Ministry Of Health

Medical Practice and Licensing Sector

Licensing Department

Healthcare Facilities
Regulation
General Hospital

2013 Version 2.0

Table of Contents

I Scope
II Purpose
1- General Considerations
2- General Conditions
3- Out Patient Service
4- Accident and Emergency Service
5- In Patient Service
6- Special Patient Care
7- Obstetrics and Gynecology Service
8- Renal Dialysis Unit
9- Physiotherapy Services
10- Operation Theatre
11- Radiology Services
12- Clinical Laboratory Service
13- Pharmacy Service
14- Catering Services
15- Mortuary Unit
16- Central Sterile Supply Department
17- Linen Services
18- Engineering Services
19- Administration Area
20- Management standards and responsibilities
21- Healthcare Professionals Minimum Requirements
22- Facility management

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3
4
7
9
10
15
18
21
23
24
25
28
33
35
37
38
39
39
40
41
41
42
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Scope
This regulation applies to every general hospital subject to licensure under the
Ministry Of Health established law.
The Ministry Of Health reserves the right to amend this regulation without prior notice.
The latest version of the regulation shall be published on the Ministry Of Health website.
www.moh.gov.ae

Purpose
The Ministry Of Health is the sole responsible authority for licensing, regulating and
monitoring healthcare facilities in the Northern Emirates. We are aiming to achieve the
highest level of patient safety and quality of care through the development and
enforcement of up to date health regulation.

Enquiries concerning these regulations should be directed to;

Dr Hessa Mubarak
Licensing Department
Medical Practice and Licensing Sector
Ministry Of Health
United Arab Emirates
Tel
+971-4-2301420
Fax
+971-4-2301851
Email hessa.mubarak@moh.gov.ae
Website www.moh.gov.ae

1- General Considerations
1.1 The regulation governs the basic requirement for all general hospitals operating in
the Northern Emirates.
1.2 The regulation will be applied to all hospitals; existing, in renovation, and in
construction. It is also applied when a new facility, service or procedure is to be
introduced.
1.3 Regulation, standards and requirements of the other concerned Federal and Local
Authorities of the UAE should be strictly followed in conjunction with present MOH
regulations.
1.4 Establishing a new hospital, renovating of existing one or adding a new facility or
procedure requires the submission of an application to the Licensing Department. The
application procedure is described on the MOH website. www.moh.gov.ae.
1.5 Feasibility studies, needs analysis, potential future expansion and researches results
are desirable but not obligatory.
1.6 The hospital shall be designated by a permanent and distinctive name which must
not be changed without prior notification and subsequent confirmation from MOH. The
name of the hospital shall not tend in any way to mislead the public as to the type or
extent of care provided by the facility.
1.7 A clearly display of signage and directions for different services and departments
must be provided in two languages (Arabic and English). Also a clearly displayed
hazardous signs aimed to restrict access for the safety of patients, visitors and staff must
be provided.
1.8 Special attention should be given to the control of environmental elements, Such as;
quality of air, temperature and humidity, lighting (natural and artificial) and noise and
vibration levels.
1.9 The hospital must insure that all clinical and medical equipment are installed and
operated according to the manufacturer specifications. The institute must maintain
effective Preventive Maintenance as recommended by the manufacturers. A safety log
book in Arabic & English languages should be annexed.

1.10 Security and safety of patients, visitors and staff should be insured at all time and
stages according to the existent rules and regulations of the concerned Federal and Local
Authorities In conjunction with present MOH regulations.
1.11 The hospital must provide security services for; access control systems, video
surveillance systems, door intercommunication systems, intrusion detection systems.
1.12 The hospital must establish a fire safety plan according to the Federal Civil Defense
Department.
1.13 The hospital shall provide safe storage and disposal of hazardous materials and
biomedical waste.
1.14 Facilities handling ionizing radiation for diagnostic and therapeutic purposes and
potentially bio-hazard material must comply with the Federal Authority Nuclear
Regulation (FANR), the National Radiation Protection Center (NRPC) and the existing
Federal and Local Laws. The facility should also provide safe storage and disposal of
hazardous materials and biomedical waste.
1.15 Special attention should be given to implement a comprehensive and up to date
infection control standards.
1.16 Privacy and confidentiality of patients, visitors and staff should be respected and
granted according to the UAE cultural requirements.
1.17 Commissioning is conducted at the completion of the construction phases, and is a
pre-requisite to practical completion and building occupancy. Commissioning must also
include the training of the staff and ongoing monitoring of system performance during a
defined period. At the end of the commissioning phase a pre-prepared check list should
be completed.
1.18The hospital must maintain health records and reports in a manner to ensure
accuracy and easy retrieval. Health records shall be maintained in the custody of the
health facility and shall be available to a patient or his/her designated representative
through the attending healthcare professional at reasonable times and upon reasonable
notice.

1.19 The hospital shall ensure that each patient is allocated a specific unique identifier,
and where multiple records for the same patient exist they are cross-referenced.
1.20 Malpractice insurance for all licensed healthcare professionals according to article
25 and 26 of the UAE Federal Law number 10/2008 concerning Medical Liability
should be maintained.
1.21 It is the responsibility of the healthcare institutes to insure their compliance with all
documents submitted to and approved by the Ministry Of Health.
1.22 Although this document was compiled according to the latest international
regulations, completeness and accuracy cannot be guaranteed. Upgraded version of this
document will be introduced as needed and could be found on the MOH website
www.moh.gov.ae .

2- General Conditions

2.1 Hospital buildings should be free standing structure with acceptable distance from
other adjacent buildings with an open access to main road to facilitate traffic movement.
The hospital building should have its independent Heating, Ventilation and Air
Conditioning (HVAC).
2.2 The main hospital entrance should be located at ground level, protected from allweather elements, and easily accessible to the public and physically disabled.
2.3 Parking area should be specious enough to accommodate patients, staff and public
needs.
2.4 The following facilities should be provided;
2.4.1 Suitable roadways to loading/unloading areas.
2.4.2 Emergency/fire access.
2.4.3 Helicopter landing area.
2.4.4 Adequate security system.
2.4.5 Pleasant Landscaping and lighting.
2.4.6 Other requirements for Federal Authorities.
2.5 Departments size and layout shall depend on the functional program requirements
and organization of services within the hospital. Combination or sharing of hospitals
functions shall be permitted, provided the layout does not compromise safety standards
or medical and nursing practices.
2.6 The ceiling height shall not be less than 2.40 meters
2.7 Slip-resistant flooring products shall be considered for flooring surfaces whenever
required for safety consideration.
2.8 Wall finishes shall be washable, moisture-resistant and smooth. Wall finish
treatments shall not create ledges or crevices that can harbor dust and dirt. Joints for
floor openings for pipes and ducts shall be tightly sealed.
2.9 Wired glass; or plastic, break-resistant material that creates no dangerous cutting
edges when broken shall be used in certain areas such as glass doors and sidelights.

2.10 Curtains used throughout the hospital shall be washable/cleanable, fireproof and
maintained clean at all times.
2.11 Adequate power back up of essential services are to be insured for critical areas and
medical equipment.
2.12 All hospitals having patient facilities located on other than the ground floor should
have electrical elevators.
2.12.1 At least two elevators should be available in hospital of 1- 200 beds
capacity.
2.12.2 At least three elevators should be available in hospital of 200 360 beds
capacity.
2.12.3 Typically vertical transportation system must provide segregation between
functions, such as patients, visitors and materials handling.
2.12.4 One elevator shall accommodate the largest option available for
equipment or patient circumstances requiring transport, e.g. a patient bed with all
attachments, trolleys and attendant staff that are needed for worst case safe
patient movement.
2.12.5 The elevator transportation system shall be able to operate during a power
failure event.
2.13 Construction work for renovations to existing buildings should comply with the
above conditions and all rules and regulations of Federal Authorities.

3- Out patient Service

Outpatient Department shall be in a distinct area on the hospital premises.
3.1 Reception area
3.1.1 A reception counter shall be located to provide visual control of the entrance to the
outpatient unit
3.1.2 The reception counter should provide access to patient records.
3.1.3 Male and Female waiting area for patients and escorts shall be separated and
under staff visual control.
3.1.4 Waiting area shall be provided with provision of drinking water and public
telephone.
3.1.5 A separate controlled area for pediatric patients shall be provided if pediatrics
service is provided.
3.1.6 Wheelchairs shall be accommodated within the waiting area.
3.1.7 Separate Male and Female toilet(s) for public use shall be conveniently accessible
from the waiting area.
3.2 Consultation, Examination and Treatment Rooms
3.2.1 The space requirements shall depend on the services provided but at least shall
meet the following;
3.2.1.1 Where consultation and examination room(s) is in the same room such as;
medical, surgical, obstetrical, dental or similar shall have a minimum floor area of 12
square meters and be provided with hand washing station.
3.2.1.2 Consultation room(s) where no examination is performed a minimum
floor area of 9 square meters must be provided with hand washing station.
3.2.2 Treatment rooms for minor procedures, specific treatment or casting shall have;
3.2.2.1 A minimum floor area of 11.15 square meters.
3.2.2.2 Treatment room arrangement shall permit a minimum clearance of 91.45
centimeters at each side and at the foot of the bed.
3.2.2.3 Hand-washing station shall be provided in all treatment rooms.
3.2.2.4 Documentation space or counter for writing.
3.2.2.5 A lockable refrigerator for medication use.
3.2.2.6 Locked storage for controlled drugs (if used).

4- Accident and Emergency Service

4.1 The function of the Emergency Unit is to receive, stabilize, and arrange for
appropriate management or transfer patients who present with a large variety of urgent
and non-urgent conditions whether self or otherwise referred.
4.2 The extent and type of emergency service to be provided depends on community
needs and the availability of other services in the hospital and adjacent area.
4.3 The Accident and Emergency Department consist of;
4.3.1 Entrance/Reception area.
4.3.2 Resuscitation area.
4.3.3 Acute Treatment and associated Consultation Rooms area.
4.3.4 Workstations area.
4.3.5 Staff Amenities area.
4.3.6 Administration area.
4.3.7 Additional, specifically designed areas to fulfill special roles, such as;
4.3.7.1 Management of pediatric patients.
4.3.7.2 Management of major trauma patients.
4.3.7.3 Management of psychiatric patients.
4.3.7.4 Extended observation and management of patients.
4.3.7.5 Procedure Rooms.
4.4 The entrance to the Emergency Unit must be at ground-level, well-marked,
illuminated, and covered. It shall provide direct access from public roads for ambulance
and vehicle traffic, with the entrance and driveway clearly marked.
Signposting that is illuminated is desirable to allow visibility at night.
Temporary parking should be provided close to the entrance.
It is recommended that the Emergency Unit should be accessible by two separate
entrances: one for ambulance patients and the other for ambulant patients. Each entrance
area contains a separate foyer that can be sealed by remotely activating the security
doors.
4.5 The Waiting Area should provide sufficient space for waiting patients as well as
relatives and escorts. The area should be open and easily observed from the Triage and
Reception areas. Space should be allowed for wheelchairs, prams and walking aids.
There should be an area where children may play.
Reception / Triage Area may perform observations and provide first aid in relative
privacy.

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From the Waiting Area there must be access to;

- Triage and Reception Areas
- Toilets
- Baby Change Room
4.6 The Reception / Triage and Staff Station shall be located where staff can observe and
control access to treatment areas, pedestrian and ambulance entrances, and public
waiting areas. The interface between the Waiting Areas and the Reception / Triage Areas
should be carefully designed so as to permit communication and reassurance to
distressed patients or visitors, yet provide safety and security for staff.

4.7 Consultation Room/s are to be provided according to Unit size and requirements for
examination and treatment of ambulant patients. Consult Rooms are to comply with
Standard Components. Consultation room space area should not be less than 12 square
meters.
4.8 Acute Treatment Areas are used for the management of patients with acute illnesses.
Treatment room may have additional space and provisions for several patients with
partition curtains for privacy. Multiple-bed treatment rooms should provide at least
of 7.45 square meters per patient partition.
4.9 Each treatment room should contain;
4.9.1 Examination bed/beds.
4.9.2 Examination light.
4.9.3 Work counter.
4.9.4 Hand washing station.
4.9.5 Medical equipment and medication storage.
4.9.6 Counter space for writing.
4.9.7 Each treatment area must be at least 9 square meters.
4.10 The Resuscitation area is used for the resuscitation and treatment of critically ill or
injured patients. Maximum possible visual and auditory privacy for the occupants of the
room and other patients and relatives should be provided.
The Resuscitation area requires;
4.10.1 Space to fit a specialized resuscitation bed.
4.10.2 Space to ensure 360 degree access to all parts of the patient for
uninterrupted procedures.
4.10.3 Circulation space to allow movement of staff and equipment around the
work area.

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4.10.4 Space for equipment, monitors, storage, workbenches, storage cupboards,

hand basins, X-ray viewing facilities and disposal facilities.
4.10.5 Appropriate lighting and equipment to hang IV fluids.
4.10.6 Easy access from the ambulance entrance and separate from patient
circulation areas.
4.10.7 Easy access to the Acute Treatment/Observation area from the Staff
Station.
4.10.8 A full range of physiological monitoring and resuscitation equipment.
4.10.9 Solid partitions between it and other areas (movable partitions between
bed spaces are recommended).
4.11 Acute mental health area for patients suffering from an acute psychological or
psychiatric crisis should have adequate facilities for the reception, assessment,
stabilization and initial treatment of patients presenting with acute mental health
problems.
4.12 Decontamination Area should be available for patients who are contaminated with
toxic substances. In addition to the requirements of an Isolation Room, this room must;
4.12.1 Be directly accessible from the ambulance bay without entering any other
parts of the unit.
4.12.2 Have a flexible water hose, floor drain and contaminated water trap.
4.13 Isolation Room if required should be provided at a suitable location of the unit with
maintained negative pressure.
4.14 General X-ray services determined by the size of the services are recommended.
Ultrasound and other imagining modalities will enhance the Emergency Units
effectiveness.
4.15 Medical Laboratory. The size and type of this service will be determined by the size
of the services provided and whether or not shared facilities are available within the
hospital.
4.16 A Pharmacy / Medication area is required for the storage of medications used
within the emergency unit. Entry should be secure with a self-closing door. The area
should be accessible to all clinical areas and have sufficient space to house a refrigerator,
which is essential for the storage of heat sensitive drugs.

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4.17 Patient toilet; a minimum of one male and one female toilet should be provided. At
least one dedicated toilet for handicapped patients/visitors equipped with safety hand
rails and suitable hand washing sink.
4.18 Storage areas should be allocated for general medical/surgical supplies, medications
and equipment.
4.19 Sufficient electrical outlets to meet medical equipment functional requirements
should be provided.
4.20 Electrical outlets must be clearly labeled and connected to an emergency power
supply.
4.21 There should be in each location a reliable source of oxygen. Oxygen piped from a
central source is strongly recommended.
4.22 Adequate ventilation and air exchange, of at least 6 air changes per hour as per
ASHRAE requirements shall be maintained in Emergency Department.
4.23 Emergency Department should be kept at equal pressure relative to the adjacent
areas.
4.24 The area temperature should be maintained around 24 C and relative humidity
30% to 50%.
4.25 High-efficiency filters should be installed in the air handling system, with adequate
facilities provided for maintenance, without introducing contamination to the delivery
system or the area served.
4.26 Undercover car parking should be available for appropriate number of wellequipped ambulance vehicle(s) which will be determined by the case load and the
availability of ambulance access to other parts of the hospital for non-emergency
patients.
4.27 Hand basins for hand-washing should be available within each treatment area and
should be accessible without traversing any other clinical area. They should be available
at a ratio of one for every four beds and at the ratio of one to one for every Procedure /
Resuscitation / Consulting Room. All hand basins in clinical areas should be of surgical
type with hands-free activation.

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4.28 The floor finishes in all patient care areas and corridors should have the following
characteristics;
- Non-slip surface.
- Impermeable to water, body fluids.
- Durable.
- Easy to clean.
4.29 Emergency Units are high volume users of telecommunications and information
technology. Telephones should be available in all offices, at all staff stations, in the
clerical area and in all consultation and other clinical rooms. The use of multi-function,
wireless communication devices should be considered. Additional phone jacks should be
available for the use of facsimile machines and computer modems where required.
All patient spaces and clinical areas, including beds, toilets, bathrooms, treatment areas,
patient day areas and lounges should have access to an emergency call facility so staff
can summon urgent assistance. The emergency call facility should alert to a central
module situated adjacent to the Staff Station, as well as to the Staff and Tutorial rooms.
4.30 The Emergency Unit receives a large number of patients and their visitors, many of
whom may be distressed, intoxicated or involved in violence. The hospital has a duty of
care to provide for the safety and security of employees, patients and visitors. Both
policies and structures should be in place to minimize injury, psychological trauma and
damage or loss of property. The precise details of security features should be designed in
conjunction with a security risk assessment for the specific site.
4.32 The emergency unit will require ready access to the following key functional Areas;
- Medical Imaging Unit
- Operating Unit - rapid access is highly desirable for surgical emergencies.
- Coronary Care Unit
- Pathology / Blood Bank Unit
- Clinical Records Unit
- Inpatient Accommodation Unit
- Pharmacy Unit - proximity is required
- Outpatients
- Mortuary
4.33 The number of licensed medical staff assigned to each service area of the unit shall
be determined by senior management and consistent with the functional program of the
unit, but a minimum of five casualty officers is required.
At least one full time consultant/specialist A shall be in charge of the unit.

14

4.34 The number of MOH licensed registered nurses and nurse assistance assigned to
each service shall be consistent with the types of nursing care needed. See staffing
matrix decision making guideline at the section of Healthcare Professionals Minimum
Requirements.

5 - Inpatient Service

5.1 All hospitals shall provide inpatient service in distinct areas.

5.2 The number of beds per room depends on the demands and the functional program,
but one bed per room is advisable.
5.3 When reconstruction work is undertaken and the present capacity is more than one
patient, maximum room capacity should be not more than the present capacity, with a
maximum of four patients.
5.4 Adequate ventilation and air exchange, with at least 6 air changes per hour as per
ASHRAE requirement shall be maintained in inpatient care area.
Inpatient care area should be kept at positive pressure relative to the adjacent areas.
The area temperature should be maintained at 24 C or less and relative humidity 30 %
to 60%.
5.5 High efficiency filters should be installed in the air handling system.
5.6 Patient Room
The following requirements shall be provided:
5.6.1 Walls shall be painted with lead free color with no sharp edges.
5.6.2 Window in patient room is required.
5.6.3 Door opening to inpatient bedrooms shall be wide enough for easy movement of
bed or stretcher, a minimum clear width of 1.15 meters with a frame that is 2.15 meters
high is required.
5.6.4 In multi-story hospital buildings, adequate family visiting areas shall be provided
at each floor.
5.6.5 Patient rooms should be constructed to meet the needs of the functional program
and have a minimum of 9.50 square meters of clear floor area per bed in multiple-bed
rooms and 11.35 square meters of clear floor area in single-bed rooms, exclusive of
toilet rooms, closets, or lockers.
5.6.6 In multiple-bed rooms, a clearance of 1.40 meters should be available at the foot of
each bed to permit the passage of equipment and beds.
5.6.7 Each patient should have within his or her room a separate locker.
5.6.8 One toilet room should serve not more than two patient rooms and not more than
four beds. Toilet room doors should swing outward or be double acting.
5.6.9 A hand-washing station for the exclusive use of the staff shall be provided to serve
each patient room and shall be placed outside the patient toilet room.
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5.6.10 Door opening to inpatient bedrooms shall be wide enough for easy movement of
bed or stretcher, a minimum clear width of 1.15 meters with a frame that is 2.15 meters
high is required.
5.6.11 Calling system shall be next to each bed.
Adequate electrical sockets for each bed are required.
5.7 Nurse Station
This area should have space for counters and storage and should have convenient access
to hand-washing stations.
5.8 Documentation Area;
Charting facilities should have linear surface space adequate to ensure that staff and
physicians can chart and have simultaneous access to information and communication
systems.
5.9 Multipurpose Room
Multipurpose rooms are provided for staff, patients, and patients families for patient
conferences, reports, education, training sessions, and consultation. These rooms may be
on other floors if convenient for regular use.
5.10 Medication Station;
The following should be provided;
5.10.1 Medicine preparation room.
5.10.2 Should be under visual control of the nursing staff.
5.10.3 Should contain a work counter, a hand- washing station, a lockable
refrigerator, and locked storage for controlled drugs.
5.11 Self-contained medicine dispensing unit;
This should be at the nurse station, in the clean workroom, provided the unit has
adequate security for controlled drugs and adequate lighting to easily identify drugs.
5.12 Clean Supply Room
5.12.1 If the room is used for preparing patient care items, it shall contain a work
counter, a hand-washing station, and storage facilities for clean and sterile supplies.
5.12.2 If the room is used only for storage and distribution of clean and sterile materials,
exclusion of the work counter and hand-washing station can be acceptable.

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5.13 Housekeeping Room

Housekeeping rooms should be directly accessible from the unit or floor they serve and
may serve more than one ward on a floor.
5.14 Areas related to Staff
5.14.1 Staff Lounge Facilities, conveniently located private room for staff to use during
their break.
5.14.2 Staff toilet rooms.
5.14.3 Staff storage facilities.
5.14.4 There should be closets or cabinet compartments for the nursing personnel usage.
5.15 Examination or Treatment Rooms
5.15.1 Centrally located examination and treatment rooms could serve more than one
nursing unit on the same floor.
5.15.2 Such rooms should have a minimum floor area of 11.25 square meters.
5.15.3 The room should contain;
5.15.3.1 Examination bed.
5.15.3.2 Examination lamp.
5.15.3.3 Hand-washing station.
5.15.3.4 Storage facilities.
5.15.3.5 Desk, counter, or shelf space for writing.
5.15.3.6 X-ray viewer that accommodates at least four films simultaneously
should be provided.
5.16 Areas for Patients and Visitors
This area should be designed to minimize the impact of noise and activity on patient
rooms and staff functions.

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6 - Special Patient Care

6.1 Airborne Infection Isolation Rooms

6.1.1 The hospital should specify airborne infection isolation room(s) for treatment of
infectious diseases based on the needs of specific community and patient populations
served by the hospital.
6.1.2 At least one airborne infection isolation room shall be provided in all general
hospitals.
6.1.3 Airborne infection isolation rooms may be located within individual nursing units
and used for normal acute care when not required for patients with airborne infectious
diseases, or they may be grouped as a separate isolation unit.
6.1.4 Isolation rooms design requirements shall include but not limited to the following;
6.1.4.1 Each patient room shall contain only one bed.
6.1.4.2 A separate toilet with shower shall be provided for each patient room.
6.1.4.3 A hand-washing station shall also be provided for each patient room.
6.1.4.4 Perimeter walls, ceilings, and floors, including penetrations, shall be
sealed tightly so that air does not infiltrate the environment from the outside or
from other spaces
6.1.4.5 An area for gowning and storage of clean and soiled materials shall be
located either directly outside or inside the entry door to the patient room.
6.1.4.6 There should be an oxygen source and first-aid kit available inside the
room.
6.1.4.7 Adequate ventilation and air exchange, with at least 12 air changes per
hour as per ASHRAE requirements shall be maintained in the Isolation Room.
The room should be kept at negative pressure relative to the adjacent areas.
6.1.4.8 The area temperature should be maintained at 24 C plus or minus 1 C.
6.1.4.9 High-efficiency filters should be installed in the air handling system, with
adequate facilities provided for maintenance, without introducing contamination
to the delivery system or the area served.
6.2 Protective Environment Rooms
6.2.1 Generally, protective environments rooms are not needed in community hospitals,
unless these facilities take care of these types of patients.
6.2.2 The differences between protective environment rooms and other patient rooms is
the requirement for positive air pressure relative to adjacent spaces, with all air passing
through high-efficiency particulate air filters to ensure the protection of patients who are
highly susceptible to infection.

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6.2.3 Protective environment rooms should;

6.2.3.1 Contain only one bed.
6.2.3.2 Have separate toilet directly exist from each protective environment
room.
6.2.4 Have a permanently installed visual mechanism to monitor the pressure
status of the room when it is occupied by patients. The mechanism should
continuously monitor the airflow.
6.2.5Have walls sealed tightly so that the air does not infiltrate the environment
from the outside or from other spaces.
6.3 Isolation Rooms for noninfectious patient
The hospital should provide one or more single-bed rooms for patients that are in need
for close supervision for medical and/or psychiatric care.
These rooms may be part of the psychiatric unit.
6.4 Intermediate Care Units
6.4.1 This unit is for patients who require frequent monitoring of vital signs or nursing
intervention that exceeds the level needed in a regular medical or surgical unit but is less
than that provided in a critical care unit.
6.4.2 Maximum room capacity should not exceed four patients.
6.4.3 A minimum of 1.15 meters should be available at the foot of each bed to permit the
passage of equipment and beds.
6.4.4 Monitoring equipment should be available for each bed.
6.4.5 There should be an emergency alarm to call for assistance from outside the
intermediate care unit.
6.4.6 A hand-washing station should be provided in the patient room in addition to that
in the toilet room.
6.5 Critical/Intensive Care Units
6.5.1 All general hospital shall provide Critical Care services. Type of units and number
of beds needed is based on many factors. In general the hospital should provide one
critical care bed for each operation theater, but it should not be less than one critical care
bed for every 20 general beds.

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6.5.2 The location should offer convenient access for the emergency, respiratory
therapy, laboratory, radiology, surgery, and other essential departments and services.
Transportation of patients to and from the critical care unit should ideally be separated
from public corridors and visitor waiting areas.
6.5.3 Design should apply privacy and quite environment for the care and comfort of
patients.
6.5.4 Each patient space (either separate rooms, or multiple bed space) should have a
minimum of 18.75 square meters of clear floor area with a minimum headwall width of
4.8 meters per bed, exclusive of toilet rooms, closets, and lockers.
6.5.5 The communication system for the unit should include supplies for an emergency
code resuscitation alarm to call assistance from outside the critical care unit.
Hand-washing stations should be suitable to nurse stations and patient bed areas.
There should be at least one hand-washing station for every three beds in open areas and
one in each patient room.
6.5.6 The documentation space should be located within or adjacent to the patient bed
space.
6.5.7 Multipurpose rooms should be provided for staff, patients, and patients families
for patient conferences, reports, education, training sessions, and consultation. These
rooms should be accessible to each nursing unit.
6.5.8 The critical care units must be supplied with medical gases outlets, (02 Air
Suction), enough numbers of electrical outlets and examination lights. Supply of medical
gases should be available and centralized medical gas system shall be according to HTM
2022 or its equivalent internationally accepted standard.
6.5.9 Adequate ventilation and air exchange, with at least 6 air changes per hour as per
ASHRAE requirements shall be maintained in Intensive Care Unit area. Intensive
Care Unit should be kept at positive pressure relative to the adjacent areas.
6.5.10 The area temperature should be maintained at 21 C 24 C and relative humidity
30 % to 60% and should be adjustable.
6.5.11 High efficiency filters should be installed in the air handling system, with
adequate facilities provided for maintenance, without introducing contamination to the
delivery system or the area served.
6.5.12 Staff areas and toilet can be located in a way that staff may be recalled quickly to
the patient area in emergencies. It should have telephone and emergency code alarm
connections to the critical care unit.

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6.5.13 The visitor waiting room should be designed to accommodate the long stays and
stressful conditions, The locations and size should be appropriate for the number of
patients and units served, with a seating capacity of not less than one family member per
patient bed.
6.5.14 For Pediatric Critical Care Unit;
6.5.14.1 An extra space at each bedside should be provided for the patient's
family.
6.5.14.2 Sleeping space for parents who may be required to spend long hours
with the patient is desirable.
6.5.15 For Newborn Intensive Care Units;
6.5.15.1 All entries to the unit should be controlled.
6.5.15.2 Viewing windows should be made to control viewing of infants.
6.5.15.3 In a multiple bed room, every bed position should be within 6.5 meters
of a hands-free washing station.
6.5.15.4 Where an individual room concept is used, a hands- free washing station
should be provided within each infant care room.
6.5.15.5 Infant bed areas should be designed to produce minimal noise and to
contain and absorb much of the transient noise that arises within the NICU.
6.5.15.6 No direct lighting should be permitted in infant unit.
6.5.15.7 At least one airborne infection isolation room should be available.
6.5.15.8 Space should be provided for lactation support and consultation in or
immediately adjacent to the NICU.
6.5.15.9 A room should be provided within the NICU to allow parents and
infants to spend private time together.

7 - Obstetrics and Gynecology Service

Obstetrical program could essentially be divided into three basic models;

- Traditional Model.
- Labor-Delivery-Recovery (LDR) Model.
- Labor-Delivery-Recovery-Postpartum (LDRP) Model.
The Obstetrics and Gynecology unit shall be located and designed to prohibit nonrelated
traffic through the unit.

21

7.1 Labor-Delivery-Recovery Model

Labor, delivery and recovery rooms are designed to accommodate the delivery process
from labor through delivery and recovery of mother and baby.
They are equipped to handle most complications, with the exception of cesarean
sections.
The birthing woman moves only as a postpartum patient to her bedroom or to a cesarean
section delivery room if delivery complications occur.
7.2 Labor-Delivery-Recovery-Postpartum Model
Labor, delivery, recovery, and postpartum occur in separate areas. The functional areas
are separate rooms consisting of the labor room, delivery room, recovery room,
postpartum bedroom, and infant nurseries.
The expectant mother is moved through these functional areas depending on the status of
the birth process.
Labor, delivery, recovery and postpartum model eliminates the move to postpartum
room after delivery. The equipment is moved into different room as needed, rather than
moving the patient to the equipped room.
7.2.1 LDR and LDRP rooms shall have;
7.2.1.1 Controlled access with doors that are arranged for observation from a
nursing station.
7.2.1.2 A minimum clear floor area of 31.60 square meters with a minimum clear
dimension of 3.95 meters.
7.2.1.3 Each LDR or LDRP room should be for single occupancy.
7.2.1.4 Satisfactory equipment and supplies.
7.2.1.5 An emergency communication system.
7.2.1.6 Hand washing sink.
7.2.1.7 Access to a toilet room.
7.2.1.8 Shower for patients use.
7.3 Postpartum Unit
Postpartum rooms have the same requirements as for the inpatient service.
In-services that have only one cesarean/delivery room should have two labor rooms.

22

7.4 Cesarean/Delivery Suite

7.4.1 Certain deliveries are handled in a cesarean section delivery room (surgical
operative room) should delivery complications occur.
7.4.2 When cesarean delivery rooms are located within the obstetrical suite, access and
service arrangements shall be such that neither staff nor patients must travel through the
cesarean delivery area to access other services.
7.4.3 There should be a minimum of one such room in every obstetrical unit unless there
is an especially reserved room in the main theatre of the hospital. These should have a
minimum clear floor area of 33.45 square meters with a minimum dimension of 4.90
meters.
7.5 Infant Resuscitation Space
7.5.1 Infant resuscitation should be provided within cesarean/delivery rooms and
delivery rooms or in a separate but immediately accessible room.
7.5.2 A minimum clear floor area of 3.75 square meters shall be provided for the infant
resuscitation space in addition to the required area of each delivery or cesarean/delivery
room.
7.5.3 Infant resuscitation space provided in a separate but immediately accessible room
shall have a minimum clear floor area of 13.95 square meters.
7.6 Gynecology Unit
The Gynecology unit has the same requirements as for the inpatient service.

8 - Renal Dialysis Unit

8.1 Space should be provided to accommodate the hospital procedure program.

8.2 The location should be in access with outpatients.
8.3 The treatment area should be acceptable to be an open area and it should be
considered to provide privacy for each patient.

23

8.4 Nurse station should be located within the dialysis treatment area and designed to
provide visual observation of all patient stations.
8.5 Hand-washing stations should be near the nurse station and patient treatment areas
and it should serve not more than four patients.
8.6 Patient toilet should be provided in the unit.
8.7 Airborne infection isolation room should be provided in the unit.
8.8 If a nourishment station is provided, it should contain a hand-washing station, a work
counter, a refrigerator, storage cabinets, a water-dispensing unit separate from the handwashing station, and equipment for serving nourishments as required. It should be
located away from the treatment area to prevent the risk of contamination.
8.9 Separate units should be kept for HBV, HCV, HIV patients and other potentially
infective diseases.
8.10 Storage space should be available for wheelchairs and stretchers.
8.11 Laboratory space can be provided to hold the process of blood draws and urine
samples.
8.12 The temperature in the unit should be maintained at 21 to 26C with a relative
humidity level of 30 to 60 percent.
8.13 A special water treatment unit should be provided.

9 - Physiotherapy Services

9.1 Space should be provided to accommodate the hospital procedures program.

9.2 The control station should provide visual control for waiting and activities areas.

24

9.3 Spaces should be provided to store the wheelchairs and stretchers.

9.4 Patients waiting area should be convenient for the access of wheelchairs and should
have activity center for patients and their company.
9.5 This department should include individualized treatment areas to insure privacy of
the patients.
9.6 The department should have multipurpose areas for different types of treatment such
as; thermotherapy, diathermy, ultrasonics, hydrotherapy and different exercise machines.
9.7 Patient dressing areas, showers, and lockers should be provided and some are
arranged for use by the disabled patients.
9.8 Hand washing stations for staff should be located either within or at each treatment
space.
9.9 Storage area should be available for soiled linen, towels, and supplies.

10 - Operation Theatre

10.1 The number of operating rooms, induction and recovery areas should be based on
the expected surgical workload.
If obstetric services are provided, an extra dedicated OT is recommended.
10.2 The operation theatre should be divided into three areas;
10.2.1 Unrestricted area, for the entrance of patients, staff and materials.
10.2.2 Semi restricted area, it has storage areas for clean and sterile supplies,
storage and processing of instruments and corridors leading to the restricted areas
of the surgical suite.
10.2.3 Restricted area: includes operating, procedure, induction, recovery and
scrub areas.

25

10.3 Operating room shall have a minimum clear floor area of 37.15 square meters.
10.4 There should be sufficient space to accommodate all necessary equipment and
personnel to allow for free and swift access to patient and all monitoring equipment.
10.5 The OT entrance door must be wide (about 2.15 meters width) and consisting of
two parts, which can be opened in either sides.
10.6 Independent dirty exit is recommended in OT.
10.7 The floors, ceilings, and walls must be created by a continuous connection.
10.8 Surfaces should be constructed of materials that are monolithic and impervious to
moisture.
10.9 The floors and walls should be anti-static, heat resistant, anti-bacterial, anti-fungal
and resistant to disinfectants.
10.10 Adequate ventilation and air exchange (with at least 25 air changes per hour as per
(ASHRAE) requirement) shall be maintained in the operation room which should be at
positive pressure relative to the adjacent areas.
10.11 Minimum of two air supply inlets with proper contamination control filters (High
Efficiency Particulate Air (HEPA) filters) delivered at or near the ceiling in addition to a
minimum of two exhaust outlets located near floor level.
10.12 Differential pressure indicating device, humidity indicator, and thermometers
should be installed and should be located for easy observation.
10.13 Operating room temperature shall be maintained between 18-22 C with room
humidity between 35-70% and the temperature and relative humidity set points should
be adjustable.
10.14 Anesthesia scavenging systems should be installed in all spaces used for
administering inhalation anesthesia.
10.15 The scrub facility shall be located adjacent to the operation room(s).
10.15.1 Two scrub positions should be provided.
10.15.2 Ceiling surfaces or tiles at this area shall be smooth, washable and free of
particular matter that can be contaminated.

26

10.16 Sterilizing area can be located near operating room(s) with adequate machine and
equipment for cleansing, sterilization and packing of surgical instruments and trolleys.
10.16.1 Sterilizing area air pressure should be kept negative pressure with respect
to any adjoining areas and should have minimum 10 air changes per hour.
10.16.2 Relative humidity should be maintained at 30% to 60%.
10.16.3 High efficiency filters should be installed in the air handling system,
with adequate facilities provided for maintenance, without introducing
contamination to the delivery system or the area served.
10.17 Staff changing area shall be separate for males and females. It must contain
special entrance for the staff and suitable place for changing of clothes, lockers, showers,
toilets and hand-washing stations.
10.18 Staff and patients toilets air pressure should be kept negative pressure with respect
to any adjoining areas and should have minimum of 10 air changes per hour.
10.19 Suitable medical store area should be available for adequate storage of all medical
and no medical requirements of the operation theatre.
10.19.1 Store's air pressure should be kept positive pressure with respect to any
adjoining areas and should have minimum 4 air changes per hour.
10.19.2 Relative humidity should be maintained at 30% to 60%. High efficiency
filters should be installed.
10.20 Sufficient supply of different medical gases should be available and adequate for
procedure(s) preformed (centralized medical gas system in accordance to HTM 2022 or
its equivalent internationally accepted standard is preferable).
10.21 Back-up emergency power supply sufficient to ensure patient protection and
safety in the event of an emergency power cut should be available.

11 - Radiology Services
27

The Radiology Services include;

A- General Radiology
Radiography: Film Radiography, Computed Radiography (CR).
Digital Radiography (DR)
Mammography
Bone Densitometry
Dental X-rays
B- Fluoroscopy-Based;
Diagnostic Fluoroscopy (Diagnostic Imaging)
Interventional Cardiology (Cath Lab)
CDEFG-

Interventional Radiology
Lithotripsy
Computed Tomography (CT) Scanning.
Magnetic Resonance Images (MRI).
Ultrasound imaging.

11.1 All General Hospitals must provide conventional Radiography, Computer

Tomography and Ultrasound services on the premises.
11.2 Patients convenience and accessibility should be considered at the planning and
designing of the Radiology Department.
11.3 Radiation protection requirements shall be incorporated into the specifications and
the building plan as required by the National Radiation Protection Center (NRPC) at the
Ministry of Health and the Federal and Local Authorities.
11.4 Consultation area or office for radiologist(s) must be provided. Office shall include
provisions for patient consultation, viewing and charting of radiological films.
11.5 Sharing support areas for diagnostic imaging services (e.g. reception area, and
Consultation area) is permitted.
11.6 Male and Female waiting area for patients and escorts shall be separated and under
staff visual control. If the suite is routinely used for outpatients and inpatients at the
same time, separate waiting areas shall be provided with screening for visual privacy
between them.

28

11.7 Waiting area shall be provided with provision of drinking water and public
telephone. Toilet(s) for public use shall be conveniently accessible from the waiting
area.
11.8 Staff lounge with lockers shall be permitted to be outside the suite but shall be
convenient for staff use.
11.9 Staff toilets shall be permitted to be outside the suite but shall be convenient for
staff use.
11.10 Radiology Services;
11.10.1 Conventional radiography room size shall be at least 15 square meters
depending on the type of machine in use and the functional program.
11.10.2 Tomography and radiography/fluoroscopy (R&F) rooms should be a
minimum of (25 square meters).
11.10.3 Room entrance shall not be less than 2 meters height with shielded door.
11.10.4 At least one designated patient gowning area for patient changing shall
be provided within the conventional radiography room.
11.10.5 Shielded viewing window (Lead glass) from the Control Area to the
conventional radiography room should be provided.
11.10.6 Minimum X-ray room surfaces and shielding thicknesses shall comply
with the Requirements of the NRCP and the Federal and Local Authorities Laws.
11.10.7 If film systems are used, a darkroom shall be provided for processing
films (at least 2 meters square) with water basin, table, benches, film holder and
Safe light.
11.10.8 Film storage (active). A room with cabinet or shelves for filing
patient film for immediate retrieval shall be provided.
11.10.9 Film storage (inactive). A room or area for inactive film storage shall be
provided. It shall be permitted to be outside the imaging suite, but must be
under imaging's administrative control and properly secured to protect films
against loss or damage.
11.10.10 Storage facilities for unexposed film shall include protection of film
against exposure or damage and shall not be warmer than the air of adjacent
occupied spaces.
11.10.11 The Ministry of Health strongly advises all new facilities not to
consider using films in their practice due to the environmental hazardous caused.

29

11.11 CT room;
11.11.1 Shall be at least 24 square meters depending on the type of machine in
use and the functional program.
11.11.2 Patient gowning area for patient changing shall be provided.
11.11.3 At least one space should be large enough for staff-assisted dressing.
11.11.4 A control room shall be provided that is designed to accommodate the
computer and other controls for the equipment.
11.11.5 A view window (Lead glass) shall be provided to permit full view of the
patient.
11.11.6 The angle between the control and equipment shall permit the control
operator to see the patients head all the time.
11.11.7 A patient toilet shall be provided.
11.11.8 If contrast media are used, this area shall include provision for
appropriate emergency equipment and medications must be immediately
available and central oxygen or oxygen cylinder to treat adverse reactions
associated with administered medication. Also the area shall include; crash cart,
sink, counter, and storage area.
11.11.9 One preparation room, if conveniently located, shall be permitted to
serve any number of rooms.
11.12 Mammography room;
11.12.1 The space requirement is at least 9 square meters.
11.12.2 Patient gowning area shall be inside to the room.
11.13 Magnetic Resonance Imaging (MRI);
11.13.1 The MRI room shall be permitted to range from 30.20 square meters to
57.60 square meters, depending on the machine type.
11.13.2 Patient gowning area shall be provided.
11.13.3 There should be a control room with full view of the MRI room.
11.13.4 At least one space should be large enough for staff-assisted dressing shall
be provided.
11.13.5 A patient holding area according to work load shall be provided.
11.13.6 Hand-washing stations convenient to the MRI room, but need not be
within the room should be provided.
11.13.7 A computer room is required.
11.13.8 Cryogen storage is required.

30

11.13.9 Equipment installation requirements;

11.13.9.1 Power conditioning.
11.13.9.2Magnetic shielding.
11.13.9.3 For super-conducting MRI, cryogen venting and emergency
exhaust in accordance with the original equipment manufacturers
specifications.
11.13.9.4 Adequate space for Coils storage based on the on these
anatomic applications.
11.13.10 Magnetic door interlock should be provided.
11.13.11MRI Warning light and signs should be provided.
11.13.12 Compatible MRI medical equipment including Anesthesia machine
should be provided.
11.13.13 Magnetic shielding may be required to restrict the magnetic field
plot.
11.13.14 Radio frequency shielding may be required to attenuate stray radio
frequencies.
11.13.15 The area around, above and below the MRI suite shall be reviewed and
evaluated for the following;
11.13.15.1 Possible occupancy by person(s) who could have pacemakers
or other metal implants.
11.13.15.2 Equipment that can be disrupted by a magnetic field.
Examples include but are not limited to personal computers, monitors, CT
scanners, and nuclear cameras.
11.14 Ultrasound imaging;
11.14.1 Room size shall not be less than 7 square meters.
11.14.2 Patient toilet shall be accessible within the ultrasound room.
11.15 Interventional Imaging Facilities;
11.15.1 The IR and /or cardiac catheterization laboratory is normally located in a
separate suite, but location in the diagnostic imaging area can be permitted
provided the appropriate sterile environment is provided.
11.15.2 The number of procedure rooms shall be based on expected utilization.
11.15.3 The procedure room shall be a minimum of 37.15 square meters
exclusive of fixed cabinets and shelves.
11.15.4 Electrophysiology labs. If electrophysiology labs are also provided in
accordance with the approved functional program, these labs may be located in a
separate functional area proximate to the cardiac care unit.

31

11.15.5 Support areas for the IR suite/ cardiac catheterization lab should have;
11.15.5.1 Scrub facilities with hands-free operable controls shall be
provided adjacent to the entrance of procedure rooms, and shall be
arranged to minimize incidental splatter on nearby personnel, medical
equipment, or supplies.
11.15.5.2 Patient prep, holding, and recovery area or room.
11.15.5.3 A patient preparation, holding, and recovery area or room shall
be provided and arranged to provide visual observation before and after
the procedure.
11.15.5.4 A control room shall be provided and shall be large enough to
contain and provide for the efficient functioning of the x-ray and image
recording equipment.
11.15.5.5 A large view window (Lead glass) permitting full view of the
patient from the control console shall be provided.
11.15.6 Electrical equipment room. An equipment room or enclosure large
enough to contain x-ray transformers, power modules, and associated electronics
and electrical gear shall be provided.
11.15.7 Viewing room. A viewing room shall be available for use by the cardiac
catheterization suite.
11.15.8 A clean workroom or clean supply room shall be provided.
11.15.9 A soiled workroom shall be provided.
11.15.10 Film file room shall be available for use by the cardiac catheterization
suite.
11.15.11 Housekeeping closet shall be provided.
11.15.12 Support areas for staff clothing and change area(s) shall be provided
and arranged to ensure a traffic pattern so that personnel can enter from outside
the suite, change their clothing, and move directly into the cardiac catheterization
suite.
11.16 General considerations;
11.16.1 Each x-ray room shall include a shielded control alcove. This area shall be
provided with a view window (Lead glass) designed to provide full view of the
examination table and the patient at all times, including full view of the patient when
the table is in the tilt position or the chest x-ray is in use.
11.16.2 Each X-ray room shall include a Warning light over the entrance door with
wording X-RAY IN USE, DO NOT ENTER.
11.16.3 Adequate ventilation and air exchange, with at least 6 air changes per hour as
per ASHRAE requirements shall be maintained in all Diagnostic Imaging service area.
The area should be kept at positive pressure relative to the adjacent areas.

32

11.16.4The area temperature should be maintained at 21 C to 24 C and relative

humidity 30% to 60% and should be adjustable.
11.16.5 High-efficiency filters should be installed in the air handling system, with
adequate facilities provided for maintenance, without introducing contamination to the
delivery system or the area served.
11.16.6 Radiology Departments must comply with the requirements of the National
Radiation Protection Center and other related Federal and Local Authorities Laws.

12 - Clinical Laboratory Service

12.1 All general hospital must provide clinical laboratory facilities according to the
expected workload in the hospital.
12.2 Services to cover the following minimum specialties should be available;
12.2.1 Hematology.
12.2.2 Clinical chemistry.
12.2.3 Immunology and serology.
12.2.4 Microbiology.
12.3 Certain procedures may be performed on-site or provided through a contractual
arrangement with external laboratory service.
12.4 Access to laboratory areas should be strictly limited to laboratory personnel. Members
of the general public should get no further than the reception areas or waiting rooms.

12.5 Phlebotomy room/Specimen Collection Area;

12.5.1 Phlebotomy room shall have minimum space of 6 square meters, a seating
space, a work counter, and a hand-washing station in the vicinity.
12.5.2 Phlebotomy room location, design and door swings should be oriented to
provide patient privacy.
12.5.3 Room shall be furnished with reclining chair or gurney for patients who
become unsteady.
12.5.4 The urine and feces collection facility shall be equipped with a water
closet and hand-washing station.

33

12.5.5 A specimen collection facility may be located outside the clinical

laboratory area.
12.6 Laboratory work areas shall include sinks with water and access to vacuum, gases,
tele/data service, and electrical service as needed.
12.7 Chemical safety provisions. These shall include emergency shower, eye-flushing
devices, and appropriate storage for flammable liquids.
12.8 Facilities and equipment shall be provided for terminal sterilization of contaminated
specimens before transport.
12.9 Where pediatrics service provided a separate, controlled area for pediatric patients
shall be provided.
12.10 Laboratory fume hoods shall meet the following general standards;
12.10.1 An average fan velocity of at least 75 feet per minute (0.38 meters per
second).
12.10.2 Connection to an exhaust system to the outside that is separate from the
building exhaust system.
1210.3 Location of an exhaust fan at the discharge end of the system.
12.10.4 Inclusion of an exhaust duct system of noncombustible corrosionresistant materials as needed to meet the planned usage of the hood.
12.11 If radioactive materials are employed, facilities for long-term storage and disposal
of these materials shall be provided.
12.12 Storage facilities for reagents, standards, supplies, and stained specimen
microscope slides, etc. shall be provided.
12.13 Refrigerated blood storage facilities should be provided.
12.14 Waiting area shall be provided with provision of; drinking water, toilet(s) for
public use.
12.15 Lounge, locker, and toilet facilities shall be conveniently located for male and
female laboratory staff.

34

12.16 Adequate ventilation and air exchange, with at least 6 air changes per hour as per
ASHRAE requirements shall be maintained in all Clinical Laboratory service area.
12.17 The Laboratory area should be kept at positive pressure relative to the adjacent
areas.
12.18 The area temperature should be maintained at 21 C to 24 C and relative
humidity 30% to 60%.
12.19 High-efficiency filters should be installed in the air handling system, with
adequate facilities provided for maintenance, without introducing contamination to the
delivery system or the area served.
12.20 Selected flooring surfaces shall be easy to maintain, readily cleanable, non-pervious
and with covings to the walls and cabinets to ensure that spills cannot penetrate underneath.
12.21 Clinical Laboratory services should comply with the Federal and Local Authorities
regulating laws.

13 - Pharmacy Service

13.1 The size and type of services to be provided in the pharmacy shall depend upon the
type of drug distribution system used and number of patients to be served.
13.2 If the functional program of the hospital requires dispensing of medication to
outpatients, providing an area for consultation and patient education is recommended.
13.3 The pharmacy area shall consist of the following;
13.3.1 A room or area for receiving, breakout, and inventory control of materials
used in the pharmacy.
13.3.2 Work counters and space for automated and manual dispensing activities.
13.3.3 A compounding area. This shall include a sink and sufficient counter
space for drug preparation.

35

13.3.4 An area for reviewing and recording.

13.3.5 An area for temporary storage, exchange, and restocking of carts.
13.3.6 Secure storage shall be provided for narcotics and controlled drugs as per
the Ministry of Health laws and regulations.
13.3.7 A hand-washing station shall be provided either in an anteroom or
immediately outside the room where open medication(s) are prepared.
13.3.8 If intravenous (IV) solutions are prepared in the pharmacy, a sterile work
area with a laminar-flow workstation designed for product protection shall be
provided.
13.4 The laminar-flow workstation shall include;
13.4.1 A non-hydroscopic filter rated at 99.97 percent (HEPA).
13.4.2 A visible pressure gauge for detection of filter leaks or defects.
13.5 Separate room shall be provided for preparation of Cytotoxic IV admixtures under a
Class II: Type B1, B2, B3 or Class III biological safety cabinet.
13.6 Cabinets, shelves, and/or separate rooms or closets shall be provided for bulk
storage.
13.7 Refrigerated storage should be provided if required.
13.8 Adequate ventilation and air exchange, with at least 4 air changes per hour as per
ASHRAE requirements shall be maintained in Pharmacy services area.
13.9 Pharmacy services area should be kept at positive pressure relative to the adjacent
areas.
13.10 The area temperature should be maintained at 23 C plus or minus 1 C and
relative humidity 30% to 60% and should be adjustable.
13.11 High-efficiency filters should be installed in the air handling system, with
adequate facilities provided for maintenance, without introducing contamination to the
delivery system or the area served.

14 - Catering Services
36

14.1 Food service should be provided for patients, staff, and visitors in according to
functional program.
14.2 Strict hygienic conditions should be maintained in the hospital kitchen during
preparing, storing and serving food.
14.3 Patient food preparation areas should be located near the deliver y and storage
facilities.
14.4 Work spaces for food preparation, cooking, and baking should be as close as
possible to the users.
14.5 A cart distribution should be provided with spaces for storage, loading, distribution,
receiving and sanitizing of the food service with temperature control.
14.6 The cart traffic should eliminate any danger of cross circulation between outgoing
food carts and incoming carts. Cart circulation should not be through food processing
areas.
14.7 Dining spaces should be provided for staff and visitors. This unit should be separate
from the food preparation and distribution areas.
14.8 The waste eliminated process should avoid the contamination of the clean products
and the waste products.
14.9 Measures should be taken to protect the food delivery for the patient and to ensure
freshness, retain hot and cold, and avoid contamination. If delivery is from outside
sources, protection against weather should be provided.
14.10 If selling devices are used for unscheduled meals, a separate room should be
provided that can be accessed without having to enter the main dining area. In this room
there should be a hand-washing station, and a sitting area.
14.11 Coolers, refrigerators, and freezers should be thermostatically controlled to
maintain desired temperature settings.
14.12 Interior temperatures shall be indicated digitally so that to be visible externally.

37

14.13 All cooking equipment should be equipped with automatic shut-off devices to
prevent excessive heat buildup.
14.14 Provision should be made for storage of a minimum of four days supplies.
14.15 Smoke should vent outside and the smell shouldnt escape inside the hospital.
14.16 Such services could be outsourced on the hospital premises or by an external
provider with written agreement. The provided services shall be in accordance with the
MOH standards on allied health services.

15 - Mortuary Unit

15.1 Each general hospital with more than 25 beds shall provide a mortuary within the
hospital premises.
15.2 Mortuary equipment shall be operated and maintained in accordance with
manufacturer specifications.
15.3 Mortuary fridge temperature shall be maintained between 2 - 6 C and provided
with alarm system.
15.4 Mortuary area shall be maintained clean and disinfected on daily basis, infection
control policy shall be available and implemented in the mortuary area.
15.5 The hospital shall maintain also a policy for handling amputated body parts which
assure proper management and disposal.
15.6 The hospital mortuary services shall be responsible for overseeing the
transportation of deceased patients from wards/departments.
15.7 All dead bodies shall be considered infectious, strict infection control measures
shall be considered during cleaning the body. Body should be cleaned and rapped/placed
in mortuary bag.

38

15.8 Transportation of deceased patient infected with communicable disease shall be

conducted according to UAE Federal and Local Law.

16 - Central Sterile Supply Department

16.1 This area should be physically separated from all other areas of the hospital.
16.2 It should be arranged to handle the cleaning, sterilization and disinfection of all
medical and surgical instruments and equipment for all hospital services.
16.3 Work tables, sinks, flush-type devices, washer and sterilizer decontaminators
should be provided as work load requires.
16.4 The clean room should contain hand-washing stations, and equipment for terminal
sterilizing of medical and surgical equipment and supplies.
16.5 Access to the sterilization room should be restricted. This room should contain HiVacuum steam sterilizers and sterilization equipment to accommodate heat-sensitive
equipment
Storage area for packs, should maintain suitable ventilation, humidity, and temperature.

17 - Linen Services

17.1 The building should include adequate space to accommodate carts for appropriate
waste isolation such as recyclables, infectious waste, sharps and others.
17.2 Corridors and materials handling systems should be designed to achieve an efficient
movement of waste from points of generation to storage or treatment while minimizing
the risk to personnel.

39

17.3 A separate room should be provided for receiving and holding soiled linen until
ready for pickup or processing.
17.4 Clean linen storage room should be available away from dirty area.
17.5 Cart storage area should be provided for clean and soiled-linen carts separately.
17.6 A service entrance should be provided for loading and unloading of linen.
17.7 A control station shall be provided for pickup and receiving of linen.

18 - Engineering Services

Engineering services and maintenance require sufficient space and access to HVAC
Plant, Central Plant, workshop and equipment areas. Typically these include;
* Plant rooms
* Electrical Transformer and Switchboard Rooms
* Standby Generator Rooms
* Cooling Tower Compounds
* Medical Gas Cylinder and Manifold Room
* Bulk medical oxygen compound for tanker access
* Cold Water Storage Tanks
* Administration
* Workshops readily accessible to building lift systems
* Biomedical Engineering Equipment Workshop
* Engineering Supply Store
* Outside Equipment Storage
* Deliveries and service parking area

19 - Administration Area
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19.1 The hospital should specify a separate department for administration.

19.2 It shall have a suitable area for the hospital manager, assistants, administration and
finance employees.
19.3 An admission Office should be located in a convenient area for patients admission
procedures if required.

20 Management standards and responsibilities

20.1 The hospital shall have a governing body responsible for directing the operation of
the hospital in accordance with its mission. If a hospital does not have an organized
governing body, then the person or persons responsible for the conduct of the hospital
shall carry out the functions.
20.2 The hospital governing body shall be legally responsible for the patient safety,
quality of care and for the conduct and obligations of the hospital as an institution.
20.3 The hospital governing body shall be legally responsible for ensuring compliance
with all UAE Federal and Local laws.
20.4 The governing body should appoint a Medical Director who is a MOH licensed
physician or dentist authorized to practice his/her profession.
20.5 The Medical Director responsibilities include, but not limited to the following;
20.5.1 Ensuring that all healthcare professionals should have active and
appropriate licensure by MOH and have necessary training and skills to deliver
medical services provided in the hospital.
20.5.2 Ensuring that all personnel (non-healthcare professional) assisting in the
provision of healthcare services in the hospital must be appropriately trained,
qualified, supervised, and sufficient in number to provide appropriate care.

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20.5.3 Developing clear internal process for gathering and submitting to MOH
healthcare professional's credentials (license, education, training and experience).
20.5.4 Ensuring a defined process for physician's privileges in the hospital, and
maintaining records of credential outcomes and privileges.
20.5.5 Providing response to any inspection report or requirements by the MOH.
20.5.6 Provide a documented policy and procedures for the following:
20.5.6.1 Infection control measures and hazardous waste management
20.5.6.2 Medication management
20.5.6.3 Patient health record
20.5.6.4 Emergency action plan
20.5.6.5 Patient discharge/transfer
20.6 The governing body should appoint a Director of Nursing Services who is a MOH
licensed Registered Nurse authorized to practice her/his profession with at least five
years experience in nursing practice where at least two years were in an administrative
or supervisory capacity.
20.7 The Director of Nursing shall supervise nursing care and nursing aid according to a
written staffing plan which provides for adequate coverage of all nursing requirements at
the hospital.

21 - Healthcare Professionals Minimum Requirements

21.1 Human resources practices should be supported by policies and procedures with
systems that influence employee's behaviors, attitudes and performance.
21.2 The recruitment selection and appointment system shall ensure that the skill mix
and competence of staff meet the hospital needs.
21.3 The hospital shall maintain accurate and complete personnel records for all
employees, including training records, such records shall be maintained and kept
confidential.

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21.4 Continuing Professional Development (CPD) activities shall be documented,

evidence of a learning and development system shall ensure the skill and competence of
staff by allocation.
21.5 Sufficient numbers of medical staff are required to be on duty at all times for good
patient management.
21.6 The number of licensed medical staff assigned to each health service in the hospital
shall be determined by senior management and consistent with the functional program of
the hospital.
21.7 All Medical staff in the hospital shall be holding an active MOH license and work
within their scope of practice.
21.8 Each clinical department must have a designated head of department.
21.9 At least one doctor for ten beds in general wards should be available during routine
working hours.
21.10 Enough number of doctors should be available to cover on call duties at off-duties
hours, weekends and public holidays.
21.11 At least one full time consultant shall be available to manage each of the following
specialties; Medical, Surgical, Pediatric, Obstetrics and Gynecology and Anesthesia.
21.12 One specialist (A) or consultant doctor shall be available for other departments in
the hospital.
21.13 At least one MOH licensed pharmacist should be available to cover the service
requirements.
21.14 There should be sufficient number of nurses on duty at all times to plan, supervise
and evaluate nursing care.
21.15 The hospital shall meet the minimum nursing staffing requirements as shown in
(tables 1&2).

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21.16 The number of MOH licensed registered nurses and nurse assistance assigned to
each department/service shall be consistent with the types of nursing care needed. See
staffing matrix decision making guideline in general hospital (table 3).
21.17 Availability of allied healthcare professionals shall be based on hospital activities
and number of patients and to be determined by senior management to ensure the
appropriate coverage of all medical services to all departments and ensuring staff
availability.

Service
General and
Surgical Ward
(Ortho, Obs&
Gyne,
Uro, ENT)
Pediatric Ward,
Burn Unit,
Neuro Surgey,
Short stay ward
CCU Unit

ICU & S.BC.U,

NICU

Registered Nurse to
patient ratio per shift

Charge
nurse

Notes

One RN / Four beds

One / Twenty
five beds

1-2 nurses extra per

shift

One RN / Three beds

One / Twenty
five beds

1-2 nurses extra per

shift

One RN / Two beds

One each shift

1-2 nurses extra per

shift

One RN / bed

One each shift

1-2 nurses extra per

shift

Table (1)

Service
44

Registered Nurse / Room

Charge Nurse

Notes

Operating Theater
Recovery Area
Delivery Room

Table (2)

Table (3)

45

One Registered Nurse +

1 Nurse assistant
One Registered Nurse

One each shift

One Registered Midwife +

One Registered Nurse

One each shift

One each shift

22 - Facility management
22.1 Hospitals shall ensure that the health care environment is safe, functional,
supportive and effective for patients, family and staff members.
22.2 The hospital shall establish a multidisciplinary Health and Safety committee.
22.3 The safety management systems and hospital policies shall comply with the
relevant Federal and Local Regulations.
22.4 The safety management system shall include fire safety, hazardous waste
management, emergency plans, security, and any other risks.
22.5 Orientation on the safety measures shall be included with the introduction program
for new staff.

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