )o t i o n s . T h e r e a r e « h o w e:/v e r 5 c. e r t a i n 1 y n o t i c e a b 1 y 1imi tâtions in relying solely upon these subj eclive notions •f Q r me a s u r i. n g 1.1’1e p 0r“ f o r m a n c t·:?. F" j. r- Vv 1:, d i. f f e r' en t: 1·»u p0 1"·visors will have different expec talions j, and the pDerformance will V ary w t \e i ) s u p e r v i s o r s c F ia n a 0 « S e c o 1"id j, t ti 0 p o s s i b i 1 i t y o f

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changing theBO expectations is limited until they become j::)a r t i a 1 1 y o b j c t i v e a n d q u a n t i f i a b 1 e - T h i r d j, it i s e >{ t r e in e 1 y difficult for management to.assess the performance of the supervisor if the performance £*u h;;I the expectations of the f Li n <:: t .1.o n s a r*·e r io t. q i..ia n t i f i a b 1 e « 1 f b o t h t h e e x p e c: t. a t i o n s» a n d the methods of measuring performance necessary to operate a f e e cJ L) a c I·;: s y s t e m c: a n b <·;? m a cJ e m c.)r e 1 e a r ¡, t h a n in a n y a f t h e s e p r D b 1 e iiis> c a n b e e 1 i m i. n a t e c;l o r" r e d u c e c:l« A s s o o n a t h ere i s a q u a n 1:i t a t i v e t e s t o f t I'le f lin c: t i cjn ' ‘ii p e r t'o r /n a n c e , t h e r e will b e a n a u t o m a t i c: t. e s 1: o f t e u p e r· v i s o r ' s p e v" f o r m a ri c e

-(Griffith, 1967)

2.1.1- DEMAND 1N HQBPITAt„ DPERAT IDNB

A second characteristic coininon to nearly ¿^11 functions b e c o /Tie s a p p a r* e ri t w ti e n a p p 1 y i n g t: h e c o n c e j.")t s o f F ;i.g i.ir e 2 ··-1. With only minor exceptions, no hospital function can be effectively performed in the absence of a demand for

it-D e m a n d i n I")o s p i t a 1 i s g e n e r a t e d b y pro c e s s e s different from functional services, and it often has a large rai“)din o r unpred ic tab 1 e compoi"ien t.. I·“ ro t h e pcjin t of view of t h e ‘Hi.u p B r V ;i. s o r o f a ri i. rid i v i d i.ia .1. u ri :l. t., i.in c;le r s t a n cJ i rig , p r e (.".1 i c t i n g a n d a d j u s t i n g t o 1:h e v a r ·i a t i o n i n d e m a n d p a 11 e r n s o f t e n .b e c o m e ‘s t h e c e n t r a 1 p r" o b 1 e <ii i.n n\o n i t o r i ri g p e r f o r in a r ic e - The model in Figure 2-1 can be modified to show the effect o f t his e 1 e rn e n t - T his i s c:lo n e i n F i g u r e 2 - 2 . I ri t li i m ni o d e 1 the concept of demand is brought to the hospital management prob 1 em a t ai"i equal level wi tI'l resoi.irces „ per f oriiiance

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a n d e >1 f:) e c t a t i a n üü - 11 p 0 r in i. t c: 1 a i-i s i. f i c a t i o n o f a l l i r-i ■ f' a r m a t i o n n e c e s s a r" y t o c:l e s c: r i b e a f 1.1 n c: t i. o n a 1 e e r v :l c e i n t o f i v e c a t e g o r ieiis s 1. D e m a n d : a in o lin t o f be r v i c e s r e q i r ‘0 d 2. R e B o Li r c e B ( i n |:x.i t ) ï lab o \.x r j, m a 10 r i a 1 s a n rJ e q u i p in e n t*. a V a i 1 a b 1 e t o p e r f o r in t l“i e f t.i n c;: t i o r 1

3. Performance (outputs): t h e a m o u n t of service rendered

4 . E p e c t a t i o n B : s t a n <:Ja r d b or p o 1 i c: ;i. e r e g a r d i n g t h e f u rîc t i a n inc 1 uding qua 1 i. ty and efficiency of per f orniance j, resource a 11 o c: a t i. o n p o I i c: i e b f s c: I") e cJ i.a 1 i n g r i\ 10 *.ii> e t c..

5. Monitor: an ac:!n 1 i n ;i. s t r a t i ve bod y respons i b 1 e f ar 1: he ru les

and policies stipulated in a hospital ensuring it's smooth r u n n .1.n g a n cJ e f f i. c i 0 n c y «

Figure 2-2

The Effect of Demand in the Operation of a F"unctioiuAl Unit

A number of extremely important management questions a I" e a p p i'-o a a h e d b y t h e s t u d y o f d e in a n cJ ^ 1 \nc 1 iading t h e

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relation of de maned to notions of what might be needed- e >i p e c t a t i c!)n s f o r t h e s y s t e n i 1 n t e r îïis oi i t s a b i. 1 i. t y t o m e e t c:le (Tta n id ^ f a c t o r b .1.n r 1 l\bn c i rj (d e m a n <d ^ a n (d t hi e 1 o bs of Ü e r 1*o I·' /ÏÎa i··]c::e id u a t o u n p r ·a d .1 c t a b 1 a d a n i.::ii )d .. A s i o r t fie u t x 1 i t y of thtïi model, the modified feedback loop shown in Figure 2-2 ;i. 11 b e t h e b a s x c îï) c:) <J e 1 o f I·*! o <:·> i::) i 1: a ;i. o p e r a t. .i. o n b us e cJ i ri t I'l i s thesis

-The e>ipectations in Figure 2-2 are the policies and 131",ai i d a r·d s se t by t he kl i. n .1ii:>i: r y o f l-de a 1 i: h , ho süp i t a 1 mai"^i a g er s a n cJ I:·.I")e (d o c t o r s - D e m a n d a n (d r e «*>□ (..ir c e i» a r e c: o n s i d e r e d a s inputs for a service as a service can not be rendered when there is no demand for it and the resources are not available- F e rfo r m a n c e i. 13 t ti e a ît1o u n t a n d 1:h e q u a 1 i t y cdf t h e ser v j. c e r enci0 red by t. he b osp ;i. 1:a 1 p0 r sanne 1 - doc to r s, n u r lir»e s , t e c h n i c i a n s j, e t c · - 13u p e r v i s e d t) y t. h e m <:*)n i t o r i n g u n i. t .

/··>« .ju w1 - . THE BENERATION OF. DEMAND

Far various hospital functions, demand comes from the decisions made by doctors about pa\tients,, but these decisions themselves are the result of a complex process which will be explored in the procojedincj section.

2.1.2.i. Demand for Medical Care

Most of the services of hospitals are not. demanded directly by the patient. They are demanded as a part of a Icirger process through which a person seeks the treatment or

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г e V e п t i o n o f s o nı e l'ie a 11 h a r o b i e in

-D e in a riıd f o r ■ la b o r’a t o r у e x a in i n a t i o n s « h a в p i t a 1 a d m i s i:i>i o n ¡, Х-гаул and other services is not generated by the patient but by his/her doctor- When the patient does decide to seek medical care- his/her normal course of action .is to turn to a doctor- The doctor carı request for tlie patient any of a number of services in the hospital, through the hospital, or i n d e p e n c:le n t о i' t,h e h о s p л. t a 1 - A g a i n , w h i c li в e r v i c e s t h e p a 1;.i e ri t a c t u ally de îtia n (d J e p e n d u p о n a о in b i n a i: i о n c) f

f·a c:: 1:о r s .i,n c 11.\d i n g t. |■‘·ıe d о î;: t о г ' ı.··^ р е г с е р t i о ı ·» ел f t ti e у m p t o rn s , the patient's financial situation and the availability of services.

Cori s i d e r a t i on о f t l-ie q u an t i t у a f he a 11 li c are rende red to a coinmunity leads to the development of a long series of questions vMhich can be shown to affect the demand upon the in e d .1 c a 1 c a r e у s t e m . T' h e a n s w e r“в t q t h e в e cj ıx e в 1:i o ı-ıs m ;i.g h t describe why a group of people used more or fewer health care resources or received greater benefit from the r e о L.İГ" с e t h a n в a m e o t h e r g i"·o i..ı f.:· - T h e f ел 1 1 ел w i.iл g i в ¿\ 1л. s t o f •fa c t o r iü> t СЛ be c: on i.t;lere c:l 1) e f o r~ e i'·e a c h i n g a full understanding of demand for health services in a community.

( G Г" i f f i t h , 1 9 6 7 ) :

Attitudes of people regarding illness and death, and I:h e i r w .1.1 ]. .1 n g n e s s t сл t сл 1 e r a t e i 11 n e <.··;s

-.2. Economic level of community and its ability to devote r"esources to prevention and cure of

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3. h o r b i d i t y t h e actucvil incidence and prevaleínce of disease ^1·.. e t Ikc:)d s o f f i n a ric:: i ri n l-ie a 11 l"i c a r" e

5 „ T' 1*1e a v a .i. 1 a b i 1 i. t y C3 f r~ o f e «5 i o n a 1 1")e a ]. t: l-ic a r"e m i n c 1 u d i.n g primari ly doctDrs but also otl'ier lieal th care protessiona 1 b 6 . T I")e a V a i 1 a b i 1 i 1:y o f i n s t i i: u 1:.i o n a 1 r e s o u r c: e tü ¡. i n c 1 u ó i n g n o t o ri 1 y t l·)e ri u a» b e r a n í:.1va r i e t:y o f |·io s p i t a 1 s a n d r e 1 a t e d i.nBti. tIXtions available tc:) ti"ie |:)opi.i 1 <::t t;i an « bat a 1 sa thei.r c::o n V e n i e n c e ¡, a 11 r a c t i v e n e íí;>í=í a n cj íh;c:> c i ci 1 h e coríc:)m i c o r" g e o g r a p l"ii. c r e s t r i c t i a n s w I'li. c:: 1·)ííi;i.g 1·«t I:)e i. in |:)o s e d a n t l“ie i r u s e „

2 . 1-2-2« The Medical Care Process

Regardless of the scope of activities of a given h o s p 1.1 a 1 ^ i t s f lin c t i o n *·:> a r" e ( a ) t <:;) fill d e n»a n d s f o r s p e c i f ;i.c s e r" v i c e s c r e a t e cj b y 111e i.n d i v i cJ u a 1 cJ o c: t o r s t r e a t i n g i n d i V i d u a 1 p a t*.i e n t s j, a r itJ ( b ) t.o p r o v .i.d e f qr t*.h e íüíy s t e ríía (:i c r e V i.e w a n ci i in p.*)r cdve ni e n t a f 11 ·)e p r· o c e <·:>b b y w h i.c I") t h e d a c t a r discovers and meets the patients needs- This process can be c a 11 e d t h e " in e cJ i c a ]. c a r e ):)i'*·o c e i-ss “ «

f) c* t: o r d i n q t o t h e c:lo c I"ri r s i n t e r v i e w e d for t h i s s t ij d y medical care process begins with the individual patient seeking the services of an individua 1 physician- The initial cJ e c i. s i o n t CD B e e k c a r e :i.iif> u s l.ia 11 y 11 ie p a t i bn 1:' *:>« All s Li b s e t-ii.ie n t d e c i s i. o n s a r e g e n e r ¿illy t h a íüe o f h i s / l“ie r p hy í¿ii c: ;i.an - TI")e p hy s i c i an in¿\ I·:;es I")i s / hb t cl ec i s i on s based on fi.i. /1Íer pro f essiaria 1 assessnier) t o f t e totality of |.;)¿\tient ' s needrs and wiskieB- When the pD¿\tient presents

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h i. m s e 11' / l"ie i"*be 11· t o the t.)ii y fB i c: i a « t l"ie c.1o c t a r ' i i r“ b1: decision is whether or not to accept the patient. After the c;lo c: t C3 r cJ e c: i cj e ii> t o - a c::c;:e p t 11 ·ie p a t i. e n t h e / bI*ie e s t a b 1 i. i:i>h e s a I-·)1'"o b a I:.) 1 e d ;i. a g n o s i. s 1.3a s e cJ o n c a r" e f u 1 x ivi t e r v .i.e w .i.n g a n d exaiiu-nation. Many diagnostic services are avai liable to aid t o t h e d o c t r i n r e f i n i n g a n d Cv?x i: e n d .i.n g h i s / li e r (.:! i a g n o i b . The second decision the doctor sliould make is the answer the the question of which diagnostic services the doctor wants to use^ Information from these tests are returned to the physician- At this point the doctor decides that he/she has obtained suf f icient irif ormation,, the process passes to the neiit decision to be made- Here the doctor can select the kind of theraphy based upon his/her knowledge of the d i a g n o sis. I f t h e i"*e i s n o t b e r a p h y t o b e r e n d e r e d j, t h e patient is discharged from the system. When the therapeutic s e r V i t: e i s o r d e r e d ¡, c e r t a i n i" e s i.i 1 t s a r e e ;-c p e c t e d a n d 11")e next step in the process involves the evaluation of whether o r n o t 11") e s e r e s ix 11 s a r" e a h i.e v e c J - If t h e y a r e n o t t h e doc toV" re tLiY"nb to hi.s/ he r di agc:)‘i:>i ‘ii> again « This pr"oc:ess is the feedback loop, i.e., the monitoring and control process previously encountered. If selected therapies are effective and no further treatment is required the patient is discharged from the medical care process.

2.1-2.3. Role of the Hospital in hedical Care Process

Hc!)sp.*i. ta 1 has two respons.;i. bi 1 a. t .i.es w i t hin the con tex t of

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11") D in B d i c: a 1 care p r qc e b«=> - I-· i r s t , it: i u iiit m e 01 t h 0 d e in a n d i o r specific:: Bervic::eB which cxrise from the medical care process- Second f it is responsible for parts of the total process by which the community seeks care and gets it-. There is growing p r e iii>s u r e f o r h o p i t a 1 s t o c o n c e i'” n t h e m f.r>e 1 v e iii> w i t h f a i. 1 u res in the process of demand generat:i.oiithat is., with patients who did not seek care when they should and patients who received care when they did not need it.

T ti e f :i. r s t r e s p o n ‘S i. b i. 1 i t y i n d i c: a t e s 1.11e i iiip o r t ¿a n c e o f lociking be^yond demand in terms c:)f potc^ntial demand and the need for hea 1 th sc-?r“vices - Considering this responsibi 1 i ty determining the demand for the (•ioaith services and deciding on the capacity accordingly should be the first step in the p 1 a n r’l i I'lg p r o c e s i·:» c.)f a lie a 11 h f a c:: 11 i t y - T h e n 0)·; t bec i: i on ;i.n t r* o d u (.·:e s s o m e o f 1:ti e f o r t·..'c.·;a bt x n g t e c h n i q ix 0s a n d a p p 1 i e s r;)n e c:)f t I'lie rti t o d e t e r *(u i n e 1:1 ie c:; a p a c x t y o f t h e hypothetical 1- 1i:;)Bpi ta 1 deve 1 opecJ in Lhe prec;:ed ing c: I'iap ter"s

-2- -2- FORECASTING

r'■Q I'··0c a *::>t fi» o K" p Y 0c;! i It i o r)i;:: ¿itt:)t:)u t cl e in a n c:l a n <;:l a b o u t the ¿HVcai 1 cHbi 1 i ty of resources are the m<i-\in elements in d 0 V 01 o p j. n g |;:ie r f o r iiia I'lc: e e p e c:: 1::a t. ;i o n s - A b c:)e r?)a r) d for h e a 11 h services change frequently, exact prediction of demand is impossible. Because of this ^ a prc*)babi 1 istic prediction must be done , g .1ving ¿iin e x p)^c: ted va 1 ixe as well as tlie

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probabi i ities or chances of cl ianges in given arnoun ts around 11·1 e )i p e c t e rJ v a J. u 0 « T‘ l-i0 0< p e c t:e d v a 1 l.ie i. s t l‘ic? in e a n o r“ a V e 1"·a g c:) t:?f t li e (J i. in; t r i b u t i o 11 o t p o s iifi i b .L e v a 1 u e s « T‘I"!u ‘:i>. 11·“!0 predictloriB to be -inade for the hospital process must be made using the ma the/na t ica 1 sciences of probabi 1 i ty and s t a t X îii>t i s - ( C l·)e r n o f a n d tl o s e iii>, 19 b 9 )

2-2-1. FORECASTIN0 TECHNIQUES

A number of techniques have been developed to predict t l”îe V a r i e d s i t u a t i o n sü i n o h 1 c h f o r- 0c a s t s a r e r e i.ii r e d - T h e s e can be separated into, two broad classes:

1 « Quan t i ta t X ye .tec bn.lci M m .. -2 - Cilu a 1 i. t a t i V e tec 1) i c| u e s

-T hi. «is. c !L a«:>{·:>;i. f j.cat :i.on gerîbra\ 1 1 y re i 1 ec: 1:s 11·ie e x 1:er 11 to whic h a f o r e c a t c a n b e I::)a s e d d i r e c; 1.1 y c.)i-i h i. «·>10 r i. c a 1 d a t a i n a /n e c li a n i c: a 1 fas li i. a n - tilu a ri t i t a t i v e t e c; h n i. q u e s are t h o s e t ^iia t Si t a r t w i t h p a s t ü a t a v a 1 u e ss a 11cJ 1:h e n ¡, 1 ■ o 11 (j w i n g a c e r·t a i n si>et of rulesij, develop a prediction of future values- Some of 11 "ie w i d e 1 y u Si e d t e c 11 n i. c| u e s i n t In i s c a t e g o r y i n c 1 u d e e:;pQriential Siijoothing ^ decomposii tion methodsîH and regression a n a 1ysi s - Qua 1i tative techniques ^ on the other hand ^ do not provide a detailed procedure of a swingle point forecast as do most quantitative techniques. in these approaches, human judgement rather than a mathematical model is the primary j:)r o c e s s o r’ o f f a c t s , I·:;n o w İL e d g e a n d inf o r m a t i o n .

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I n te r i::)i'"e ta t ioi") a f v”e 1 a ted d¿\ ta i «s cJane by c?x per“t«> ^ w ho may simply be individuals in the firm with the best L{ n d e r ■B t.a n rJ ;i.n g a f - t li e rr:>:i. t u a I:i o n « A s c: a n b e e x p e c t e d t h e s e tec::finiques are high 1 y irii tui tive « ( Thoinopou Inus ,, .1.980 )

2 - 2 « 2 . APPF^QACHES TO FQF-ilECAS I’ 1NG 1M HEALTH CARE FIELD

There are three approaches to demand forec:asting for f 114 e l”ii::?alt b c are f i.e 1 d - If)e f :l r t: i üs t h r a u g I'l h i в t о r i c a 1 екperience. A demand which has ocücurrec:! in the past can be u s e Ö a в a b a в .1 s f о r t h e f u t и r e - J. f a d e p a r t m e n 1: p r о v i. d e d 1 C> ^ 0 C> 0 u n i t ÜS Q f s e r v i. c e la î;st у e a r ¡, о ne carı f о г e с а s t that the e X p e c: t e d v a 11\ e w i. 1 I I;:)e .1.0 ц 000 ix n i t n e îî t year“- "Г о i Ic: r e a iii>e t l“ie a c c i.ir a c::у о f t F ii s p r" о j e c t i c:)n ^ d a t a f r о m t e past iise V e r a 1 у e r üs cоu 1 d b e r e v .i.e w e d I"I )e s e îîîi. g b t в b c:)w I:Fta t demand Fwas grown by bOO units pe:?r year“- Thus tFie estimate

iar· tFie с::опи.1тд yei:U'·· wijuld .liL,bOO units- ^Analysing a ÜS e r X e s о f c:l t a f о i'·üse ve г"a 1 F11 üi: t о r i.c a 1 p e r i о c:ls i.s called a t X m e в e r .i.e is a n a 1 у üs i в а гт d е I·.е п s i v e s t a i: i ı:s t i c a 1 techniques ejîist for analysing t Fie data in tFu.s form- Estimates of need is tFie second appr"QacF*) „ wher“e expected demand can be d e r i V e d f r* о ni a f о r" e c: a üst c:)f e )·( p e c:: t e d r ie e d - For e и a in p 1 e j, if e X p e c: (:e d n u m b e r о f I::)i r t Itüs x n a

community is 1000^ and it is known that 997- of the birtFTS occur in hospitals, tFie expected demand far obstetrical deliverieüs can be forecaüst a«s

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I l"iB t hi X r' d a i")v" o a i*: h t o d a /n <:.iri r.J f o r*·e c::hhüt x n g .1 t hi r o u g h (.1 i i· ■ t./ ( t‘ 1::; 111 .■ ,j (;/ c t J V a i;:i íi:> iiivt: í.:Wi i L·/11 1: í !> c · I 111. * ííi ^ i’ i (.1 .. í’ 11 i V·; ¿ I p p I* O a C hl X B i ií;;>(::d íiiobLIv iii BX Ix.iai‘I Oi iB 1.11 Id’iari.·? ;i.b no ra.lavant lixí:;: to i- x c a l i.n f o rr/ia t I o n on dem..:ii h.I ;;aiü n o o a v l:<:· x s o l a t e t h e rio o d ¿md A. t B r o i a t Innol » i p i i > dt-'ii.ai m.I « í lio iiK ^o t coniiíinn e x a m p l e would bo il l a new or (;*xnor Iiiioi i I:.m ). Borv.i.ce « which has never been pr eviously of fer eJ . l/i Idi i s case, the only r*emainxng al heriiative is to obta.in suhnec h .i ve assessmentB from persons wl"io will h)e o rd e ring t:iie í::>erv i.ce .in qaxetioi-i« Sa..arveys of i::)p 1 f’l X oriíü>of c:l(.;)c t o r's ,, n a..a r íí;;.i·;*í:í:·^ r .. :i.n ^:>ome c:: aseííií , pa t i. en t s Ij r o v i d e 11*1 e b a s i s f c:) r t hi e f o r e · ¿i s t.

-T11e f o r ec a i·:·1: :i.rihieu 1111 < ;u e i x 01 d d peri c;ls a..apon t wo cc)mpone 111 s ( 1 ) a rato 111r-f n·amIxc:^'r íxf even ts per naxmber of popu 1 a tion ( adm.i SBxoiis per Ihii M.Asand per sons absence per** 1 0 A.;i0 amp 1 ci)y eei·:;,, o r X..i"iX y !:> p ( »r l o o 0 adm i «;>«:> i o n s ) ,, a n d ( 2 ) an indr^pendi'in t forecast (xt hh¿x p«;.·! lu I a t ion Changes can result either from changes in the ;*ato ar i;rom changes in the sxze of thie popixlation served- Ihio ' pni.xx 1 at i o n ' in this sense is sometimes a geographica 1 1 y identified groAxp of pDeople, or by extension j, the censaxs of patients in a hospital or the I"1A..Am l::iaí?r a f p a t i e n t s a cj m i 11 e d o v e r* a ix e r i o cJ o f t i.m e , D e m a n d

f o rec asii t b pr e pa r”ed via t hi i s p roc ed axre a r e c: ommon « ( L u c k m a n ^ B m i t h S t r .1 n g e r ■n. 1 71)

A statistical techniqixe cal led regression analysis provides a mA.xrA^ objective projec tion of historic: data., and

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j ·] a t:j d i. t i o i”) d r“ o v i d e b f u r t h tí? r* i r 11*' o r” m a I: i o n o n t. h e a l\ e s t i o n s o i w h e t h e r a t i m e r e l a t i o n s h i p e i i i s t s a n d w h e t h e r i t s h o u l d be p r o j e c t e d a s a s t r a ^ i g h t o r c u r v e d l i n e « T h i s me-·?thod f i t s a 1 i n e i: G t*. h e a v a i. 1 avi:;) 1 e d a t a a n cJ 1: h e 1 i. i") e p a s s e «r» t h oi..i g h t h e me a n cü*f a l l 11"ie pr:)in t «·> a t 1 1-1e mean t i n i e per i. oc; l « The ítíe t h o d a l s o g i v e s i n f o r m a t i o n on t h e g o o d n e s s o f f i t o f t h e l i n e j ,

t h a t -i. ‘5 ^ w l"i e t h e r t h e 1 i. ri e e p I a i n s a «:;> i g n i. f i c a n t p o r“ t i o n o f t ti e V a r i a t i o n of t h e a r i. g i. n a 1 d at a «

Thee objective of linear regression is to obtain an e c| u a ti o n o f a s t r a i g h t 1 i n e 1:h a t in i n i ít)i s e·?s th e s u m a f

iii; qu a r e c:l c:l e v i a t ;i. on s o f p o i r'i t s a r ou n cJ t he J. i n e « T hi ;i. s 1 i. ri e ha s

the equation

y - a "I·· t) Í-Í

where "y“ i-^ predicte^d variable which is dependent on th(f? independent variable. The slope of the line is '*b** and “a*' is the value of '*y*‘ when "x" is equal to :-::ero«

( T hi o m o p o IX1 c.·)u s , 19 B 0 )

2.2..3« FORECASTING THE MEED FOR HOSPITAL BEDS IN ANKARA

T ri e t i m e s e r i a s r e g r a s s i o n a n a 1 y s i s m a n t i o n a d a b o v e d£v?velops a model which can be used to predict demand in the form of an equation j, y- a i·· bt based upon changes in demand "y" associated with changes in time “t". The forecast derived from the model is usually based upon the assumption thc\t whatever the causes of relationship w e r e ,, t h e y i 11 re in a i n a p p r o x i m a t e 1 y t h e s a in e i n t hi e f i.it u r e .

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Making the same aBsumptions for demand in the city of Ankara,. a forecast can be made considering the increase in “the number of bed's" in the last 10 years- Other assumptions (i)ac:le fо r cоnв truc tirig the fо rec ast are as follow«:> з

1, The demand forecast will be made for the year 1992,

2- The forecast will consider the population in city centre Q f A г ‘11·:;a r a a n ci i t s s u b и r b s .

T I'le a V a .i. 1 a b I в cJ a t a 1 g a t h e r e c;l f r о m t li e 1^1;i.n i t r у о f Health and the State Institute of Statistics- The data is p r e nije n t e c;l i n T‘a k:) 1 e 1.

A 11 e r n a t ;i.v e f о г" e c: a s t i n g ш в t Гiо d s c: a и 1 d b e l\t i 1 i s e d i n determining the capacity of a hospital; but the data given in Table 1 is not sufficient to build forecasting models other than the rri-gression model given above. “Outpatient." f i.gures can not be used to determine the “number of beds" because the percentage of the outpatients taken to the wards i. s n о t I·::n о w n « " N t д ni t:)e r* of day s s:>t a у e c:l'' f i g i.ir e s c::a n not b e related to the "number of beds" as well„ because the increase in "number of days stayed" figures may be the result of some other reasons. H e n c e > constructing a regression analysis·) to find the reflation between "number of beds" and "years" is the most realistic method of forecast given the? reasons mcv?ntioned above. Thus„ a reigression analysis is done considc^ring the increase in the "number of beds" figures in the last ten years in the city of Ankara.

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R e u :i. t ?,> a f t h e a n a 1 y b.1b ca n d i.ic t e d i..is i n g t h a M i n :L t a b software p«ackage is given where

y 9287 -i-l59t.

This equation shows that number of actual beds are ii"ic: r*easing by '1 b9 ' eac h year . Us:i.ng tliis equa t ion th€? forecast for 1992 iss

y 9287 1^9 M 18 12149 beds.

Assuming no hospitals are made since 1967 whe?re the number of beds was 11.633 in Ankciraj, the increase in the nuinber of beds is ‘500. H e n c e5 the capacity of the hospital can be cJe te?r“iniI")ed as 500 becJs .

"I"l"ie way 1:o d e ter·inine w he ther thii-ii r~ei·»uIt isi> ‘isi.ari 1 fi.cant or not is to use the p-value given in Appendix 1 j, which is the achieved significance level. This p-value is 0.005 which leads to the conclusion that the increase in the number of beds can be explained with the time and the requireme?nt of 500 beds determined is a recilistic value. Hence, this number wi 1 1 be usec;l as a s tartirig poiri t for d t e rinirii.riq tl"ie bpace requir6?ments of the hypothetical hospitcKl that will be suggested in the preceding chapters.

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# of Beds Year # of Hosp. Design Actual'

# of Davs Outpatient Stayed 1975 1976 1977 197(3 1979 19(30 1981 1987 46 4 3 4 2 4 4 46 45 46 4 3 10,245 9,857 10,602 10,303 11.314 11.508 11.577 12.824 9,693 9,818 9,861 9,985 9,340 10.281 10.204 11.633 192,280 209,783 220,901 174,5(34 199.870 208,472 222.355 285.588 2,121.099 2,180,353 2,482,876 2,194,265 1.966.298 2.051.154 2.356.485 2.606.317 Table 1

Hospitals, Hospital Beds, and Outpatient l-igures in Ankara Between Years 1975--1987

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CHAPTER 3.

HOSPITAL FACILITIES PLANNING

3.1- ENGINEERING DESIGN PROCESS

To dBVe 1DD a satibfact.ory hospita 1 f c i 1 it.ies p 1 art, an iterative process is required. For an engineering design process, the following si>! steps would be available

( T l“io fiip k i n s , W h i t. e , 1984) t

1"" Define the problem 2···" Analyse the problem

3····· Generate alternative dcssigns 4·- EVa 1 ua te the a 11ern a t. i ves 5- " Sielect the preferred design 6 - Implement the design

Applying this process to hospital facilities planning will result in the following procedures

1-· Defining the health needs

2" Specifying the' medical services required to satisfy those health needs

3··· Determining the interrelationships for all services 4- Determining the space requirements for all services 5··" Generating alternative hospital plans

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6·- Evaluating al ternativa* hospital plans 7““· Selecting a hospital plan

These i terns Ciim be brief 1 y exp 1 ained as f o 11 ows s

1 - ·· D e f .i.1*1 a.ri g t h e h e a 11 h needs: A t 11" ii s s t e p i t i s e s s e n t a. a 1 to specify the services to be provided and to identify the volu/nes or levels of activities.

2'- Specifying medical services required to satisfy health needs: The primary and support activities to be performed and the requirements to be me^t should be specified in terms of the? operations ^ equi pmen t ^ personne 1 and materia 1 f 1 ows involved. Support activities are those that aid the primary a c t i V i t. i e s a n d all o w t h e m t o f u n c t i o n w i t h iria. n i m a 1 ;i.n t e r r L.i|::)t i o n a n <:J ci e 1 a y .

3·· · De tero)in;i.r-ig t he iri ter re 1 at ionshi ps ior all se rvi.c::es s

E.stabl ishing if cmd how emotivities interact or support one another within the boundaries of the hospital is to be L.(n d e r t a I·:;e n . Both qua n t i t a 1:i v e a n c j c| u a 1 i t a t i v e r e 1 a t ;i.on s h i p s s. h o u 1 c:l b e i d e n t i *f i e d .

4- ^ Determining the space requirements for all activities: All equipment., materials., and personnel requirements must be c onBidered i.n calcu 1 at.irig t e space i'“ec|uirement«·>.

5- Generating alternative hospital plans: Hospital plan alternatives w i l 1 include alternative layout designs.

6- Evaluating all hospital plans: On the basis of accepted

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c r i t e r i a !, the specified plans should tae ranked. For each candidate plan, the subjective f«actors involved should be determined and evaluated to see if (and how) these factors affect the hospital f£»cilities.

7 Selecting a hospital plans At this step, the problem is to determine which plan, if any, will be most .acceptable in satisfying the goals and objectives of the hospit«al.

In this thesis, thei firs»t three? ste?ps of the process described above will intercict with anothe»r approach developed by Muther (1961), and s. new process will be proposed in determining the layout of the suggested hospital. This process is introduced in the next se?ction.

3.2. HOSPITAL FACILITIES PLANNINB PROCESS

In the planning process of a hospital the first step is the definition of the health needs «and the specific«ation of the medical services to satisfy those he«alth needs. Then the interrelationships for all services, flow p«atterns of the goods and paitients, and spaure requirements of the departments is determined. The relationship chart which will be the input for the layout technique is formed. The lc\st two steps of the procedure is m«aking the lav'out and evaluating the layout. The health facilities design process described above is given in Figure 3-1

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D e f i n i t i QI I a f I Ie a 1 1:1"i N e e cJ s

V

2- Specification of hedical Services S a t i B f V t h e l-le a 11 l*'i I'^ie e d s» t o 5- Space requirements « R e 1 a t i. C J n s l"'ii. p Diagram

7. De^velop A.1 tejrnative Layouts

B M Evaluation

F“igure 3-1

Health Facilities Design Process

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In the forthcoming sections the procedure described in Figure Zi. 1 will be followed step by step to develop a layout for the hospital to be suggested in Chapter IV. As suggested in the figure the first step in a facility layout process s h bu 1 cJ be the d e f i n i t i an o f t he has a 11 h n eed s w h i c h w i 11 be perforiiiEsd in the next seiction.

3.2..1 . DEFININ(3 THE HEALTH NEEDS

Based on consultations with physicians and hospital administrators, the major health nee?ds requirc-?d within a hospitacl can be categorisead as follows:

■“ Physical examinations

First ciid and tsmergency trteatment

-- Treatment of illnesses and procurement of related services

3.2.2. SPECIFYING THE MEDICAL SERVICES TO SATISFY THE NEEDS

Once the major h«?alth needs a hospital should satisfy is determined, th«? medical stsrvices to satisfy those needs should be specified. These services and the related primary and support actiyitit-js may vary depending on the types and functions of a hospital and the neesds of the patitsnts it serves. As no relevant data exist and predictions of the needs of the potential patients in Ankara can not be obtained, the following bcUaiic services will be considered as

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the inputs of the layout in the next chaptei?r. These are viewed to be the most important services that a hospital in Апкагсч should have by the doctors and the·? nurse whcj c оn t r‘i bi.i tecJ tо this s tixdу . Tf iese ser·v i.c es c: ari be eteri(iвd о r r e c j LX c: e cJ i n a c c: о r d a nee w i. t h t h e r в c| u i r e:?n iв n t iLi.

A и 0 LX I:.|Z)a t: i. e г ) t ( A in fc)u 1 a\ n 1: P a t. .i.e n t ) F· ¿л i 1 i t i e В . N uriii;i.ng 3BrvicBiis

J. „ F·'a 1:'. i e n t Care D J. v ± s i. a riв

2 - Opera ting The-iatre ( Surgery ) Departmen t 3 - Emergency ^1· - 0 bs 1:e t r i c s an d (3у г) aec о 1 од i с a 1 De pa r t /nen t 0 - A cJ j i..in c t F a a i 1 i t i e «s 1 - Fk’adiolagy 2 « I...a b о r a t о r i e s 3 Э F"*hysica 1 Therapy D . S e r ·V1c в D e |::)a r t iiie n t в 1 „ F· c) о cJ S e r V i c e 2.. Laundries 3- Employee Facilities 4 M I·-ID u s e I·.·:e e p i n g

5. F^eceiving and storage 6 „ M a .1.n t e n a n c; e

Ei, Ad m i n i s t r a t i on .1. - Offices

Şekil

TABLE  OF  CONTENTS

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