Introduction to IUSS guidelines norms and standards MODULE

Introduction to IUSS guidelines norms and standards MODULE: Built Environment guidelines PURPOSE: Overview of building guidelines for health infrastructure in South Africa, with reference to the IUSS standards NAME: Jako Nice E. MAIL: jnice@csir. co. za This program has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control & Prevention (CDC) under the terms of Grant Number - NU 2 GGH 001937 -01 -02.

Contents • • 2 Infrastructure Current state of guidelines, pre IUSS The Law IUSS background, application and overview IUSS sample documents IUSS generic room data sheets IUSS TB services, engineering services Resources

INFRASTRUCTURE INVESTMENT Buildings are expensive to build – and even more expensive to operate and maintain • Buildings take a long time to construct • But last long when complete 6 months – 8 years life expectancy > 40 years Good buildings (manufactured capital) are context – specific • • Financial capital – economy, allocations, expenditure Human capital – culture, policy environment, skills Natural capital – climate, resources, public health Change – technology, disease, climate … unknowns

INFRASTRUCTURE HEALTH SOUTH AFRICA v Service delivery in the healthcare sector is profoundly affected by the built infrastructure provided to support it v 4122 public healthcare facilities v Current replacement rate - > 40 Yrs v Current replacement value – R 331. 2 Billion (MERC) v Inconsistent quality, budgeting and programming: 4 v Inaccurate budgeting, poor spending patterns v undermining equity v lack of transparency, and v lack of confidence

CURRENT STATE OF GUIDELINES THE NEED (CURRENT AND PRE-IUSS) § Weak health infrastructure law: • SAHNorms (public sector) repealed • R 158 (private sector) – outdated • R 187 (WC) and draft regulations (GP, FS) § Built environment professionals have no healthcare specialisation, and vice versa § Initial capital cost: maintenance: service delivery • § 5 1 : 5 : 25 New national guidelines commissioned by the National Department of Health…in need

CURRENT STATE OF GUIDELINES 158 & 187 • Regulation Governing Private Hospitals and Unattached Operating Theatre Units, published in Government Gazette, Notice No. R. 158 of 1 February 1980, (last formally amended in 1993); (KZN – 1996? ) • Regulation Governing Private Health Establishments, Western Cape, published in Provincial Gazette Extraordinary 5728, Provincial Notice No. 187 of 22 June 2001 But The R. 158 & R. 187 are promulgated in terms of the National Health Act, of 1977, which was repealed in whole by the new National Health Act, of 2003 6

CURRENT STATE OF GUIDELINES INFRASTRUCTURE CONTEXT EVOLVING • COUNCILS, BUREAUS, FEDERATIONS…ETC SAIA (SOUTH AFRICAN ISNTITUE FOR ARCHITECTS) SACAP ( SOUTH AFRICAN COUNCIL FOR THE ARHCITECTURAL PROFESSION), NHBRC (NATIONAL HOME BUILERD REGISTRATION COUNCIL), SABS (SOUTH AFRICAN BUREAU OF STANDARS), IBC (INTERNAITONAL BULDING CODE), ECSA (ENGINEERING COUNCIL OF SOUTH AFRICA), SAFHE (SOUTH AFRICAN FEDERATION OF HOSPITAL ENGINEERING), CIBSE (CHARTERED INSTITUTION OF BUILDING SERVICES ENGINEERS), ASHRAE (AMERICAN SOCIEY OF HEATING, REFRIGERATING AND AIRCONDITIONING ENGINEERS ) GBC (GREEN BUILDING COUNCIL), CBE (COUNCIL FOR THE BUILT ENVIRONMENT), ISO (INTERNATIONAL ORGANISATION FOR STANDARDISATION) • IUSS (INFRASTUCTURE UNIT SUPPORT SYSTEM) National Norms, Standards and Guidelines for healthcare infrastructure in South Africa, 48 packages considering all aspects of the healthcare environment (Replaced the SAH Norm and R 158) • SANS 10400 - BUILDING STANDARDS Part A: General Principles and Requirements, Part B: Structural Design, Part C: Dimensions, Part D: Public Safety, Part E: Demolition Work, Part F: Site Operations, Part G: Excavations, Part G: Foundations, Part J: Floors, Part K: Walls, Part L: Roofs, Part M: Stairways, Part N: Glazing, Part O: Lighting and Ventilation, Part P: Drainage, Part Q: Non-water-borne Sanitary Disposal, Part R: Stormwater Disposal, Part S: Facilities for Disabled Persons, Part T: Fire Protection, Part U: Refuse Disposal, Part V: Space Heating, Part W: Fire Installation Parts X & XA: Energy Usage • LOCAL MUNICIPAL BY LAWS EMERGING • ENERGY EFFCIENCY AND SUSTAINABILITY • Parts X & XA: Energy Usage

THE LAW HIERARCHY Constitution: The Constitution of South Africa is the supreme law of the country of South Africa. It provides the legal foundation for the existence of the republic, sets out the rights and duties of its citizens, and defines the structure of the government. Act: The government, elected by the people has the prerogative of making laws. It must consult, but it is not required to concede to all inputs. Acts of Parliament (National) and Acts of Legislation (Provincial) Regulations: Delegated (indirect) legislation (from Act) or direct law-making (enabled through the Constitution) and original legislation (surviving historical). These are promulgated by Government Notices. By-laws: By-laws are passed by municipal councils. 8

THE LAW DESCRIPTION BY HIERARCHY Policies: General provisions that provide direction, transparency and consistency of approach, often covers more than one entity. Norms: 1. 2. Normal – what is usually found/ typical Normative – what “should” be, ideally General “rules of thumb” about rates of provision to provide benchmarking. Standards: In contrast to legislating, standards are negotiated by the industry and the content is determined by “majority vote” of the committee involved. Standards may be mandatory or voluntary. South African Bureau of Standards (SABS) is custodian of South African National Standards (SANS). Standards are Mandatory standards are enforced by the National Regulator of Compulsory Standards (NRCS) Standard operating procedures (SOPs) & codes of practice : Unless mandated as compulsory by legislation are voluntary, technical processes or procedures. 9

THE LAW NATIONAL BUILDING REGULATIONS & BUILDING STANDARDS ACT By-laws are subservient to the regulations. Building By-Laws can only be made with the approval of the Minister of the dti 1 2 NRCS = REGULATOR = NBR National Building Regulations Chapters contained in Regulations TECHNICAL REGULATIONS Standards can be called up in to regulations m ak Standards and best practices are purely technical documents that do not contain policy or principles-based provisions. To provide for the promotion of uniformity in the law relating to the erection of buildings in the area of jurisdiction of the Local Authorities ing them manda tory SABS = National Standards SANS 10400 Deemed-to-satisfy Chapters A to X. Other SANS documents Act of Parliament determines the scope of the issues under regulation, as well as embodies the policy direction of such regulation and creates structures to administer Regulations the regulation contain: Policy, principal provisions, procedures and other detail SANS 204, SANS 10252, SANS 10005 for protection of timber 3 4 Voluntary Standard An Act always trumps regulations and regulations always trump standards or any other documents incorporated into their regulations by reference. Act 103 of 1977 Mandatory Legislation Four-tier + 1 legislative model Local Authority Building By-Laws; To be endorsed by the Minister before it has jurisdiction and: Town Planning Schemes, TP ordinances, TP regulations 10 S A B S 5 Source: Hierarchy of legislation. October 2010 - National Regulator - www. arcdirectory. co. za/ C O N S U L T A T I V E C O N S E N S U S

IUSS NATIONAL DEPARTMENT OF HEALTH VISION By 2030, the health system should provide : quality care to all, Universal access to primary health care, free at the point of service, or insurance-funded. Focus on prevention, education, disease management and treatment More health professionals trained IUSS = National Department of Health initiative + DBSA and CSIR structured collaboration “… sustainable set of norms and standards for all levels of health care facilities to inform and guide work related to all stages of the health infrastructure lifecycle from strategic planning through to operation and disposal…” 11

IUSS BACKGROUND (1) These IUSS voluntary standard/ guidance documents have been prepared as national Guidelines, Norms and Standards by the National Department of Health for the benefit of all South Africans. They are for use by those involved in the procurement, design, management and commissioning of public healthcare infrastructure. It may also be useful information and reference to private sector healthcare providers. . The development process adopted by the IUSS team was to consolidate information from a range of sources including local and international literature, expert opinion, practice and expert group workshop/s into a first level discussion status document. This was then released for public comment through the project website, as well as national and provincial channels. 12

IUSS BACKGROUND (2) At all development stages documents may go through various drafts and will be assigned a version number and date. The National Department of Health will establish a Health Infrastructure Norms Advisory Committee, which will be responsible for the periodic review and formal update of documents and tools. Documents and tools should therefore always be retrieved from the website repository www. iussonline. co. za or Department web portal (forthcoming) to ensure that the latest version is being used. The guidelines are for public reference information and for application by Provincial Departments of Health in the planning and implementation of public sector health facilities. The approved guidelines will be applicable to the planning, design and implementation of all new public-sector building projects (including additions and alterations to existing facilities). Any deviations from the voluntary standards are to be motivated during the Infrastructure Delivery Management Systems (IDMS) gateway approval process. The guidelines should not be seen as necessitating the alteration and upgrading of any existing healthcare facilities. 13

IUSS APPLICATION IN SUMMARY v 14 Govt Gazette -> Mandatory v Remainder & public sector public information v Application by provincial departments of health v New building projects (incl. adds & alts) v Not requiring upgrade of existing facilities v Deviations motivated in IDMS v Consultants and professional service providers not absolved of duties of care or due diligence

IUSS APPLICATION • Gazette No – 37348: R 116, – 37790: R 512, – 38776: R 4141, • • 15 17 February 2014 30 June 2014 8 May 2015 Prospective Public sector Private sector guidance Some relevant documents – – – TB Services Infection Control Building engineering services etc. Waste management But…they all are relevant , and should be seen as a suite

Clinical services X Support services Adult Inpatient Services Admin & Related General Hospital Support Laboratories X X Mental Health Catering Services Adult Critical Care Linen and Laundry Hospital Mortuary Services Nursing Education Institutions Health Facility Residential Central Sterilising Services Department Training and Resource Centre Emergency Centres Maternity Care Facilities Oncology Outpatient Services Paediatric and Neonatal Facilities Pharmacy Primary Health Care Diagnostic Radiology X 16 Adult Physical Rehabilitation Adult Post-acute Services Facilities for Surgical Procedures TB Services X Infrastructure Design for Waste Management Healthcare environment/ crosscutting issues Procurement and operation Integrated infrastructure planning Generic Room Data Project planning and briefing Security X Engineering design principles Environment and Sustainability Materials and Finishes Future healthcare environments Healthcare Technology Inclusive environments Infection prevention & control Information Technology & Infrastructure Regulations X Space guidelines Cost Guidelines Innovative Building Technologies Commissioning Maintenance Decommissioning Capacity development LEGEND X Gazetted Guidelines Toolkits Position papers Regulations 16

IUSS PHC DOCUMENT, EXAMPLE (1) v Policy and Service Context v Strategic planning v Site selection v Briefing the implementing agent or consultant team PLANNING AND DESIGN v 17 First, do no harm v Healing environment for users v Occupational well-being and motivation for staff v Accessibility and inclusive design v Emergency preparedness and resilience

IUSS PHC DOCUMENT, EXAMPLE (2) v v Lean v Right-sized v Generic, flexible and adaptable design v Functional zones within the clinic & CHC Green v v Legibility v 18 Energy, water, waste, materials, biodiversity Way-finding, signage etc…

IUSS PHC DOCUMENT, EXAMPLE (3) v Access, and flow v Intra area relationships 19

IUSS PHC DOCUMENT, EXAMPLE (4) 20 v Rooms v Room relationship matrix

IUSS PHC DOCUMENT, EXAMPLE (5) v Interdepartmental relationships v Optimal departmental placement v Process 21

IUSS PHC DOCUMENT, EXAMPLE (6) Ngcizela Clinic 22

IUSS PHC DOCUMENT, EXAMPLE - APPLICATION 23

IUSS PHARMACY, INTEGRATED DATA AND GENERIC DRAWINGS (1) 24

IUSS PHARMACY, INTEGRATED DATA AND GENERIC DRAWINGS (2) 25

IUSS PHARMACY, INTEGRATED DATA AND GENERIC DRAWINGS (3) 26

IUSS ROOM DATA SHEETS v 5 Gazetted v 100 extensive reviewed and workshopped v Room requirements v Room specifications v Room sizes v Graphical representation v Cross referenced 27

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IUSS TB SERVICES 30

IUSS TB SERVICES (EXAMPLES) – CATHERINE BOOTH 31

IUSS TB SERVICES – DESIGN PRINCIPLES 32

IUSS TB SERVICES – CONSTRUCTION, WINDOWS AND VENTILATION 33

IUSS CSSD – DESIGN GUIDANCE

CSSD process zones

CSSD workflow through zones

IUSS ENGINEERING PRINCIPLES – AIRFLOW IN AN MDR UNT 38 2021 -03 -03 38

IUSS BUILDING ENGINEERING SERVICES (1) • Evidence based guidance on: • Engineering for Infection Control • Engineering for Energy Efficiency • Engineering for Cost Control • Engineering for Reliability 39

IUSS BUILDING ENGINEERING SERVICES (2) • Commissioning of Ventilation • • • 40 Pipe and Duct Pressure Testing Filter Tests Heater Tests Particle Counts Airflow Room Pressure

IUSS BUILDING ENGINEERING SERVICES (3) 41

IUSS BUILDING ENGINEERING SERVICES – ENGINEERING DONE RIGHT • Apply the right level of engineering to the problem • Always consider the resilience and lifecycle cost of any solution • High-tech solutions demand high-level commissioning, training and maintenance • Over-design and Under-design can both result in increased: • Capital Costs or • Operational Costs 42

IUSS LEAN PRINCIPLES - OOM v 43 Cost-model tools: v Order of magnitude estimators for greenfield & brownfield capital work v Clinics & hospitals v Cash flows v Operating costs incl. maintenance v Maintenance estimators v Detailed estimators v Briefing v Commissioning & decommissioning v Maintenance

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ADDITIONAL RESOURCES www. tb-ipcp. co. za

http: //www. ghdonline. org

47 SAFHE – South African Federation of Hospital Engineering Objectives To promote and develop in the healthcare field: • • All aspects of design, engineering, and technology, including construction, commissioning, and maintenance of buildings, plant, equipment, machinery and apparatus. The principle of integrated design by improved collaboration amongst all professions. The more efficient management of planning, operation, maintenance and safety. The advancement of education of personnel. The encouragement throughout the world of the unrestricted acquisition, exchanges, and spread of information, and research. The arranging of conferences, seminars and discussions to provide a medium of communication for interested persons on a professional and industrial basis. The evaluation of professional standards and etiquette, and establishment of good relationships between members and other bodies interested in or having objectives similar to those of SAFHE. (IFHE, CEASA) The encouragement, investigation and publicising of innovations which may be of benefit to members, and assist in the furtherance of the objectives of SAFHE. www. safhe. co. za/

48 FIDSSA –Federation of Infectious Diseases of South Africa The federation is an amalgamation of existing societies representing adult and paediatric infections diseases, sexuality transmitted diseases, clinical microbiology, infection control and travel medicine. They produce a journal and a biannual national congress : • • • ICSSA - The Infection Control Society of Southern Africa IDSSA - The Infectious Diseases Society of Southern Africa SASCM - The South African Society for Clinical Microbiology SASPD - The Southern African Society for Paediatric Infectious Diseases SASTM - The South African Society of Travel Medicine STDSSA – Sexually Transmitted Diseases Societies of South Africa http: //www. fidssa. co. za/ ICAN –Infection Control African Network http: //www. icanetwork. co. za/

RESOURCES DEPARTMENTS, FEDERATIONS AND ORGANISATIONS CDC Centers for Disease Control and Prevention http: //www. cdc. gov/globalhealth/countries/southafrica CSIR Council for Scientific and Industrial Research http: //www. csir. co. za/ MRC Medical Research Council http: //www. mrc. ac. za/ NDo. H National Department of Health http: //www. health. gov. za/ NHLS National Health Laboratory Services http: //www. nhls. ac. za/ NIOH National Institute of Occupational Health http: //www. nioh. ac. za/ NICD National Institute of Communicable Diseases http: //www. nicd. ac. za/ WHO World Health Organisations http: //www. who. int/en/ SAFHE South African Federation of Hospital Engineering http: //www. safhe. co. za/ FIDSSA Federation of Infectious Diseases of South Africa http: //www. fidssa. co. za/ CIBSE Chartered Institution of Building Services Engineers http: //www. cibse. org/ REHVA Federation of European Heating Ventilation and Air Conditioning http: //www. rehva. eu/

RESOURCES ONLINE PORTALS IUSS Infrastructure Unit Support Systems www. iussonline. co. za GHD online Global Health Delivery Online www. ghdonline. org CSIR TB IPCP www. tb-ipcp. co. za ICAN Infection Control African Network http: //www. icanetwork. co. za Etc………

RESOURCES CSIR COURSES UP Building Design and Engineering Approaches to Airborne Infection Control University of Pretoria 2017… CSIR: TB IPCP 3 x course: Airborne Infection Prevention Control Management and Risk Assessment CSIR: TB IPCP The International Clinicians Course CSIR: TB IPCP PEPFAR Seminar CSIR: TB IPCP PPE Summit CSIR: TB IPCP TB IPC Seminar Etc………

WHAT IS NEXT? • Are they being implemented in practice? • Yes (the Auditor General checks) • Please let us know about your projects! • Do the “BETTER HEALTHCARE BUILDINGS – Introduction to IUSS” 5 -day CPD course…October 2018 • Do the Building Design & Engineering for Infection Control 5 -day CPD course… You have just done it !!! • Join SAFHE (its not just for engineers!) • Speak to us… 52

QUESTIONS • Questions on day 1…? 53