1. Introduction to IUSS guidelines norms and standards
Built Environment guidelines
Overview of building guidelines for health infrastructure in South Africa, with reference to the IUSS standards
ventilation and its limitations in controlling transmission of airborne diseases.
Jako Nice

2. Contents 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
Difficult for an engineer to talk to a group of healthcare professionals. You are more knowledgeable about clinical matters so I need to hide my limited depth of knowledge of clinical issues while not bewildering you with engineering jargon.

3. INFRASTRUCTURE
INVESTMENT
Buildings are expensive to build – and even more expensive to operate and maintain
Buildings take a long time to construct months – 8 years
But last long when complete 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 … unknown unknowns

4. INFRASTRUCTURE
HEALTH SOUTH AFRICA
Service delivery in the healthcare sector is profoundly affected by the built infrastructure provided to support it
4122 public healthcare facilities
Current replacement rate - > 40 Yrs
Current replacement value – R331.2 Billion (MERC)
Inconsistent quality, budgeting and programming:
Inaccurate budgeting, poor spending patterns
undermining equity
lack of transparency, and
lack of confidence

5. Current state of guidelines
THE NEED (current and pre-IUSS)
Weak health infrastructure law:
SAHNorms (public sector) repealed
R158 (private sector) – outdated
R187 (WC) and draft regulations (GP, FS)
Built environment professionals have no healthcare specialisation, and vice versa
Initial capital cost: maintenance: service delivery
1 : 5 : 25
New national guidelines commissioned by the National Department of Health…in need

6. 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

7. 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 R158)
SANS 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

8. 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.

9. The law DESCRIPTION BY Hierarchy Policies:
General provisions that provide direction, transparency and consistency of approach, often covers more than one entity.
Norms:
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.

10. Mandatory Legislation
The law
NATIONAL BUILDING REGULATIONS & BUILDING STANDARDS ACT
Act 103 of 1977
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 the regulation
Four-tier + 1
legislative model
CONSULTAT I VE
Mandatory Legislation 1
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
An Act always trumps regulations and regulations always trump standards or any other documents incorporated into their regulations by reference.
By-laws are subservient to the regulations.
Building By-Laws can only be made with the approval of the Minister of the dti 2
NRCS = REGULATOR = NBR National Building Regulations
Chapters contained in Regulations
TECHNICAL REGULATIONS
Regulations contain: Policy, principal provisions, procedures and other detail
Standards can be called up into regulations making them mandatory 3
SABS
Standards and best practices are purely technical documents that do not contain policy or principles-based provisions.
SABS = National Standards
SANS Deemed-to-satisfy
Chapters A to X.
CONSENSUS
Voluntary Standard 4
Other SANS documents
SANS 204, SANS 10252, SANS for protection of timber 5
Local Authority Building By-Laws; To be endorsed by the Minister before it has jurisdiction and: Town Planning Schemes, TP ordinances, TP regulations
Source: Hierarchy of legislation. October National Regulator -

11. 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…”

12. 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.

13. 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 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.

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

15. IUSS Gazette No Prospective Public sector Private sector guidance
APPLICATION
Gazette No
37348: R116, 17 February 2014
37790: R512, 30 June 2014
38776: R4141, 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

16. Healthcare environment/ crosscutting issues Procurement and operation
11/2/2019
Clinical services
Adult Inpatient Services
Laboratories
Mental Health
Adult Critical Care
Emergency Centres
Maternity Care Facilities
Oncology
Outpatient Services
Paediatric and Neonatal Facilities
Pharmacy
Primary Health Care
Diagnostic Radiology
Adult Physical Rehabilitation
Adult Post-acute Services
Facilities for Surgical Procedures
TB Services
Support services
Admin & Related
General Hospital Support
Catering Services
Linen and Laundry
Hospital Mortuary Services
Nursing Education Institutions
Health Facility Residential
Central Sterilising Services Department
Training and Resource Centre
Infrastructure Design for Waste Management
Healthcare environment/ crosscutting issues
Generic Room Data
Security
Engineering design principles
Environment and Sustainability
Materials and Finishes
Future healthcare environments
Healthcare Technology
Inclusive environments
Infection prevention & control
Information Technology & Infrastructure
Procurement and operation
Integrated infrastructure planning
Project planning and briefing
Space guidelines
Cost Guidelines
Innovative Building Technologies
Commissioning
Maintenance
Decommissioning
Capacity development X X X X X X
LEGEND
Gazetted
Guidelines
Toolkits
Position papers
Regulations X X
Regulations
Regulations

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

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

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

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

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

22. IUSS
PHC DOCUMENT, EXAMPLE (6)
Ngcizela Clinic

23. IUSS
PHC DOCUMENT, EXAMPLE - APPLICation

24. IUSS
Pharmacy, integrated data and generic drawings (1)

25. IUSS
Pharmacy, integrated data and generic drawings (2)

26. IUSS
Pharmacy, integrated data and generic drawings (3)

27. IUSS 5 Gazetted 100 extensive reviewed and workshopped
Room data sheets
5 Gazetted
100 extensive reviewed and workshopped
Room requirements
Room specifications
Room sizes
Graphical representation
Cross referenced

30. IUSS
TB SERVICES

31. IUSS
TB SERVICES (EXAMPLES) – CATHERINE BOOTH

32. IUSS
TB SERVICES – DESIGN PRINCIPLES

33. IUSS
TB SERVICES – CONSTRUCTION, WINDOWS AND VENTILATION

34. IUSS
CSSD – DESIGN GUIDANCE

36. CSSD process zones

37. CSSD workflow through zones

38. IUSS ENGINEERING PRINCIPLES – AIRFLOW IN AN MDR UNT 11/2/2019
(Also point out the different spaces and rooms in the ward and their use and functions)
(Point out to class the different pressures of air supply in different areas of the renovated ward)
(Pressure is measured in Pascals (SI unit = Pa))
(Discuss with class how air will move in this ward to achieve the objective of transmission prevention from patients to staff)
2019/11/02

39. IUSS Evidence based guidance on: Engineering for Infection Control
BUILDING ENGINEERING SERVICES (1)
Evidence based guidance on:
Engineering for Infection Control
Engineering for Energy Efficiency
Engineering for Cost Control
Engineering for Reliability
The BES guide provides:…
Note that these are all engineering outcomes above and beyond the basic service function

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

41. IUSS
BUILDING ENGINEERING SERVICES (3)

42. IUSS Capital Costs or Operational Costs
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

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

45. ADDITIONAL RESOURCES

46. 11/2/2019

47. SAFHE – South African Federation of Hospital Engineering
11/2/2019
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.
The first HEPA filter (high efficiency particulate air) was designed in the 1940's by the research and development firm Arthur D. Little under the Manhattan Project.
The filter solved a critical need to control very small contaminated particles.
Considering the condensation nuclei of radioactive iodine to be most harmful, researchers focused on the ability to capture solid particles that were created through the condensation of gases and liquid aerosols into solid matter. Having identified 0.3 micron size particles as the most penetrating size particle and representative of the particle of concern, 0.3 microns was established as the particle size fraction at which to determine filter efficiency performance.
Because of its effectiveness, the filter was originally referred to as an "absolute filter." The generic acronym HEPA came into use some time following 1950 when the filter was commercialized and the original term became a registered tradename.
Over the next 50 years, HEPA filtration gradually evolved as technological breakthroughs in aerospace, pharmaceutical processing, photographic film manufacturing, data processing and microcircuitry demanded higher and higher levels of air cleanliness. If not for HEPA filtration, such milestones as the lunar landing and the introduction of the silicon chip might not have been achieved and adequate control of hazardous and toxic particulate would not be possible
The first HEPA filter (high efficiency particulate air) was designed in the 1940's by the research and development firm Arthur D. Little under a classified government contract as part of the Manhattan Project, where the first atomic bomb was developed during World War II. A major advancement in air filtration technology, the filter solved a critical need to control very small particles which had become contaminated by nuclear radioactive sources.
Because of its effectiveness, the filter was originally refered to as an "absolute filter." The generic acronym HEPA came into use some time following 1950 when the filter was commercialized and the original term became a registered tradename.

48. FIDSSA –Federation of Infectious Diseases of South Africa
11/2/2019
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
The first HEPA filter (high efficiency particulate air) was designed in the 1940's by the research and development firm Arthur D. Little under the Manhattan Project.
The filter solved a critical need to control very small contaminated particles.
Considering the condensation nuclei of radioactive iodine to be most harmful, researchers focused on the ability to capture solid particles that were created through the condensation of gases and liquid aerosols into solid matter. Having identified 0.3 micron size particles as the most penetrating size particle and representative of the particle of concern, 0.3 microns was established as the particle size fraction at which to determine filter efficiency performance.
Because of its effectiveness, the filter was originally referred to as an "absolute filter." The generic acronym HEPA came into use some time following 1950 when the filter was commercialized and the original term became a registered tradename.
Over the next 50 years, HEPA filtration gradually evolved as technological breakthroughs in aerospace, pharmaceutical processing, photographic film manufacturing, data processing and microcircuitry demanded higher and higher levels of air cleanliness. If not for HEPA filtration, such milestones as the lunar landing and the introduction of the silicon chip might not have been achieved and adequate control of hazardous and toxic particulate would not be possible
The first HEPA filter (high efficiency particulate air) was designed in the 1940's by the research and development firm Arthur D. Little under a classified government contract as part of the Manhattan Project, where the first atomic bomb was developed during World War II. A major advancement in air filtration technology, the filter solved a critical need to control very small particles which had become contaminated by nuclear radioactive sources.
Because of its effectiveness, the filter was originally refered to as an "absolute filter." The generic acronym HEPA came into use some time following 1950 when the filter was commercialized and the original term became a registered tradename.
ICAN –Infection Control African Network

49. resources Departments, federations and organisations CDC
Centers for Disease Control and Prevention
CSIR
Council for Scientific and Industrial Research
MRC
Medical Research Council
NDoH
National Department of Health
NHLS
National Health Laboratory Services
NIOH
National Institute of Occupational Health
NICD
National Institute of Communicable Diseases
WHO
World Health Organisations
SAFHE
South African Federation of Hospital Engineering
FIDSSA
Federation of Infectious Diseases of South Africa
CIBSE
Chartered Institution of Building Services Engineers
REHVA
Federation of European Heating Ventilation and Air Conditioning

50. resources Online portals IUSS Infrastructure Unit Support Systems
GHD online
Global Health Delivery Online
CSIR
TB IPCP
ICAN
Infection Control African Network
Etc………

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

52. 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…

53. QUESTIONS
Questions on day 1…?